Menstrual Cycle/Menstrual Problems Flashcards
Endometrial effects in proliferative phase?
Endometrium thickens ↑ stromal cells, ↑ glands, blood vessels.
By ovulation endometrium 2-3mm thick.
Endometrial effects in secretory phase?
↑secretion, ↑lipids and glycogen, ↑blood supply
Endometrium 4-6mm thick
Optimal condiitons for implantation of fetilised egg
What happens to endometrium if no fertilisation?
Vasodilation (vasospasm) –> necrotic layers of endometrium separate from uterus –> uterine contractions –> menstruation
Cervical effects of menstrual cycle?
- Mucus production from columnar glands
- Stringy and runny midcycle (spinnbarkeit) –> facilitates sperm access at ovulation
- Tenacious and inelastic in luteal phase (moderated by progesterone)
Definition of abnormal menstrual bleeding (AUB)?
Any menstrual bleeding that is either:
o Abnormal in volume (excessive duration or heavy)
o Abnormal in regularity, timing (delayed or frequent)
o Non-menstrual (IMB, PCB, PMB)
Structural causes of AUB?
PALM
Polyps (endometrial/cervical)
Adenomyosis
Leimyoma
Malignancy/pre-malignancy
Non-structural causes of AUB?
COEIN
Coagulopathy Ovulatory dysfunction (PCOS, hypoT) Endometrial disorders (inflammatory - endometritis) Iatrogenic (COCP, IUS, warfarin) Not yet classified
Questions to ask to determine whether coagulation problems are present?
Heavy from menarche?
FH?
PPH?
Definition of heavy menstrual bleeding?
Excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material QoL.
History in menorrhagia?
• How heavy is the bleeding? o Clots (including size), flooding. o Frequency of pad change, type of pad o Waking at night to change protection o How is it affecting her daily life?
- Associated symptoms? – pain/pressure
- Anaemia symptoms?
- Smear history
- Gynae history contraception use
- Past obstetric history
- Medical (bleeding disorders), drug (warfarin), social, family histories.
Examination in menorrhagia?
• Anaemia common.
• Pelvic signs often absent
o Irregular enlargement of uterus suggests fibroids
o Tenderness with or without enlargement suggests adenomyosis
o Ovarian mass may be felt
• Tenderness and immoblile pelvic organs are common with infection/ endometriosis (not a cause but may co-exist)
Main investigation in menorrhagia? Bloods if history suggests?
FBC (Hb)
Coagulation (VW disease screen) and TFTs
Further investigations in menorrhagia if indicated?
TV USS Pelvis - indicated if enlarged uterus, mass, treatment failure - assess endometrial thickness, exclude fibroid/ovarian mass/polyps
Hysteroscopy - Allows inspection of uterine cavity – detection of polyps and submucous fibroids that could be resected.
Endomtrial biopsy - done at hysteroscopy with a Pipelle – to exclude endometrial malignancy or premalignancy.
Indications for endometrial biopsy in menorrhagia
o If endometrial thickness >10mm or polyp suspected
o If woman >40 years old with recent onset menorrhagia
o IMB
o Not responding to treatment
1st line medical treatment for menorrhagia?
Mirena coil – reduces menstrual flow by >90% with considerably fewer side effects.
2nd line medical treatments for menorrhagia?
- Antifibrinolytics (tranexamic acid) - Taken during menstruation only. Reduce blood loss by 50% - few side effects.
- NSAIDs (Mefanamic acid) - Inhibit prostaglandin synthesis –> reduce blood loss by 30%. Also useful for dysmenorrhoea. Similar side effects to aspirin.
- Combined Pill - Induces lighter menstruation – less effective if pelvic pathology present. Use limited - complications more common in older patients.
3rd line medical treatments for menorrhagia?
• Progestogens - Taken in high doses orally/IM –> amenorrhoea. Bleeding follows withdrawal. NOT CONTRACEPTIVE.
GnRH agonists - Produce amenorrhoea. Unless add-back HRT used, duration limited to 6 months. Bleeding follows withdrawal.
Surgical options for menorrhagia?
Endometrial ablation - destruction of endometrium –> amenorrhoea or lighter periods (not contraceptive)
Uterine artery embolisation - collateral circulation keeps uterus alive.
Hysterectomy - last resort - uterus normal in 50%
When is irregular menstruation/IMB more common?
At extremes of reproductive age
Two main causes of irregular bleeding/IMB?
Anovulatory cycles
Pelvic pathology
What are anovulatory cycles and why do they cause IMB?
