Menstrual bleeding

Question 1

How does the menstual cycle work?

Answer 1

1. Follicular phase: FSH an LH are released from pituitary and act on the oocyte, which causes follicles to grow and compete to be dominant. (day1-10).
2. These follicles convert androstendione and aromatase into oestrogen. This oestrogen is at first a negative feedback effect on the hypothalamus and LH and FSH decrease. (day 10-14)
3. A dominant follicle emerges which continues rising the oestrogen levels. Once they are high enough they have a positive feedback effect on LH and FSH causing a surge 1-2 days before ovulation (day 14).
4. menstrual phase - old layer of endometrium is shed (occurs during 1-3) lasts 5 days
5. proliferative phase - high oestrogen causes thickening of the endometrium, spiral arteries and glands in preparation for implantation. Occurs during 1-3, lasts 5 days.
6. luteal phase - the corpus luteum (which is the remnant of the dominant follicle) switches from making oestrogen to making more progesterone due to low LH levels. This creates a negative feedback on LH and FSH. Due to these low LH and FSH levels oestrogen decreases. The progesterone helps to make the endometrium ready for implantation.
7. secretory phase - after day 15 and theres implantation luteum -> corpus albicans -> makes no hormones so no oestorogen or progesterone. endometrial arteries collapse and functional layer slough offs for menstruation. Menstruation is day 1-5 of cycle.

Question 2

What day is the oocyte released of the mestrual cycle

Answer 2

day 14

Question 3

What do oestrogen and progesterone do in the menstrual cycle

Answer 3

Oestrogen causes thickening of the endometrium and spiral artery emergence
Progesterone increases mucus and spiral arteries and makes endometrium more hospital to fertilised egg —- If pregnancy occurs, then progesterone levels don’t decrease but stay at the same level throughout pregnancy. Initially the corpus luetum will be source of progesterone but will become the placenta from 7-8 weeks post fertilisation

Question 4

How is the corpus luteum made?

Answer 4

The remnant of the dominant follicle becomes the corpus luteum which is made of theca and granulosa cells

Question 5

What is hCG responsible for and where does it come from?

Answer 5

Blastocyte will produce hCG - hcg prevents decline of corpus luteum

Question 6

What is an ectropium?

Answer 6

An inverted uterus

Question 7

What bleeding should you ask about in a gynaecological history?

Answer 7

PCB- post coital, IMB- intermenstrual, PMB- post menopausal

last menstrual period

Question 8

What are causes of heavy menstrual bleeding?

Answer 8

Dysfunctional uterine bleeding (unknown cause), , warfarin, fibroids, polyps, adenomyosis, endometriosis

Question 9

What is a fibroid?

Answer 9

An often asymptomatic benign tumour of myometrium made of SM and collagen

Question 10

How may a fibroid present?

Answer 10

Bleeding, pain and infertility (interfere with implantation) are main symptoms
May be a palpable, non-tender mass if large enough and outside uterus
Fibroids associated with high oestrogen- so enlarge with pregnancy and COCP and atrophy with menopause

Question 11

What are the different types of fibroids? Which is most common?

Answer 11

subserosal, submucosal, intramural (most common), pedunculated

Question 12

What are uterine polpys?

Answer 12

Benign growths of the endometrium
Fibrous tissue core covered by columnar epithelium
Arise as a result of disordered cycles of apoptosis and regrowth of endometrium

Question 13

What are the investigations for HMB?

Answer 13

FBC and haematinics if signs of anaemia or clotting disorder
TSH if suspect hypothyroid
STI screen
Smear if due
TVUS (trans vag US) for fibroids, polyps and endometrial thickness
Hysteroscopy and biopsy if scans shows abnormality evidence or suspect cancer ie over 45 yrs

Question 14

What is the management for HMB?

Answer 14

Hormones: IUS mirena (can cause irregular bleeding in first 3-6 months) or COCP or Progestogens used in day 5 to 25 but not luteal phase

Meds: Antifibrinolytics eg tranexamic acid which lower TPA
NSAIDs eg mefenamic acid for pain

Surgery: Endometrial ablations- use laser, balloons and electrosurgery – complications perforation, fluid overload, intra abdo trauma
Uterine artery embolization (artery is catheterised and then embolised)/ myomectomy if have fibroid and want to remain fertile
Hysterectomy
GNRH analogues/ ullipristal acetate can be used to shrink fibroids before surgery

Question 15

What is endometriosis?

Answer 15

endometrial tissue in the wrong place ie not in the endometrium of the uterus

Question 16

What is the suspected pathophysiology of endometriosis?

Answer 16

Retrograde menstruation, although other factors are at play
Endometriosis implants and endometrial tissue has same oestrogen receptors (so bleed whith rest of tissue) -> chocolate cysts full of old blood -> rupture
Endometriosis implants however have high levels of aromatase so produce oestrogen by self and release inflammatory factors -> adhesions

Question 17

How does endometriosis present?

