Menstrual Disorders Flashcards
What is the role of LH in females? What cell type does it act on?
Promote production of oestrogen from the ovaries by acting on theca cells
What is the role of FSH in females? What cell type does it act on?
Promote the growth of ovarian follicles by acting on granulosa cells
Within each ovarian cycle, what happens to a developing follicle?
It matures, releases an oocyte and differentiates into the corpus luteum
In the follicular phase of the menstrual cycle, what hormone stimulates follicular development and granulosa cells to produce oestrogen?
FSH
In the follicular phase of the menstrual cycle, raising levels of which hormones by the dominant follicle inhibits FSH production?
Oestrogen and inhibin
At the end of the follicular phase of the menstrual cycle, the declining levels of FSH have what effect?
Atresia of all follicles except the dominant one
The rising levels of oestrogen peak between days 12 and 14 which triggers a surge of which hormone?
LH
What happens to the dominant follicle in response to the LH surge at ovulation?
It ruptures and releases an oocyte
What happens to the dominant follicle in the luteal phase of the menstrual cycle?
It becomes the corpus luteum
In the luteal phase of the menstrual cycle, granulosa cells in the corpus luteum produce what hormone?
Progesterone
What is the role of progesterone in the luteal phase of the menstrual cycle?
Inhibit the release of FSH to prevent further follicle development
If pregnancy does not occur, what happens to the corpus luteum and levels of oestrogen and progesterone?
The corpus luteum degenerates and oestrogen and progesterone levels drop
What effect does progesterone have on the uterine endometrium?
Matures the endometrium
What effect does oestrogen have on the uterine endometrium?
Stimulates endometrial growth
What endometrial stage corresponds to each of the following ovarian cycle stages a) follicular? b) ovulation? c) luteal?
a) Menstrual phase b) proliferative phase c) secretory phase
What days of the menstrual cycle correspond to a) the menstrual phase? b) the proliferative phase? c) the secretory phase?
a) Days 1-5 b) days 5-14 c) days 15-28
What hormone is responsible for the proliferative phase of the endometrial cycle? What happens?
Oestrogen - growth of endometrial glands and stroma
What happens to the cervical mucus during the proliferative phase of the endometrial cycle?
It becomes thin and sticky, making it more penetrable to sperm
What hormone is responsible for the secretory phase of the endometrial cycle? What happens?
Progesterone - there is glandular secretory activity and decidualisation in the later stages
The decrease in both oestrogen and progesterone at the end of the preceding cycle has what effect on the endometrium?
Cells in the functional endometrium die and this is shed (menstruation)
What is a normal amount of blood to lose during menstruation?
< 80mls
Are clots and flooding normal during menstruation?
No
What range is considered a normal length of menstrual cycle?
21-35 days
During the menstrual cycle, when would it be abnormal to have vaginal bleeding?
Inter-menstrually (i.e. between periods) or post-coital
What is the difference between amenorrhoea and oligomenorrhoea?
Amenorrhoea is when there has been an absence of menstruation for > 6 months, oligomenorrhoea is when there is menses at intervals of > 35 days
What are some physiological causes for amenorrhoea?
Pregnancy, lactation, menopause, hysterectomy
What is menorrhagia?
Prolonged and increased menstrual flow with a normal cycle
What is metrorrhagia?
Regular inter-menstrual bleeding
What is polymenorrhoea?
Menses occurring at < 21 day intervals
What is polymenorrhagia?
Increased bleeding and a more frequent than average cycle
What is menometrorrhagia?
Prolonged menses and inter-menstrual bleeding
Menorrhagia can be divided into having organic and non-organic causes. What is non-organic and what is this often known as?
Heavy menstrual bleeding with absence of pathology, also known as dysfunctional uterine bleeding
Non-organic causes of menorrhagia can only be diagnosed by what?
Excluding organic causes
What are some systemic disorders that could present with menorrhagia?
Endocrine conditions, disorders of haemostasis, liver disorders, renal disease, drugs (anti-coagulants)
What is the 1st priority in all women of reproductive age who present with abnormal vaginal bleeding?
