menstrual disorders Flashcards
GnRH is secreted by the hypothalamus and stimulates the release of what two hormones from the ant pituitary
- FSH
- LH
FSH initiates what growth?
- follicular growth
LH stimulates what?
- further development of follicles
FSH and LH stimulate ovarian follicles to secrete what?
- oestrogen
progesterone is secreted mainly by what?
- corpus luteum
progesterone and oestrogen work together to do what?
- maintain endometrium ready for implantation
what hormone allows primary follicles to develop into secondary follicles?
- FSH
a fall in what hormones stimulates the release of prostaglandins causing uterine spiral arterioles to constrict?
oestrogen and progesterone
what part of the endometrium sloughs off after the cells supplying the spiral arterioles die off?
- stratum functionalis
-> leaving thin stratum basalis (2-5mm)
what is the normal amount of blood loss from the vagina?
5-80ml
what phase of the menstrual cycle varies in time?
- preovulatory phase
which type of follicles secrete oestrogen?
- secondary follicles
- one secondary follicle outgrows the rest to become dominant and develops into the graafian follicle
what happens in the uterus in response to oestrogens being released into the circulation?
- oestrogen released by the secondary follicles and graafian follicle stimulates the growth of the endometrium
what part of the endometrium undergoes mitosis during the preovulatory phase?
- stratum basalis and produces a new stratum functionalis
- endometrial thickness doubles to 4-10mm
what day does ovulatory phase occur?
- day 14 (14 days before menstruation)
what occurs in the ovaries during the ovulatory phase?
- oestrogen stimulates more GnRH release
- leading to an increase in LH and FSH
- LH causes the rupture of the graafian follicle and expulsion of a secondary oocyte (approx 9 hrs after the LH surge)
- the oocyte is taken into the fallopian tube
what occurs in the uterus during the ovulatory phase?
- progesterone and oestrogen continue to stimulate proliferation of the endometrium
what occurs in the ovaries during the preovulatory phase?
- secondary follicles secrete oestrogen
- one secondary follicle outgrows the rest to become the dominant and develops into the graafian follicle
what occurs in the uterus during the preovulatory phase?
- oestrogens released into the circulation by the growing secondary follicles and graafian follicle stimulate growth of the endometrium
- cells of stratum basalis undergo mitosis and produce new stratum functionalis
- endometrial thickness doubles - 4-10mm
how long does postovulatory phase occur for?
- routinely lasts for 14 days w little variation
what occurs in the ovary during the postovulatory phase?
- the collapsed follicle becomes the corpus luteum under the influence of LH
- the corpus luteum secretes progesterone, oestrogen, relaxin, and inhibin
- if fertilisation does not occur, this secretory activity declines after 2 weeks and a new cycle begins
what occurs in the uterus in the postovulatory phase?
- progesterone and oestrogen promote growth and coiling of the endometrial glands, vasculisation and further thickening of the endometrium - 12-18mm
- endometrial glands begin to secrete glycogen
how long does a normal cycle last for and how long should bleeding occur for?
- 24-38 days
- bleeding should last 8 days or less each cycle
how many women are affected by pre-menstrual disorders?
- 5% of women
- seen as a disorder when premenstrual symptoms impact on daily living
name 3 physical symptoms in PMD?
- breast tenderness
- bloating
- headache
name 3 psychological symptoms in PMD?
- mood swings
- anger
- depression
name 3 behavioural symptoms in PMD?
- sleep disturbance
- change in appetite
- restlessness/poor concentration
what helps make a diagnosis of PMD?
- keeping a symptom diary - paper, online, apps
- needs to occur for a minimum of 2 cycles
what kind of management is used for PMD?
- ovulation suppression through a variety of different medications
what is the 1st line tx for PMD?
- Yasmin and Eloine COC (combined oral contraception pill)
-> can be used continuously
-> those containing drospirenone COC have proven impact
name some other treatments for PMD?
- GnRH agonists
- danazol
- oestrogen
- bilateral oophorectomy and hysterectomy w add back oestrogen only
side effect of GnRH agonists
- menopausal symptoms i.e. hot flushes and osteoporosis
- trial of tx 3-6 months
what is GnRH indicated for?
- PMD and approaching menopause
- severe endometriosis in younger women to see if they would benefit from an oophorectomy or hysterectomy (i.e. if symptoms improve opt for surgery)
side effects of Danazol?
- teratogenic effect so must be used alongside contraceptive
side effect of oestrogen
- unopposed oestrogen increases chances of endometrial hyperplasia or cancer
- counteracted by giving progesterone but can bring on PMD symptoms again…
other pharmacological and lifestyle mx for ovulation suppression?
SSRIs
- used continuously or during luteal phase only
Diuretics
- reduce bloating
Herbal supplements
CBT
Exercise
vit B6 and calcium
what is heavy menstrual bleeding?
- blood loss is perceived by the patient as interfering w physical, social, emotional or material aspect of a woman’s life.
assessment for heavy menstrual bleeding?
- exclude pregnancy
- history and examination
- bloods (anaemic), cervical smear, swab for infection, USS and if clinically indicated coag screen
- if no abnormality or fibroids <3cm causing no distortion of uterine cavity start medical mx
1st line mx for heavy menstrual bleeding
mirena coil
- slowly releases localised progesterone and prevents proliferation of endometrium
2nd line heavy menstrual bleeding?
- tranexamic acid
anti-fibrolytic
or
- COC
suppresses ovulation and endometrial proliferation, regulates cycle
3rd line for heavy menstrual bleeding?
norethisterone
- prevents proliferation of the endometrium
DMPA
- long acting progesterone, suppresses ovulation and prevents proliferation of the endometrium
4th line for heavy menstrual bleeding?
- surgical management/referral to secondary care
main cause of menstrual bleeding?
- fibroids (20-30%)
benign SM tumours of uterus, v common, harmless unless they have a pressure affect
other causes of menstrual bleeding?
- polyps 5-10%
may be diagnosed on spec exam, USS or hysteroscopy
may be endometrial or endocervical - adenomyosis 5%
presence of non-neoplastic endometrial glands and stroma in myometrium instead of endometrium
what is adenomyosis?
presence of non-neoplastic endometrial glands and stroma in myometrium
assoc w hyperplasia and hypertrophy of surorunding myometrium
risk factors for adenomyosis?
- associated with a history of c/section, uterine curettage, surgical termination of pregnancy, inc age, oestrogen exposure and tamoxifen use (blocks action of oestrogen - given as a prevention in breast cancer)
most common coagulative pathology causing heavy menstrual bleeding?
- von willebrand disease
von willebrand typical presentation?
- younger patient presenting not long after menarche - w heavy menstrual bleeding
how else is coagulopathy caused?
- medication
- PPH, inc bleeding during surgery or inc bleeding during dental work
- referral to haem required
red flag concern for heavy menstrual bleeding?
- malignancy
surgical mx for polyp?
- hysteroscopy then polypectomy
surgical mx for minimising monthly blood flow or stopping it?
- endometrial ablation
- less effective in younger patients and it is not contraceptive
surgical mx for fibroids?
- uterine artery embolization
cut off blood supply and thus shrink fibroid
can be a painful procedure
or
- myomectomy - fibroids removed surgically from uterus and preserving the uterus (for fertility reasons)
indications for hysterectomy?
- older patient
- had a family, do not wish to have any more children
