menstrual cycle and abnormalities Flashcards
define menstruation
process of the endometrium being discharged each month if pregnancy fails to occur
basic physiology of menstruation
sloughing of the endometrium of pver a period of days
bleeding and subsequent repair so that the uterus is receptive to an implanting embryo in the next cycle
state the phases of the menstural cycle
follicular phase
luteal phase
define the follicular phase
from start of menstruation to moment of ovulation (first 14 days in 28 day cycle )
define the luteal phase
from moment of ovulation to start of mensturation (final 14 days of the cycle)
define the cells that develop into eggs
-what happens to them
oocytes
-surounded by granulosa cells foroming structures called follicles
define how a follicle changes during the menstural cycle
PRIMORDIAL FOLLICLES mature into primary and secondary follicles
-this is always occurring and happens independently of the menstrual cycle
once they reach the secondary follicle stage they develop FSH receptso
at the start of the menstural cycle FSH stimulates secondary follicles to grow and the granulosa cells surrounding them secrete oestrogen
one of the follicles will develop further than oterhrs and become the dominant follicle
how does oestrogen released from the granulosa cells impact the menstrual cycle
oestrogen negatively feedback on FSH and LH in the ant pit gland
also causes cervical mucus to become more permeable-> allows sper to penetrate the cervix at time of ovulation
how does LH affect the menstural cycle
LH spikes just before ovulation cuasing the dominant follicle to realse the ovum (unfertilitsed egg) from the ovary
-this happens 14 DAYS BEFORE THE END OF THE MENSTURAL CYCLE
Descibre the intial parts of teh luteal phase
follicle that released the ovum collapses and become shte corpus luteum
-this releases high levels of progesterone
-and a small amount od oestrogen
impact of progesterone at the start of the luteal phase
maintains the endometrial lingin
also causes cervical mucus to become thick and no longer permeable
what ahppens at fertilitsaiont
syncytiotrophoblasts of the embryo secrete hCG
hCG maintains the corpus leuteum
-whitou it the corpus leutuem degenerates
what happens if tehres no fertilisation
no production of hCG
corpus leutuem degenerates and stiops producing oestrogen and progesterone
-fall in both causes the endometruium to break down and mensturation occurs
-ve feedback from porgesterone and oestrogen stops and this allows FSH and LH to rise again and the cycle restat
what does the endometrium release when no fertilation occurs
stromal cells of the endometrium release rpostaglandins
prostaglainsn encourage the dnometrium to break down and the uterus to contract
mensturation starts on day 1 of the menstural cycle
which parts of the endometrium are involved in menstration
-what else happens
superficial and middle layers of the endometrium separate from the basal layer
-tissue is broken down inside the uterus and released via the cervix and vagina
-can last for 1-8 day s
define heavy menstrual bleeding
bleeding that has an adverse impact on woman QoL
-commonest causes of IDA in women in affluent world
average age of menarche in uk
13 yo
average age of menopause in uk
51
ranges from 45-55
on average how much blood do women loose during menstruation
40ml
what value of blood loss defines heavy menstural bleeding
-how is this quantified for diagnosis
over 80ml (although this is rarely measured)
-based on symptoms
-changing pads every 1-2hours
-bleeding lasting more than 7 days
-passing large clots
how can causes of heavy menstrual bleeding be classified 3
uterine pathology
HMB in absence of pathology (previously DUB (dysfunctional uterine bleeding))
medical disorders
uterine pathology that can cause heavy menstrual bleeding 5
-incidence of this type
fibroids
endometrial polyps
andeomyosis
pelvic infection
endometrial malignancy
-incidence- common
causes of heavy menstrual bleeding in abscence of pathology 2
-incidnce
anovulatory
ovulatory
-incidence - v common
medical disorder causes of heavy menstrual bleeding 1
-incidence 1
clotting disorders
-incidence - very rare
investigations for heavy menstrual bleeding 8
pelvic examination - with a speculum and bimanual
-assess for fibroids, ascites, cancer
FBC- look for IDA
outpatient hysteroscopy if fibroids, cancer or persistetn intermenstrual bleeding
pelvic an dtransvaginal ultrasound
Swabs
coagulation screen- if FHx
ferritin If clinically anaemic
TFTs if features of hypotrhydoisim