No ovulation –> no progesterone - oestrogen cannot support growing endometrium –> bleeding = oestrogen breakthrough bleed
What pelvic pathology can cause irregular bleeding/IMB?
Fibroids, uterine/cervical polyps, adenomyosis, ovarian cysts, chronic pelvic infection
MALIGNANCY
Investigations in IMB/irregular bleeding?
FBC - assess effect of blood loss
Exclude malignancy
- smear if needed
- USS - >35 or not responding to treatment
- Biopsy - if thickened, polyp suspected, >40
1st line management of IMB/irregular bleeding?
IUS or COCP
2nd line managment of IMB/irregular bleeding?
Progestogens - give on a cyclical basis to mimic normal cyle
HRT - can regulate bleeding in perimenopause
Other treatments for menorrhagia can be used.
Causes of primary amenorrhoea?
Anorexia nervosa Physiological athleticism Hyperprolactinaemia Hypo/hyperthyroidism Adrenal tumours/hyperplasia PCOS Premature ovarian failure Imperforate hymen Transverse vagainal septum Turner's syndrome
Non-pathological causes of secondary amenorrhoea?
Pregnancy
Lactation
Menopause
Drugs
Pathological causes of secondary amenorrhoea?
Anorexia nervosa Physiological athleticism Hyperprolactinaemia Hypo/hyperthyroidism Adrenal tumours PCOS Premature ovarian failure Asherman's syndrome Cervical stenosis
What is post-coital bleeding?
ALWAYS ABNORMAL must exclude carcinoma
Causes of post-coital bleeding?
Situations where cervix not covered in healthy squamous epithelium --> more likely to bleed after mild trauma • Cervical carcinoma • Cervical ectropion • Cervical polyps • Cervicitis, vaginitis
Management of post-coital bleeding?
- Cervical examination – smear taken.
- If polyp evident –> avulsed and sent for histology
- If smear -ve –> ctropion can be frozen with cryotherapy
- Otherwise –> colposcopy to exclude malignant cause
What causes pre-menstrual syndrome?
Progesterone - occurs in luteal phase
Features of pre-menstrual syndrome?
Behavioural changes – ‘tension’, irritability, aggression, depression, loss of control.
Physical symptoms – bloatedness, minor GI upset, breast pain.
Medical management of premenstrual syndrome?
• SSRIs – continuous or intermittently in second half of cycle.
• Ablation of cycle
o Continuous oral contraception; oestrogen HRT patches.
o Trial of GnRH agonist and add-back oestrogen therapy –> perimenopause.
o Bilateral oophorectomy
Supplements to help premenstrual syndrome?
- Oil of evening primrose oil – good for breast tenderness
- Pyridoxine (vitamin B6) – good in mild doses, can cause neuropathy in excess.
- Vitex agnus-castus extract
Diagnostic criteria for PCOS?
(2/3 needed)
o PCO on USS
o Irregular periods (>35 days apart)
o Hirsutism (Clinical – acne or excess body hair, Biochemical – raised serum testosterone)
Aetiology of PCOS
Disordered LH production and peripheral insulin resistance –> increased insulin –> raised ovarian androgen production
Environmental factors (weight) can modify phenotype
Clinical features of PCOS?
• Obesity • Acne • Hirsutism • Oligomenorrhoea/ amenorrhoea • Subfertility/miscarriage Changes in weight over time will alter insulin levels and severity of syndrome.
Bloods in PCOS?
Anovulation - FSH (↑ in ovarian failure, ↓in hypothalamic disease, normal in PCOS)
Prolactin (to exclude prolactinoma)
TSH
Hirsutism - Serum testosterone levels (androgen-secreting tumour or congenital adrenal hyperplasia if very raised)
LH - Often raised in PCOS but not diagnostic
Complications of PCOS?
• Diabetes - 50% develop TIIDM; 30% develop gestational diabetes risk reduced by weight reduction
• Endometrial cancer -
More common after many years of amenorrhoea due to unopposed oestrogen action.
• Normal oestrogen levels so not at risk of osteoporosis.
Treatment for PCOS?
Weight Reduction - Will reduce insulin levels improvement in PCOS symptoms
COP - If fertility not required –> regulates menstruation and treats hirsutism. 3-4 bleeds per year necessary to protect endometrium
Antiandrogens -
Cyproterone acetate/spironolactone – effective for hirsutism, but conception must be avoided.
Metformin - Insulin sensitizer –> reduces insulin levels –> reduces androgens and hirsutism and promotes ovulation.
Eflonithine - Topical antiandrogen for facial hirsutism.
