Menstrual bleeding Flashcards
How does the menstual cycle work?
- 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).
- 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)
- 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).
- menstrual phase - old layer of endometrium is shed (occurs during 1-3) lasts 5 days
- proliferative phase - high oestrogen causes thickening of the endometrium, spiral arteries and glands in preparation for implantation. Occurs during 1-3, lasts 5 days.
- 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.
- 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.
What day is the oocyte released of the mestrual cycle
day 14
What do oestrogen and progesterone do in the menstrual cycle
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
How is the corpus luteum made?
The remnant of the dominant follicle becomes the corpus luteum which is made of theca and granulosa cells
What is hCG responsible for and where does it come from?
Blastocyte will produce hCG - hcg prevents decline of corpus luteum
What is an ectropium?
An inverted uterus
What bleeding should you ask about in a gynaecological history?
PCB- post coital, IMB- intermenstrual, PMB- post menopausal
last menstrual period
What are causes of heavy menstrual bleeding?
Dysfunctional uterine bleeding (unknown cause), , warfarin, fibroids, polyps, adenomyosis, endometriosis
What is a fibroid?
An often asymptomatic benign tumour of myometrium made of SM and collagen
How may a fibroid present?
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
What are the different types of fibroids? Which is most common?
subserosal, submucosal, intramural (most common), pedunculated
What are uterine polpys?
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
What are the investigations for HMB?
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
What is the management for HMB?
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
What is endometriosis?
endometrial tissue in the wrong place ie not in the endometrium of the uterus
What is the suspected pathophysiology of endometriosis?
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
How does endometriosis present?
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
Why does endometriosis spread and where is the commonest place it can spread to?
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
What are the investigations for endometriosis? WHat is gold standard, what will you see with it?
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
What is the management of endometriosis?
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.
What is the management of endometriosis?
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
What are the side effects of having goserelin?
low oestrogen means menopause symptoms and osteoporosis
How do GnRH agonists work?
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
What is adenomyosis?
It is like endometriosis but occurs in the myometrium
