Menstrual cycle & disorders Flashcards
When is the first day of the menstrual cycle
First day of menstruation
Explain the hypothalamic-pituitary-ovarian axis
- Hypothalamus secretes gonadotrophin releasing hormone (GnRH) to pituitary gland
- Pituitary Gland secretes luteinizing hormone and follicle stimulating hormone
- FSH binds to ovaries:
a. development of follicles
b. secretion of oestrogen
c. secretion of inhibin - LH binds to ovaries:
a. Production of oestrogen-ovulation and endometrial thickening
b. Graafian follicle into progesterone producing corpus luteum
c. Progesterone-endometrium receptive to implantation
Follicular phase
- FSH rises causing stimulation of few ovarian follicles
- Follicles compete for dominance
3a. 1st molecule to mature (Graafian molecule) produce large amount of oestrogen
3b. Inhibits growth of other competing follicles - Oestrogen causes endometrial thickening and thins cervical mucous
- Oestrogen initially inhibits LH production
- When ovum is mature oestrogen causes a spike of LH (day 12)
- LH makes graafian follicle thinner
- Within 24-48 hrs follicle releases secondary oocyte
- Secondary oocyte matures into ootid and then mature ovum
- Ovum released and taken up by fallopian tube via fimbriae
Luteal Phase
- After ovulation LH and FSH cause graafian follicle to form corpus luteum
- Corpus Luteum produces progesterone
- Progesterone cause:
a. endometrium receptive to implantation of blastocyst
b. production of oestrogen by adrenal glands
c. negative feedback causes decreased LH and FSH
d. increase in woman’s basal body temperature - As levels of FSH and LH corpus luteum degenerates
- No more progesterone
- If ovum fertilises it produces hCG (similar to LH)
- Prevents degeneration of corpus luteum
- Placenta takes over role of corpus luteum (week 8)
Define menarche
Date of first period
Define menopause
Healthy women over 45 years who have not had a period for at least 12 months and are not using hormonal contraception, or who do not have a uterus and have menopausal symptoms
Symptoms of menopause
Vasomotor symptoms: hot flushes, night sweats
Vulvovaginal atrophy
Dyspareunia
Sleep distrurbances
Diagnosing menopause
Primarily based on symptoms
Pregnancy test to exclude pregnancy
FSH test in women with menopause under 40-45
Do not use on those in perimenopause or on COC or high progestrogen
Managing menopause with mild vasomotor symptoms
Lifestyle changes:
Lose weight, good diet, avoid spicy food, no smoking. reduce alcohol and caffeine intake.
Managing menopause with uterus and severe vasomotor symptoms
Continuous combined regimen-if amenorrhea>12 months
If perimenopause:
1.Sequential regimen
2.oestrogens, conjugated/bazedoxifene: 0.45/20mg PO OD
3.SSRI/SNRI: Paroxetine 7.5mg PO OD or Escitalopram 10-20mg PO OD
4. Gabapentin 300mg PO OD, increase gradually by 300 max 2400
5. Clonidine transdermal (patch)
Managine menopause without uterus or hormonal IUD inserted and sever vasomotor symptoms
- Oestrogen. Commonly patch
- SSRI/SNRI
- Gabapentin
- Clonidine
Atrophic vaginitis risk factors
Post menopausal women
Women on anti-oestrogenic treatment (Tamofixen)
Women who have had chemo or radiotherapy
Women who are post partum/breastfeeding
Symptoms of atrophic vaginitis
Dysuria Haematuria Stress incontinence Urinary frequency Recurrent UTI
Genital Dryness Burning Itching Dyspareunia Post-coital bleeding Vaginal discharge
Treatment
Hormone Replacement Therapy
Non hormonal vaginal moisturiser and lubricant
Osteoporosis
Rapid loss of bone density
Who should have BMD test
Post menopausal women who:
suffer fracture suspicious of osteoporosis
are under 65 with one or more additional risk factors
age 65 and over
Hormones in HRT
oestrogen – types used include estradiol, estrone and estriol
progestogen – a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel
Two types of HRT
Combined HRT
Oestrogen only HRT
Benefit of combined HRT over oestrogen only
Reduced risk of endometrial cancer
Forms of HRT
Patches Tablets (most common) Creams IUD Vaginal ring (pessary) Gels (only oestrogen so have to take porgestrogen some other way) Vaginal oestrogen (helps with dryness not hot flushes) Injection
Cyclical HRT (recommended for women taking combined HRT who have menopausal symptoms but still have their periods)
Cyclical can be:
monthly HRT – you take oestrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle. Recommended for regular periods
three-monthly HRT – you take oestrogen every day, and take progestogen alongside it for around 14 days every three months. Recommended for irregular periods
Continuous combined HRT (recommended for women who are post-menopausal)
continuous HRT involves taking oestrogen and progestogen every day without a break.
