Menstrual Cycle Flashcards

1
Q

What hormone secreted by the hypothalamus controls the menstrual cycle?

What type of hormone is this?

A

Gonadotrophin releasing hormon, GnRH for short.

It is a peptide hormone.

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2
Q

In what way is GnRH released?

A

In a pulsatile fashion.

These pulses are necessary to stimulate pituitary release of LH and FSH.

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3
Q

What effect does low level oestrogen have on the amount of LH/FSH released by the anterior pituitary?

A

Low level oestrogen has an inhibitory effect (negative feedback) on LH.

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4
Q

What effect does high level oestrogen have on the amount of LH/FSH released by the anterior pituitary?

A

High level oestrogen has a stimulatory effect on LH/FSH release (positive feedback).

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5
Q

How do combine hormonal contraceptives inhibit ovulation?

A

CHC lead to a constant low level of oestrogen in the blood, leading to negative feedback on LH/FSH release, thereby inhibiting ovulation.

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6
Q

What effect does low level progesterone have on the release of LH/FSH?

A

Low level progesterone causes positive feedback, i.e. it stimulates the produciton of LH/FSH from the pituitary.

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7
Q

What effect does high level progesteron have on the amount of LH/FSH released by the anterior pituitary?

A

High level progesterone has a negative feedback effect on LH/FSH release, i.e. it inhibits their produciton

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8
Q

What are the three ovarian phases of the menstrual cycle?

A
  1. Follicular, where the follice(s) grow
  2. Ovulation, where the egg is released
  3. Luteal phase, where the corpus luteum forms from the remaining follicle
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9
Q

Why is the FSH peak smaller than the LH peak when oculation occurs?

A

This is due to the action of inhibin, produced by the Graafian Follicle, which specifically inhibits FSH production.

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10
Q

What are the two cell types found in the follicle (excluding oocyte)?

What receptors do they express, and which molecules do they produce?

A

Theca and Granulosa cells.

Theca cells express LH receptors. When stimulated, they produce androstenedione.

Granulosa cells express FSH receptors. When stimulated, they produce aromates, which converts androstenedione into oestradiol.

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11
Q

Describe the process that leads to the selection of the Graafian Follicle.

A

Several follicles start to mature independant of hormones. At some point they become hormone dependant - due to the increased production of oestradiol, however, there is negative feedback on the produciton of LH/FSH. Only the follicle with the mot LH and FSH receptors can continue growing - i.e. the Graafian Follicle.

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12
Q

What causes ovulation?

A

The LH surge due to the positive feedback of high oestradiol concentrations.

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13
Q

What do over-the-counter ovulation predictors measure?

A

They measure the LH surge.

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14
Q

Why should women who wish to conceive not take prostaglandin snythetase inhibitors?

A

It is thought that prostaglandins are involved in breakdown of the follicular wall to release the oocyte.

NSAIDs, who block prostaglandin synthesis, therefore might block ovulation.

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15
Q

How long do the phases of the menstrual cycle last?

A

The luteal phase lasts pretty much exactly 14 days.

The follicular phase is more variable, but also lasts around 14 days.

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16
Q

What causes menstruation?

A

Progesterone withdrawal (i.e. a drop in progesterone levels, as the corpus luteum has died).

The low concentration of progesterone also stimulates the production of FHS/LH and therfore the growth of more follicles.

17
Q

What are the 3 endometrial phases of the menstural cycle?

A
  1. Menstruation (shedding of the layer)
  2. Proliferative (under oestrogen, the endometrium proliferates and becomes thicker)
  3. Secretory (spiral arteries form, endometrium prepares for implantation)
18
Q

What is the endometrial thickness just before and just after menstruation?

A

Just after: 0.5mm

Just before: 3.5-5mm

19
Q

How is amenorrhoea defined?

A

Amenorrhoea is defined as the absence of menstruation for more than 6 months in the absence of pregancy, lactation or the menopause in a women of fertile age.

Pirmary amenorrhoea is if a girls fails to menstruate by 16, secondary if she had periods that have now stopped.

20
Q

How is oligomenorrhoea defined?

A

Oligomenorrhoea is defined as irregular periods at intervals of >35 day, with only 4-9 periods a year.

NICE just says: Oligomenorrhoea is defined as irregular periods at intervals of 35 days - 6 months.

21
Q

What are the causes of (pathological) amenorrhoea?

A

Hypothalamic disorders: (hypothalamic hypogonadism)

  • Excessive exercise/weight loss/stress
  • Hypothalamic lesions
  • Head injury
  • Kallmann Syndrome (GnRH deficiency)
  • Systemic disorders leading to infiltration of hypothalamo-pituitary region (e.g. Sarcoid)
  • Drugs: progestogens, HRT, dopamine agonists

Pituitary disorders:

  • Adenoma (e.g. prolactinoma)
  • Pituitary necrosis (e.g. Sheehan’s)
  • Iatrogenic (Surgery, radiotherapy)
  • Congenital failure of pituitary development

Ovarian Causes:

  • PCOS (anovulation)
  • Premature ovarian failure

Endometrial disorders:

  • Abesent uterus
  • Outflow obstruction (imperforate hymen)
  • Asherman Syndrome (scarring of the endometrial lining)
22
Q

How would you investigate amenorrhoea/oligomenorrhoea?

A

Always put your Ix in perspective to the patient’s history!

Investigations to consider:

  • Pregnancy test (if of reproductive age)
  • LH (raised in PCOS)
  • Testosterone (raised in PCOS)
  • FSH (raised in primary ovarian failure)
  • Prolactin (prolactinoma)
  • TFT (both hyper- and hypothyroidism cause menstrual irregularities)
  • Exclude Cushing’s and congenital adrenal hyperplasia
  • USS (polycystic ovaries)
  • MRI (if history consistent with prolactinoma)
  • Hysteroscopy (is history suggestive of Asherman’s or obstruction)
  • Karyotyping (if Kallmann’s or Turner’s suspected)
23
Q

What are the physiological causes of amenorrhoea?

A

Physiological (non-pathological) causes of amenorrhoea include:

  • (Primary) constitutional delay - common and often familial.
  • (Secondary) pregnancy
  • (Secondary) lactation
  • (Secondary) menopause