Ruling out pregnancy related causes
What are some pregnancy related causes of menorrhagia?
Miscarriage, ectopic pregnancy, gestational trophoblastic disease, postpartum haemorhage
What are some differentials of menorrhagia associated with pain?
Endometriosis, PID, adenomyosis
Abnormal vaginal bleeding with a history of other bleeding abnormalities suggests what?
Coagulation disorder
How could you tell if abnormal vaginal bleeding was due to fibroids?
They are palpable on pelvic and vaginal exam
What examinations are used to exclude more sinister causes of abnormal vaginal bleeding?
Speculum and pelvic exam
What is the difference in the demographic of women who tend to get cervical vs uterine cancer?
Cervical tends to present in younger women while uterine is more commonly postmenopausal
For about 50% of women who present with abnormal uterine bleeding, what is the cause?
Dysfunctional uterine bleeding
What are the two subtypes of dysfunctional uterine bleeding?
Anovulatory and ovulatory
What is anovulatory dysfunctional uterine bleeding?
There is an irregular cycle, and because there isn’t ovulation every month, periods may be delayed and cause excessive bleeding
Who does anovulatory dysfunctional uterine bleeding usually occur in?
Usually at extremes of reproductive life, more common in obese women
What is ovulatory dysfunctional uterine bleeding?
Regular heavy periods due to inadequate progesterone production by the corpus luteum
Who does ovulatory dysfunctional uterine bleeding usually occur in?
Those aged 35-45
How do you get an idea of how much blood is passed in a period?
Ask about sanitary products, having to change once an hour is abnormal, also clots and flooding suggests heavy menstrual bleeding
What is the most important blood test to do in someone presenting with dysfunctional uterine bleeding? Why?
FBC to exclude anaemia
What are some blood tests which may or may not be done for a presentation of abnormal uterine bleeding depending on clinical suspicion?
TSH, coagulation screen, renal and liver function tests
As well as FBC, what is a first line investigation for abnormal uterine bleeding if not up to date?
Cervical smear
If a pelvic examination for abnormal uterine bleeding is abnormal, what is the next indicated investigation?
Transvaginal ultrasound
What is a transvaginal ultrasound good for detecting?
Endometrial thickness, fibroids and other pelvic masses
If an US scan for abnormal uterine bleeding is not conclusive, what are some other imaging tests which could be done?
Hysteroscopy or MRI
When would endometrial sampling be done for someone with abnormal uterine bleeding? Why?
In those > 40 with persistent inter-menstrual bleeding to exclude an endometrial carcinoma
What is the first line treatment for dysfunctional uterine bleeding?
Progestogen releasing IUCD - Mirena coil
What are the advantages to using the Mirena coil as treatment for dysfunctional uterine bleeding?
Lasts for 5 years so no compliance issues, distributed locally so few systemic side effects
What are some medical treatments that can be used for dysfunctional uterine bleeding?
Progestogens, COCP, tranexamic acid (anti-fibrinolytic)
For who is the COCP a good treatment for dysfunctional uterine bleeding?
Young nulliparus women who also want contraception
What is progestogen? How should it be taken?
A synthetic progesterone which has a longer half-life so requires less frequent dosing. It should be taken 5 days into the period and continued until day 21 of the cycle, with bleeding occurring after this to regulate periods
Patients who you are giving the COCP to must not have what two things?
Any predisposing factors to thrombotic disease and no renal disease
What are the surgical management options for dysfunctional uterine bleeding?
Endometrial ablation or resection or hysterectomy
When should surgical managements for dysfunctional uterine bleeding be used?
When medical management has failed
How does endometrial ablation/resection work?
The endometrium which bleeds excessively can be destroyed or removed by ablation or resection respectively. This damaged tissue is then replaced with fibrous tissue during healing.
Who is surgical management of dysfunctional uterine bleeding suitable for?
Women who do not want children or have completed their families
What is the advantage of vaginal hysterectomy?
Shorter recovery time than abdominal surgery
What is the main advantage of medical treatment of dysfunctional uterine bleeding over surgical?
Fertility is retained
