Menstrual Disorders

Question 1

what happens in follicular phase?

Answer 1

FSH stimulates ovarian follicle development and granulosa cells to produce oestrogens
negative feedback from increasing oestrogen (and inhibin by dominant follicles) inhibits FSH production
decreasing FSH levels causes atresia of all follicles except dominant follicle

Question 2

what happens in ovulation?

Answer 2

occurs due to LH surge

dominant follicle ruptures and releases the oocyte

Question 3

what happens in luteal phase?

Answer 3

corpus luteum forms from left over follicle
corpus luteum produces progesterone
corpus luteum degrades (luteolysis) around 14 days after ovulation

Question 4

how do hormones change over menstrual cycle?

Answer 4

FSH is declining at day 1
LH is fairly constant
FSH and LH surge around day 12 as oestrogen levels pass threshold where it exerts positive feedback on FSH and LH production, then decrease again
oestrogen steadily rises from day 1 peaking around day 12, then decreases
progesterone peaks a few days after oestrogen

Question 5

endometrial events in menstrual cycle?

Answer 5

proliferative phase = oestrogen induced growth of endometrial glands and stroma
luteal phase = progesterone induced glandular secretory activity, decidualisation in late secretory phase, endometrial apoptosis and subsequent menstruation
menstruation = arteriolar constriction and shedding of functional endometrial layer, fibrinolysis inhibits scar tissue formation

Question 6

normal menstruation?

Answer 6

lasts 4-6 days
flow peaks day 1-2
<80ml per menstruation
no clots or flooding

Question 7

normal cycle length?

Answer 7

average = 28 days
between 21-35
should be no bleeding between menstruations and after intercourse

Question 8

how long must there be no menstruation to be called amenorrhoea?

Answer 8

> 6 months

Question 9

common causes of oligomenorrhoea?

Answer 9

PCOS

Question 10

organic vs non-organic menorrhagia?

Answer 10

organic = pathology present
non-organic = no pathology, can be hormonal, AKA DUB

Question 11

local organic causes of menorrhagia?

Answer 11

fibroids
adenomyosis
endocervical or endometrial polyp
cervical eversion
endometrial hyperplasia
intra-uterine contraceptive device
pelvic inflammatory disease
endometriosis
malignancy of cervix/uterus
hormone producing tumours
trauma
others (e.g AVM etc)

Question 12

features of endometriosis?

Answer 12

chocolate brown cysts on endometrium

Question 13

what systemic disorders can cause menorrhagia? (organic)

Answer 13

endocrine
- hyper/hypothyroid
- diabetes
- adrenal disease
- prolactin disorders
haemostasis disorders 
- von willebrand's
- ITP
- factor II, V, VII and XI deficiency
liver disorders
renal disorders
drugs (anticoagulants)

Question 14

pregnancy related causes of menorrhagia (organic)?

Answer 14

miscarriage
ectopic pregnancy
gestational trophoblastic disease
postpartum haemorrhage
common causes in very young/old

Question 15

how is DUB diagnosed?

Answer 15

diagnosis of exclusion

Question 16

subgroups of DUB?

Answer 16

anovulatory
- 85% of DUB
- occurs in very young/old
- irregular cycle (miss a period so twice as much to shed at next period)
- more common in obese women
ovulatory
- more common in women aged 35-45 (just before menopause)
- regular heavy periods
- due to inadequate progesterone production by corpus luteum

Question 17

how is DUB investigated?

Answer 17

FBC (haemoglobin most important)
cervical smear
TSH
coagulation screen
renal/liver function
transvaginal ultrasound if examination indicates pathology(TVU)
- endometrial thickness
- presence of fibroids and other pelvic masses
endometrial sampling
- pipelle biopsies
- hysteroscopic directed
- dilatation and curettage

Question 18

important test if endometrial carcinoma is suspected?

Answer 18

endometrial sampling to test thickness

hysteroscope

Question 19

when is a hysteroscope used?

Answer 19

if a pipelle biopsy has failed?

done under general anaesthetic

Question 20

how is DUB managed medically?

Answer 20

progestogens (synthetic progesterone analongue)
combined oral contraceptive
danazol (testosterone analogue, not used often)
GnRH analogues (downgrades anterior pituitary receptors to reduced FSH and LH production, rarely used)
NSAIDs
anti-fibrinolytics (transalamyic acid?)
capillary wall stabilisers
progesterone releasing IUCD (mirena IUS)

Question 21

when is hormonal treatment used?

Answer 21

irregular cycle

progesterone or combined pill

Question 22

surgical management of DUB?

Answer 22

endometrial ablation
- endometrium is burned away
- safer and simpler
hysterectomy
- can be sub-total or total
- can be done vaginally or laproscopically