Answer 17

infertility,
pelvic pain – which is cyclic and increases with rises of oestrogen in the cycle and when the endometrium is shed,
dysmenorrhoea
HMB
dyspareunia,
if in pouch of douglas - pain when urinate and defecate + bld
bleeding from other areas of body, commonly younger and lower parity

Question 18

Why does endometriosis spread and where is the commonest place it can spread to?

Answer 18

Endometriosis commonly spreads to the pouch of Douglas due to retrograde menstruation going back up into the pelvis

Can embolise and metastasise- can also occur in umbilicus and lungs- where it will grow and bleed during menstruation before shrinking again

Question 19

What are the investigations for endometriosis? WHat is gold standard, what will you see with it?

Answer 19

Fixed, retroverted uterus on bimanual vaginal exam
CA 125 (cancer marker) rises
Gold standard = laparoscopy with biopsy
Ground glass appearance due to bleeding on histology
Cysts on ovaries are “chocolate” cysts due to fibrin of old blood

Question 20

What is the management of endometriosis?

Answer 20

NSAID most effective pain relief - 1st line mx

Hormonal mx

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy

Induce a menopause-like state using GnRH agonists. Examples of GnRH agonists are goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.

Question 21

What is the management of endometriosis?

Answer 21

NSAIDs
COCP- no need to have bleed and therefore no pain – triphasic.
POP/ Depot Provera/ Mirena coil/ implant for progesterone
GnRH agonists eg goserelin
Laparoscopy- option if want to remain fertile, involves ablasion of endometrium.
Hysterectomy when post menopause usually

Question 22

What are the side effects of having goserelin?

Answer 22

low oestrogen means menopause symptoms and osteoporosis

Question 23

How do GnRH agonists work?

Answer 23

binds to receptor for around a month so although causes initial surge of LH and FSH (which have a short half life) and therefore initial pain but there will be no pain for rest of month

Question 24

What is adenomyosis?

Answer 24

It is like endometriosis but occurs in the myometrium

Question 25

How does adenomyosis present?

Answer 25

Pain is the main symptom
Commonly occurs in pregnancy
Occurs more in older women with higher parity

Question 26

What is the difference between a polyp and fibroid presentation?

Answer 26

A polyp is less likely to present with pain than a fibroid

Question 27

What does LH do?

Answer 27

stimulates sex hormones in particular testosterone that converts to oestradiol, also causes ovulation

Question 28

What does FSh do?

Answer 28

stimulates follicular growth and stimulates sex hormones in particular oestradiol

Question 29

What happens in day 1-8 of the menstrual cycle?

Answer 29

rise in FSH and LH in response to fall of oestradiol and progesterone. This rise means follicle stimulation takes place

Question 30

what happens in day 9-14 of the menstrual cycle?

Answer 30

follicle increases in size –> oestradiol rises with follicle development which causes a decrease in FSH and LH, this is to stop the maturation of multiple follicles

Question 31

What happens on day 14 of the cycle?

Answer 31

rapid follicle enlargement. Oestradiol now changes effect and causes an LH surge and to lesser extent FSH rise. LH rise causes ovulation

Question 32

What happens on day 15-28 of the cycle?

Answer 32

remainder of the follicle undergoes luteinisation and forms the corpus luteum. The corpus luteum is then a source of sex steroids which then fall if corpus luteum is not maintained by hCG

Question 33

What happens to fibroids in pregnancy?

Answer 33

Fibroid growth is related to sex steroids and they therefore grow during pregnancy
Necrosis of the fibroid can occur in the middle due to inaqdeuate blood supply of large fibroid (red degeneration) –> abdo pain in pregnancy

Question 34

How do we know a menstrual period is particularly heavy?

Answer 34

Ask about flooding and use of double sanitary products indicates heaviness and this impact on work

Question 35

What is ulipristal acetate?

Answer 35

Ulipristal acetate is used as emergency contraception and in treatment of large fibroids, it works as a progesterone receptor modulator

Question 36

How does a polyp present?

Answer 36

Irregular menstrual bleeding
Menorrhagia
Inter-menstrual bleeding
Post-menopausal bleeding
Infertility

Question 37

Ix for a fibroid?

Answer 37

exam and US, sometimes biopsy to check not cancer

Question 38

mx for fibroid?

Answer 38

< 3 cm – IUS, tranexamic acid, NSAID (mefenamic acid) or COCP
>3 cm – Trans-cervical resection of fibroids (TCRF), myomectomy, hysterectomy, uterine artery embolisation

Question 39

Is a myomectomy or UAE better for preserving fertility?

Answer 39

Myomectomy may increase pregnancy rates compared with UAE in women with fibroids who wish to retain fertility.