when would a biopsy be used in investigations for heavy menstrual bleeding 3
peristent menstural bleeding
women aged over 45
treatment failure or ineffective treatment
how does managemnt of heavy menstrual bleeding differ
if patient willing/accepts use of contraception
-* remember to exclude serious underlying patholgies
management of heavy menstrual bleeding if patient denies contraception 2
if patient does not want contraception
-transexamic acid - if no assoc pain
-mefenamic acid- if assoc pain
managemnt of heavy menstural bleeding if patient accepts contraception 3
if contraception wanted/accepted
-mirea coil- first line
-combined OCP
-cyclical oral progestogens
how doe progesterone receptor modulators work
agonist and antagonistic effects of progesterone
-bind to progesterone receptors
-little effect on ovarian function
act directly on endometrium
-induce amenorrhea
-shrink biroids by 20-40%
-well tolerated, oral medication
what is important regarding biospy of the endometrum
must indicate time in cycle and any hormonal preparations the patient is taking
-this may influence interpretation by pathologist
anotehr name for mirena coil
LNG-IUS
describe endometrial ablation
local or general anaesthetic
-ablation of enodmetirum to border with myometrium
-PREGNANCY CONTRAINDICATED POST PROCEDURE
-must ensure tissue sampling pre procedure
20-50% amenorrhea
70-80% satisfaction
assoicated morbiitidy and mortality of hysterectomy
mortatlity 1/1000-2000
major complication 3%
minor complciation 15-30%
*-level of satifaction high
amenorrhea guaranteed
define amenorrhoea
absent menses
describe the two types of amenorrhoea
primary - fialure to menstruate by age of 15
-may be associated w normal or delayed/absent development of secondary sexual characteristics
secondary
-established menses stop for ≥6mnths in absence of pregnancy
define oligomenorrhoea
cycle which is persistently greater than 35 days in length
how can medical hormonal management of heavy menstrual bleeding be split
pseudo-pregnancy
-pesudo-menopause
options for psuedo-regnacy medical hormonal management of heavy menstrual bleeding 3
COCP
progestogens
local - (coil)
what is the pseudo-menopause treatment for medical hormonal management of heavy menstrual bleeding called
GnRH analouges
how do GnRH analouges work for medical hormonal management of heavy menstrual bleeding
pusaltile release fo GnRH from hypothalamus
continous levels ‘switch off’ FSH and LH release form pituitary (FSH and LH become desensitized to GnRH)
useful for short term (6mnths-2yrs)
can shrink fibroids by up to 40%
imrpve haemoglobin
can be combined w HRT
administer by injection
describe the two types of hypogonadism
hypogonaodotropic hypogonadism -
-deficiency of LH and FSH
hypergonadotropic hypogonadism
-lack of response to LH and FSH by the gonads (testes and ovaries)
causes of hypogonadotropic hypogonadism
hypopituitarism
damage to hypothalamus or pituitary
significant chronic conditions eg CF or IBD
excesvie ecervise or dieting
consitituaila delay in growth and development
endocrine- hypothryoidm, cushings, hyperprolcatinaemia
kallman syndrome
cuases of hpyergonadotropic hypogonadism
previous damge to gonads
-torsion, cacner, infections (mumps)
congential absence of the ovaries
turners syndrome (XO)
what is kallmans syndrome assocaited with
hypogonadotrophic hypogonadism and a reduced or absent sense of smell
common causes of primary ammenrorhea 4
physiolgoical delay
weight loss/ anorexia/ heavy exercise
polycystic ovaries
imperforate hymen
compoents of history for primary amernorhea
FHx
weight
excersie
stresss/exams/ family
sexual activity
compoentnes of exmaination for primary amenorrhoea 2
secondary sexual cahractereitstcs
tanner staging
investgations for primary amenroreha 4
plasma FSH,LH oestradiol, prolactin, TFTs
karyotype
X-ray for bone age
cranial imaging
first line invesitgation in primary amernorrhea if patient has normal secondary sexual characteristics
-what is looked for
ultrasound scan
-if uterus is present
after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics
-if the uterus is present what happens next
check for outflow tract obstruction
-imperforate hymen
-transverse vaginal septum
if normal anatomy-> hormone profile
after an ultrasound scan of a patient with primary amenorrhea and normal secondary sexual characteristics
-if normal hymen and vaginal canal what happens next
karyotype
-XX-> MRKH Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that mainly affects the female reproductive system. This condition causes the vagina and uterus to be underdeveloped or absent, although external genitalia are normal. Affected individuals usually do not have menstrual periods due to the absence of a uterus
