Menstrual disorders Flashcards
How long does menstrual phase of cycle last?
5 days
Menstrual phase in the ovaries?
Under the influence of FSH primary follicles develop into secondary follicles. This may take several cycles
Menstrual phase in the uterus?
A fall in oestrogen and progesterone stimulates release of prostaglandins causing uterine spiral arterioles to constrict.
The cells supplied by these arterioles die and the entire stratum functionalis of the endometrium sloughs off leaving the thin stratum basalis (2-5mm).
50-150ml of blood, tissue, mucus and epithelial cells shed from the endometrium passing through the cervix and vagina. Normal blood loss is 5-80ml.
What is the preovulatory phase?
Time between menstruation and ovulation
Varies in length and has main impact on length of cycle
Preovulatory cycle in ovaries?
Secondary follicles secrete oestrogen
One secondary follicle outgrows rest to become dominant and develops into Graafian follicle
Preovulatory cycle in the uterus?
Oestrogen released into circulation by growing secondary follicles and grafiaan follicle stimulates growth of endometrium
Cells of stratum basalis undergo mitosis and produce new stratum functionalis
Endometrial thickness doubles to 4-10mm
When does ovulatory phase occur?
Occurs on day 14 in a 28 day cycle (14 days before menstruation)
Ovulatory phase in ovaries?
Oestrogen stimulates more GnRH release
• This leads to an increase in LH and FSH release
• LH causes the rupture of the graafian follicle and expulsion of a secondary oocyte (approximately 9 hours after the LH surge).
• The oocyte is taken into the fallopian tube.
Ovulatory phase in uterus?
Progesterone and ostrogen continue to stimulate proliferation of the endometrium
“Normal” menstrual cycle?
• Lasts 24-38 days
• There should be no more than 9 days difference between the length of a woman’s shortest cycle and her longest cycle
• Bleeding should last 8 days or less each cycle
Physical symptoms during menstrual cycle?
•Breast tenderness
•Bloating
•Headache
• Skin disorder
•Weight gain
•Swelling
• Joint pain
•Fatigue
Psychological symptoms during menstrual cycle?
•Mood swings
•Anger
•Depression
•Tension
•Not in control
•Lack of interest
•Loneliness
•Hopelessness
•Suicidal ideation
Behavioural symptoms during menstrual cycle?
•Sleep disturbance
•Change in appetite
•Restlessness
•Poor concentration
•Confusion
•Social Withdrawal
How can menstrual cycle be diagnosed and checked?
Symptom diary
- Paper
- Online
- Apps
Hormone profiles are NOT helpful
First line management of ovulation suppression and example?
Yasmin and Eloine combined oral contraceptive pill
Example is drospirenone containing COC which can be used continuously.
Side effects of GnRH agonists for ovulation suppression?
Can cause vasomotor symptoms such as hot flushes and osteoporosis
Examples of GnRH agonists?
Most common is leuprolide acetate, nafarelin acetate and goserelin acetate
What can 3 month trial of GnRH treatment for ovulation suppression be useful for?
• Making a definitive diagnosis
• Confirming which symptoms are of ovarian endocrine origin
• Useful for short treatment for women approaching menopause
• Highlights which women may benefit from oophorectomy and hysterectomy
Heavy menstrual bleeding is no longer defined by specific blood loss. Regarded as blood loss that interferes with physical, social or material aspect of women’s life.
True/false?
True
Assessment for heavy menstrual bleeding?
• Exclude pregnancy
• History and examination
• FBC, cervical smear, swabs for infection, USS and if clinically indicated coagulation screen
• If no abnormality is identified (or fibroids 3cm causing no distortion of uterine cavity) commence medical management
First line management for heavy menstrual bleeding?
Mirena coil
T-shaped plastic frame that’s inserted into the uterus, where it releases a type of hormone.
Slowly releases hormone progesterone and prevents proliferation of endometrium
Second line management options for heavy menstrual bleeding?
Tranexamic acid - an antifibrinolytic agent. It works by blocking the breakdown of blood clots, which prevents bleeding.
Combined oral contraceptive (COC) - suppresses ovulation and endometrial proliferation reducing bleeding and regulating cycles.
Potential causes of heavy menstrual bleeding?
Fibroids
Polyps
Adenomyosis
Coagulopathy (blood clotting)
Malignancy
Fibroids are a common cause of heavy menstrual bleeding. True/false?
True
Account (20-30%)
They are benign smooth muscle tumours of the uterus and are extremely common
What are endometrial polyps?
overgrowths of endometrial glands that typically protrude into the uterine cavity. Benign in nature and can affect both reproductive age and post menopausal women
Account for around 5-10% of heavy menstrual bleeding cases
How are endometrial polyps diagnosed?
Speculum examination, USS or hysteroscopy
May be used endometrial or endocervical
Percentage of adenomyosis heavy menstrual bleeding cases?
Around 5%
What is adenomyosis and what is it associated with?
• Defined as the presence of non-neoplastic endometrial glands and stroma in the myometrium
• Associated with hyperplasia and hypertrophy of the surrounding myometrium
• Associated with a history of c/section, uterine curettage, surgical termination of pregnancy, increasing age, ostrogen exposure and tamoxifen use.
Most common coagulopathy in heavy menstrual bleeding?
Von willebrand disease - hereditary blood clotting disorder. Deficiency in quality or quantity of von-willebrand factor required for platelet adhesion
Other blood clotting causes associated with heavy menstrual bleeding?
• May be caused by medication
• May have history of PPH (postpartum haemorrhage), increased bleeding during surgery or increased bleeding during dental work
• Referral to haematology required
What is the mnemonic that can be used for remembering causes of heavy menstrual bleeding?
“PALM COIN”
Structural issues causing heavy menstrual bleeding?
PALM
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy
Can be seen in ultrasound scan and MRI
What causes of heavy menstrual bleeding can’t be seen on scans?
COIN
Coagulopathy
Ovulatory dysfunction i.e. PCOS
Iatrogenic
Not yet classified