Oestrogen-only HRT is also usually taken continuously.
Adverse effects of HRT
Headaches Upset stomach/bloating Diarrhoea Weight/appetite changes Change in libido Acne Peripheral swelling Breast tenderness/enlargement
Define dysfunctional uterine bleeding
diagnosis of exclusion and is defined as any abnormal uterine bleeding in the absence of pregnancy, genital tract pathology, or systemic disease.
Dysfunctional uterine bleeding signs and symptoms
Heavy/irregular/prolonged bleeding
May have dysmenorrhoea
Anemia
Ix for dysfunctional uterine bleeding
Pregnancy test (excl. pregnancy)
FBC (Hb + MCV) diagnose anaemia
STI screen
If >45 with risk factors for endometrial disease consider:
TVS USS-fibroids and polyps. Can measure endometrial thickness
Biopsy to exclude malignancy
Hysteroscopy and biopsy if no response to initial Tx
Tx for dysfunctional uterine bleeding (medical)
Mirena IUS
Tranexamic acid 1g TDS-antifibrinolytic day 1-4 period
Mefenamic acid 500mg TDS- NSAID day 1-5 period
COCP-regulates cycle
Oral progestagens
If irregular also consider:
Norethisterone 5mg TDS or medroxyprogesterone acetate 5-10mg TDS-regulates cycle day 5-26 of cycle
If none work in severe cases:
GnRH analogues-Induce amenorrhoea
Medroxyprogesterone acetate 10g TDS continuous- iduce amenorrhoea
Tx for dysfunctional uterine bleeding (surgical)
Endometrial ablation or hysterectomy
Complications include:
Haemorrhage, infection, bladder, uteric or bowel injury
Types of Uterovaginal prolapse
Cystocele: Prolapse of anterior vaginal wall involves bladder, often has prolapse of urethra (cysto-urethrocele)
Uterine (apical) prolapse- Prolapse of uterus, cervix and upper vagina. If uterus removed the vault or top of vagina can prolapse
Enterocele: Prolapse of upper posterior wall of vagina. Pouch usually contains small bowel loops
Rectocele:Prolapse of lower posterior wall of the vagina involving anterior wall of rectum.
Prolapse symptoms general
Often asymptomatic but can include: Dragging sensation/uncomfortable Feeling of lump coming down Dyspareunia or difficulty inserting tampon Backache
Prolapse symptoms cysto-urethrocele
Urinary urgecy + frequency
Incomplete bladder emptying
If urethra kinked: urine retention
Prolapse symptom rectocele
Constipation
Difficulty with defecation.
Prolapse Ix
USS: Exclude pelvic or abdominal mass
Urodynamics if there is incontinence ECG, CXR, FBC, U&E to asses fitness for surgey
Prolapse conservative management
Pelvic floor muscle exercises
Pessary
Prolapse surgical management
Anterior: colporrhapy or trasvaginal mesh repair
Apical: Vaginal hysterectomy, sacrospinous fixation
Posterior: P repair, Transvaginal mesh repair, perineal body repair
