Menstrual Cycle and Abnormalities Flashcards
What is normal menstruation
Process by which the endometrium is discarded each month , if pregnancy fails to occur
- sloughing of the endometrium over a period of days, bleeding and subsequent repair, so that the uterus is ready for receiving an embryo in the next cycle
What are the hormones involved in normal menstruation
GnRH
Gonadotropins - LH, FSH
Oestrogen and Progesterone
What happens to oestrogen and progesterone levels during the menstrual cycle
Oestrogen rises from day one, peaking just before ovulation (around day 12/13). After this it decreases until the end of the cycle (with a small second peak in mid-luteal phase)
Progesterone remains low until the corpus luteum is created (after ovulation), where it begins to rise. Peaks in mid-luteal phase, from which it decreases until the end of the cycle
What is menarche
The first onset of menstruation
- average age of 13
- investigate if onset before 8 years, or after 16 years
Definition of heavy menstrual bleeding.
Bleeding that is having an effect on the woman’s quality of life
- quantification of blood loss not used clinically
Most common cause of iron deficiency anaemia in women in the developed world
Causes of heavy menstrual bleeding
Uterine pathology - fibroids (a.k.a uterine leiomyoma) - endometrial polyps - pelvic infection - adenomyosis - endometrial carcinoma HMB in absence of pathology (previously called dysfunctional uterine bleeding) - anovulatory - ovulatory Medical disorders - clotting disorders (very rare)
How do uterine fibroids cause heavy menstrual bleeding
Due to decreased uterine contractility, increased endometrial surface area and dilated vessels overlying the fibroid
Not related to size or location
What investigations are required in ?heavy menstrual bleeding
History and examination (abdominal and bimanual) Blood tests - FBC ?anaemia and serum ferritin - coagulation disorders - female hormone testing - thyroid testing Biopsy - in women >45 years old with treatment failure OR - treatment was ineffective Ultrasound (TV or TA) - for endometrial thickness Cervical smear
Management of heavy menstrual bleeding
No treatment - for women who just want reassurance Pharmacological - hormonal or non-hormonal Surgical management Endometrial ablation
Describe the non-hormonal pharmacological management of heavy menstrual bleeding
Mefenamic acid - NSAID
- prostaglandin synthase inhibitor
Tranexamic acid
- antifibrinolytic
Describe the hormonal pharmacological management of heavy menstrual bleeding
Pseudo-pregnancy
- COCP (tricycle packs)
- progesterones (POP, depo-provera, mirena coil)
Pseudo-menopause
- GnRH analogues (continuous release causes LH and FSH ‘switch-off’ at the pituitary)
Progesterone receptor modulators (a.k.a esmya)
What are the benefits of GnRH analogues
Good in the short-term - combine with HRT add-on for longer term use Symptom relief Fibroid shrinkage Given by injection
What are the pros and cons of using the mirena coil
Pros
- useful for shrinking small fibroids (<5cm)
- progesterone and oestrogen release also provides contraception
Cons
- may come out during heavy menses
Describe the surgical management of heavy menstrual bleeding
Hysterectomy and resection
- can inspect the uterine cavity and sample endometrium
- allows resection of polyps
Myomectomy
- removal of uterine fibroids (fertility sparing)
- pre-op GnRH analogues or esmya required
Uterine artery embolism
- interrupts fibroid blood supply (decreases by roughly 50%)
- also fertility sparing
What are the pros and cons of hysterectomy for the management of heavy menstrual bleeding
Pros - amenorrhoea guaranteed - high satisfaction levels Cons - influenced by age and fertility
What is endometrial ablation
Ablation performed until the border with the myometrium
Pregnancy is contraindicated post-procedure
Tissue sampling mandatory post-procedure
Define amenorrhoea, primary and secondary
Amenorrhoea is absent menses
Primary
- failure to menstruate by 16 years