-XY- >androgen insensitivity
common causes of secondary amenorrrhoea 6
pregnacy
lactaion
menopause
weight loos/stress/anoerxia
PCOS
surgery -hysterectomy, endometrial ablation, IUD
criteria for PCOS diagnosis
Rotterdam Criteria for diagnosis
Requires 2 of the 3 features:
Clinical or biochemical evidence of hyperandrogenism (high Free androgen index)
Oligomenorrhoea/amenorrhoea
Ultrasound features of PCO
consequences of PCOS 6
Reduced fertility
Insulin resistance and diabetes
Hypertension
Endometrial cancer ‘unopposed oestrogen’
Ensure progesterone protection or withdrawal bleeding
Depression and mood swings
Snoring and daytime drowsiness
PCOS managemnt 5
Education
WEIGHT LOSS AND EXERCISE
Endometrial protection
Progesterone or withdrawal bleed
Fertility assistance
Lifetime awareness +/- screening for complications
define the tanner staging criteria for girls regarding pubic hair (works for males aswell)
Stage 1: No hair
Stage 2: Downy hair
Stage 3: Scant terminal hair
Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh
describe the tanner staging criteria for girls regarding breast development scale
Stage 1: No glandular breast tissue palpable
Stage 2: Breast bud palpable under the areola (1st pubertal sign in females)
Stage 3: Breast tissue palpable outside areola; no areolar development
Stage 4: Areola elevated above the contour of the breast, forming a “double scoop” appearance
Stage 5: Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion
define dysmenorrohea
excessive menstural pain
-usualy involves cramping lower abdo pain that may radiate to lower back and legs
assoc w GI symptoms or malaise
-affects 30-50%
split the causes of dysmeorrhoea
primary -idiiopathic
secondary - pelvic pathology
charactertistics for primary dysmenorrhoea
begins w onset of ovaulatory cycles
-usuallyw within first 2 years of menarche
pain most sever on day of or day prior to starting menstruation
cuase of primary dysmenorrhoea
prostaglandins are involved
PGF2å increases the contractility of the myometrium adn can lead to dysmenorrhoea
managment of primary dysmneorrhoea
pelvic exam may not be appropriate when dealing with an adolecsent
transandbominal US scna to reveal normal pevlic organs and provide reassurance
discussion and reassurance essential part of management
if dysmenorrhea unresponsive to standard treatment - consider possibility of underlying pathology
treatment for primary dysmenorrhea
prostaglandin synthesis inhibitors
-NSAIDs reduce uterine production of PGF2å
COC- suppression of ovulation is highly effective
depot progestogens
-injectable progesogen-only contraceptive suppresses ovulation
-
mirena coil
what is secondary dysmenorrheoa usually assocaited with 4
endometriosis
adenomyosisi
pelvic infection
fibroids
-can also be assoc w precesnce of IUD
managemnt of secondary dysmenorrhoea
swabs from genital tract to exclude active pevlic infection
if pelvic massess- US
laparoscopy for endometriosis
-treatement dependent on underlying pathology
define intrermenstual bleeeding
bleeding (incl brown discharge) in between periods
define post-coital bleeding
bleeding after intercousre
define post menopausal bleeding
bleeding occuring >12 months after last menstural period
some general casues of post-coital, post-menpausal and intermenstrual bleeding 7
infection
truama
polyps
cervical ectorpion
neoplasia/cancer
contraception
pregnancy
assessemnt and investigations for intermensturl and post coital bleeding 4
cervical smear history
-should have had negative smear ≤3yr
-DO NOT TAKE IF NOT DUE A SMEAR
speculum and bimanual examination
-urgent colposcopy if sus of cancer
STD screen + treat
Urine pregnancy test
describe the urgetn gynaecologcy referral pathway
women OVER 35 w persistent (over 4 weeks) post coital or intermensrual bleeding
describe the routine gynaecology referral pathway
women UNDER 35 w PCB or intermenstrual bleeding persistenitng over 12 weeks
or
- singel eheavy episode of postcoital or intermenstual bleeeding AT ANY AGE
describe reassurance given for intermenstual or post coital bleeding
in women uner 35 w normal findings and results
-most will resolve within 6 months
if on hormonal contraception or coil consider changing or stopping
for post menopausal bleedin what is the investigation of choice
-when should it be biopsed
transvaginal USS
-Biopsy if ET>3mm (non-HRT and CC-HRT users)
Biopsy if ET>5mm (Sequential HRT users)
Hysteroscopy/biopsy in Tamoxifen users
