Menstrual Disorders (Menorrhagia) Flashcards
What occurs during the follicular ovarian phase?
FSH from anterior pituitary:
- stimulates follicle(s) development
- stimulates granulosa cells to produce oestrogens
- Negative feedback on FSH production by oestrogen
- Declining FSH levels cause atresia of ALL BUT dominant follicle
What hormone is involved in ovulation?
- LH surge 12 hours prior to ovulation
- Dominant follicle then ruptures and releases oocyte
What happens during the luteal ovarian phase?
- Formation of corpus luteum
- Progesterone production
- Luteolysis (breakdown of CL) 14 days post-ovulation
Aside from the shedding of the endometrial layer, what else occurs during the menstrual phase?
- Arteriolar constriction to allow shedding to take place
- Fibrinolysis inhibits scar tissue formation
What is considered to be a normal menstrual cycle and normal menstrual bleeding?
- Cycle lasts between 21-35 days (av. 28)
- Menstrual loss usually lasting 4-6 days
- Flows peaks day 1-2
- < 80 ml lost per menstruation
- No clots passed
- No bleeding between periods or after intercourse
If a patient is complaining of amenorrhoea (no period for >6 months) what must you check?
HCG to check they are not pregnant
What local organic pathology can cause menorrhagia?
- Fibroids (leiomyomas)
- Adenomyosis
- Polyp
- Some forms of IUD
- Pelvic inflammatory disease (PID)
- Endometriosis
- Cervical Eversion
- Malignancy
- Hormone producing tumours
- Trauma
What is an ovarian endometrioma?
- benign oestrogen-dependent endometrial tissue (cyst) on ovary
- most common form of endometriosis
- can cause infertility
- can cause menorrhagia
What systemic organic disorders can cause menorrhagia?
Endocrine:
- Hyper/ hypothyroidism
- Diabetes Mellitus
- Adrenal disease
Disorders of haemostasis
- Von Willebrand’s disease (low vW Factor causes bleeding)
- Idiopathic Thrombocytopenic Purpura (low platelets)
- Clotting Factor II, V, VII and XI deficiency
- Liver/Renal disorder
- Anticoagulant drugs
What organic disorders of pregnancy can cause menorrhagia?
Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Postpartum haemorrhage
DO A PREGNANCY TEST IN THESE PATIENTS
What are the 2 main causes of DUB?
Anovulatory:
- Occurs at extremes of reproductive life
- Irregular cycle
- More common in obese women
Ovulatory
- More common in women aged 35-45 years
- Regular heavy periods
- Due to inadequate progesterone production by corpus luteum
How is DUB investigated?
- Full blood count (Hb, serum ferritin)
- TSH levels
- Cervical smear
- Coagulation screen
- Renal/Liver function tests
- Transvaginal ultrasound scan
- Endometrial sampling
Heavy periods can cause a normal Hb but low iron stores in a patient. TRUE/FALSE?
TRUE
What is TVUS used to investigate?
- Endometrial thickness
- Presence of fibroids/other pelvic masses potentially palpated on abdominal exam
How can endometrial sampling be carried out?
Pipelle biopsies
Hysteroscopic directed
Dilatation and curettage (D + C)
What side effects can a pipelle biopsy cause during the procedure?
Patient may experience abdominal cramps
Endometrial thickness can also be measured using a trans-abdominal US. TRUE/FALSE?
FALSE - must be transvaginal
Why is hysteroscopy potentially unsuitable as an outpatient treatment?
- uncomfortable for patient
- time consuming
- messy as fluid needs to be used for visualisation
Hysteroscopies can be completed under general anaesthetic. TRUE/FALSE?
TRUE
What pharmacological treatments are currently used for Dysfunctional Uterine Bleeding?
- Progestogens - e.g. Norehisterone (synthetic progesterone => longer 1/2 life)
- Combined Oral Contraceptive Pill
- Progestogen releasing Mirena Coil (IUD)
- Antifibrinolytics - e.g. Tranexamic acid
- NSAIDs - e.g. Mefenamic Acid
- GnRH analogue - e.g. Zoladex - down regulates receptors in anterior pituitary
What other treatments have previously been used for DUB, but are not widely used now?
- Danazol (testosterone analogue)
- Capillary wall stabilisers
What drug treatments would be used in DUB if patients have regular period cycles?
Non-hormonal
e.g. antifibrinolytics
If patients had an irregular period cycle, what drug treatments should be used as first line in DUB?
Hormonal
=> Progestogens OR the Combined Oral Contraceptive Pill
Why do many perimenopausal patients not use hormonal treatments for DUB?
- Averse to taking contraception
- GP reluctant to prescribe them due to increased clotting risk (DVT/PE)
If drug treatment is unsuccessful in DUB, what other form of treatment can be used?
Surgery
- endometrial resection/ ablation
- hysterectomy
What happens during endometrial resection or ablation?
- Endometrium is burnt away to prevent growth and bleeding
- 10-15% failure rate means bleeding can sometimes remain unchanged
How can a hysterectomy be carried out?
Removal of uterus via vagina OR abdomen
- can be done laparoscopically
What is a Subtotal hysterectomy?
Cervix is left behind
if it is removed there is a high rate of vaginal prolapse
Why can spotting occur after a subtotal hysterectomy?
Some endometrium still attached to top of cervix will bleed slightly
Can patients get pregnant after either endometrial ablation OR a hysterectomy?
- NO but patients with ablation can conceive but embryo implants into myometrium instead as endometrium is no longer there