- with/without delayed development of secondary sexual characteristics
Secondary
- established menses stop for 6 months or more in the absence of menses
Define oligomenorrhea
A cycle of menses that is persistently 35 days or longer
What are the causes of primary amenorrhoea
Hypothalamic (causes decrease in GnRH release)
- physiological delay
- weight loss/anorexia/exercise
Ovarian
- polycystic ovaries (causes decreased oestrogen and progesterone release)
Vaginal
- imperforate hymen (HPO-axis intact)
What are the causes of secondary amenorrhoea
Physiological (normal ovarian failure or suppression) - pregnancy/lactation - menopause Hypothalamic (decrease in GnRH release) - weight loss/anorexia - heavy exercise - stress Ovarian - polycystic ovaries (decrease oestrogen and progesterone release) Uterine/vaginal - surgery (hysterectomy) - endometrial ablation - IUS
Investigations of primary amenorrhoea
History - family history, weight, exercise, sexual activity and stress Examination - secondary sexual characteristics (Tanner staging) Bloods - plasma FSH and LH - oestrodiol - prolactin Karyotype X-ray for bone age Cranial imaging Ultrasound
What is looked for on an ultrasound when investigating primary amenorrhoea
Uterus not present - karyotype
Uterus present
- normal anatomy = hormone profile
- outflow tract obstruction e.g. imperforate hymen or transverse vaginal septum
What is the most common cause of anovulatory ovarian subfertility
Polycystic ovarian syndrome
- 20% of women
What is Asherman syndrome, and how is it managed
Excessive curettage of endometrial cavity
Management
- hysteroscopy; allows breakdown of adhesions
- IUCD to ensure adhesions don’t reform
Define dysmenorrhoea
Cramping lower abdominal pain
- may radiate during menses
Define primary and secondary dysmenorrhoea
Primary
- idiopathic (onset within one year of menarche)
- usually associated with commencement of ovulatory cycles and higher prostaglandin level, causing contractions
Secondary
- due to pelvic pathology; onset years after menarche
- associated with endometriosis/adenomyosis
Investigations for ?dysmenorrhoea
Pelvic ultrasound
- transabdominal may be useful for reassurance if normal in primary
- transvaginal if pelvic mass suspected e.g. endometrioma
Laparoscopy
- if endometriosis or PID suspected
- if initial management fails
What is the management in dysmenorrhoea
Dependant on cause of pain, fertility wishes, patient choice and co-morbidities
Involves
- conservative/lifestyle
- medical non-hormonal (NSAIDs/analgesia)
- medical hormonal (same as heavy menopausal bleeding - suppression of endometrial activity)
- surgical
What is the surgical management for dysmenorrhoea
Diathermy or laser
Removal or endometrioma
Release of adhesions
Hysterectomy +/- oophorectomy
Define intermenstrual bleeding (IMB)
Bleeding (including brown discharge) between periods
Define post-coital bleeding (PCB)
Bleeding after intercourse
Define postmenopausal bleeding (PMB)
Bleeding occurring over 12 months after last menstrual bleeding
What are the causes of IMB, PCB or PMB
Originates from the cervix, vulva, uterus and vagina
- infection
- trauma
- polyp
- cervical ectropion
- neoplasm/cancer
- contraception
- pregnancy
Assessment and investigation of IMB, PCB and PMB
Cervical smear history - negative smear within last 3 years - don't take unless it is due, as the smear is only a screening test Speculum and bimanual examination - urgent colposcopy referral if suspicious of cancer STD screen and treat - refer to GUM if positive Urine pregnancy test
What are the referral pathways for IMB, PCB and PMB
Urgent gynaecology referral for women >35 years with persistent PCB or IMB (over 4 weeks)
Routine gynaecology referral for women <35 years with PCB or IMB for over 12 weeks
- a single heavy episode of PCB or IMB at any age
Reassurance
- women <35 with normal findings and results
- most resolve within 6 months
- if on hormonal contraception/mirena you should consider changing or stopping
