Menstrual Disorder

Question 1

what happens to hormones in the follicular phase of the menstrual cycle

Answer 1

FSH stimulates ovarian follicle development and granulosa cells to produce oestrogens
raising oestrogen and inhibin secreted by dominant follicles inhibits FSH production
declining FSH then causes atresia of all but dominant follicle

Question 2

what happens during ovulation phase of menstrual cycle

Answer 2

triggered by prior surge

dominant follicle ruptures and releases oocyte

Question 3

what happens in the luteal phase of the menstrual cycle

Answer 3

the formation the corpus luteum
this produces progesterone
Progesterone-induced glandular secretory activity Decidualisation in late secretory phase
luteolysis occurs 14 days post ovulation
Endometrial apoptosis and subsequent menstruation

Question 4

when in menstrual cycle does menses occur

Answer 4

first 7 days of follicular phase

Question 5

when does the secretory phase occur

Answer 5

during the luteal phase (when egg is in uterus after ovulation)

Question 6

what phase does ovulation occur in

Answer 6

proliferative phase of endometrium

Question 7

withdrawal of what hormone causes withdrawal of blood supply to endometrium and endometrial shedding

Answer 7

progesterone

Question 8

what hormone induces the growth endometrial glands ans stroma

Answer 8

oestrogen

Question 9

what happens during menses

Answer 9

ateriolar constriction and shedding of functional endometrial layer
fibrinolysis inhibits scar tissue formation

Question 10

what does an organic cause mean

Answer 10

there is the presence of a pathology

Question 11

how many causes of menorrhagia are inorganic

Answer 11

50%

also known as DUB

Question 12

what are the local causes of organic menorrhagia

Answer 12

fibroids 
adenomyosis 
endocervical or endometrial polyp 
cervical eversion 
endometrial hyperplasia
IUCD
PID
endometriosis
malginancy of cervix/uterus
hormone producing tumours 
trauma 
AVMs

Question 13

can someone who is post menopausal have menorrhagia

Answer 13

no

Question 14

what causes pelvic inflammatory disease

Answer 14

most commonly infections of the fallopian tube

Question 15

what causes endometriosis

Answer 15

ectopic endometrium outside the uterus

will bleed every month as under hormonal control, this irritates the surrounding tissue causing pain

Question 16

what are the systemic causes of organic menorrhagia

Answer 16

endocrine disorders: hyper/hypothyroidism
diabetes mellitus
adrenal disease
prolactin disorders

disorders of haemostasis:
von willebrands disease
ITP (immune thrombocytopenic pupura)
factor II, V, VII, XI deficiency

liver disorders
renal disease
drugs - anticoagulants

Question 17

what can cause organic menorrhagia in pregnancy

Answer 17

miscarriage
ectopic pregnancy
gestational trophoblastic disease
postpartum haemorrhage

Question 18

what are the two types of dysfunctional uterine bleeding

Answer 18

anovulatory (85% of DUB, occurs at extremes of reproductive life, irregular cycle, more common in obese women) and ovulatory (women 35-45, regular heavy periods, due to inadequate progesterone production by coprus luteum)

Question 19

what causes DUB

Answer 19

no organic cause (pathology) by disrupted hormones affecting menstruation

Question 20

how do you investigate DUB

Answer 20

FBC (esp Hb)
cervical smear
TSH
coagulation screen
renal/ liver function tests
TVUS (endometrial thickness, presence of fibroids and other pelvic masses)
endometrial sampling: (pipelle biopsies- definitive test), hysteroscopic directed, dilatation and curettage

Question 21

what is the peak age of endometrial cancer

Answer 21

60 (the thicker your endometrium the more likely you are to have it)

Question 22

what do you need to exclude in anyone over 40 with DUB

Answer 22

endometrial carcinoma

Question 23

what type of scan to measure the width of endometrium

Answer 23

transvaginal US

Question 24

what are the non surgical managements for DUB

Answer 24

progestogens (synthetic progesterone analogues)
COCP
danazol (testosterone analogue, not used as virulisation)
GnRH analogues (risk of osteoporosis)
NSAIDs
anti-fibrinolytics (tranexamic acid- stop clots)
capillary wall stabilisers
progesterone releasing IUCD (mirena IUS)

for regular cycle with heavy periods= non normal treatments

for irregular cycles= hormonal treatments

Question 25

what are the surgical treatments for DUB

Answer 25

endometrial resection/ ablation: transcervical resection, rollerball ablation, bipolar mesh ablation, thermal balloon ablation, thermal hydroablation)

hysterectomy (remove the uterus): sub total (leave cervix behind), total abdominal hysterectomy, vaginal

these if drug treatments dont work

Question 26

what are the pros and cons of medical and surgical treatments of DUB

Answer 26

medical:
- cheaper
- no waiting list
- less risks
- SEs less non permanent
- fertility retained
- may not be affected

surgery:

• expensive
• waiting list
• risks
• very effective
• fertility lost

Question 27

what are the pros and cons of hysterectomy and endometrial ablation (hysteroscopy surgery)

Answer 27

ablation:

• daycase
• shorter op time and recovery
• less complications
• requires cervical smear
• combined HRT required

hysterectomy:
- major op
- longer surgery and recovery
- more complications
- no smears required (for total hysterectomy)
- oestrogen only HRT (unless cervix retained)