Menstrual Dysfunction

Question 1

How long does a normal menstrual cycle typically last? What is the duration of menstrual loss? How much blood is lost per menstruation?

Answer 1

28 days +/- 7 days
4-6 days
<80ml per menstruation

Question 2

What are the 3 stages of the menstrual cycle?

Answer 2

Proliferative/follicular phase
Luteal phase
Menstrual phase

Question 3

Which layer of the uterus is shed during menstruation, causing bleeding?

Answer 3

Endometrium

Question 4

Define “menorrhagia”

Answer 4

Prolonged and increased menstrual flow

Question 5

Define “metrorrhagia”

Answer 5

Regular menstrual bleeding between menstrual periods

Question 6

Define “polymenorrhoea”

Answer 6

Menstrual bleeding occurring at <21 day interval of cycle

Question 7

Define “polymenorrhagia”

Answer 7

Increased bleeding and increased frequency of cycles

Question 8

Define “menometrorrhagia”

Answer 8

Prolonged menstrual cycle and bleeding between cycles

Question 9

Define “amenorrhoea”

Answer 9

Absence of menstrual cycle for more than 6 months

Question 10

What is the difference between organic and non-organic causes of menorrhagia?

Answer 10

Organic - pathology present

Non-organic - no obvious/observable pathology identified (dysfunctional uterine bleeding)

Question 11

List some local organic causes of menorrhagia

Answer 11

Fibroids 
Adenomyosis
Polyps
Cervical eversion
Hyperplasia, carcinoma
Pelvic inflammatory disease
Contraceptive devices
Endometriosis
Trauma e.g. intercourse
AV malformations

Question 12

What is adenomyosis?

Answer 12

Endometrium present in myometrium, causing irritant blood to pool and intense pain

Question 13

List some systemic organic causes of menorrhagia

Answer 13

ENDOCRINE: Hyper/hypothyroidism, DM, Adrenal disease, Prolactin disorders
HAEMOSTASIS: Von Willebrand’s disease, ITP, coag factor disorders
LIVER
RENAL
DRUGS: Anticoagulants

Question 14

Non-organic (dysfunctional) menstrual bleeding makes up 50% of cases. True/False?

Answer 14

True

Question 15

List the types of DUB. Which type of dysfunctional menstrual bleeding (DUB) is more common?

Answer 15

Anovulatory (85%)

Ovulatory

Question 16

What can be assessed on a transvaginal ultrasound scan?

Answer 16

Endometrial thickness

Presence of fibroids + pelvic masses

Question 17

How can endometrial sampling be done?

Answer 17

Pipelle biopsy
Hysteroscopy
Dilate and curettage

Question 18

How can dysfunctional menstrual bleeding be managed medically? What is first line

Answer 18

Progestogens
Combined OCP
Danazol
GnRH analogues
NSAIDs
Anti-fibrinolytics
Capillary stabilisers
Progesterone-releasing intra-uterine contraceptive
(MIRENA IUS COIL = FIRST LINE)

Question 19

What are the main surgical interventions for dysfunctional menstrual bleeding? Which is first line?

Answer 19

Endometrial resection/ablation (1ST LINE)

Hysterectomy

Question 20

At what endometrial thickness is biopsy indicated?

Answer 20

Greater than 4mm in postmenopausal

16mm in premenopausal

Question 21

Describe the follicular phase of the menstrual cycle

Answer 21

FSH stimulates ovarian follicle and granulosa cells to produce oestrogen from the dominant follicle
Rising oestrogen inhibits FSH production
Low FSH levels causes atresia of the dominant follicle

Question 22

Describe the proliferative phase of the menstrual cycle

Answer 22

Oestrogen-induced growth of endometrial glands and stroma

Question 23

Describe ovulation within the menstrual cycle

Answer 23

Prior LH surge

Dominant follicle ruptures and releases oocyte

Question 24

Describe the luteal phase of the menstrual cycle

Answer 24

Formation of the corpus luteum
Progesterone production
Luteolysis 14 days post-ovulation
Endometrial apoptosis leads to menstruation

Question 25

Describe menstruation during the menstrual cycle

Answer 25

Arteriolar constriction shedding functional endometrial layer Fibrinolysis inhibits scar tissue formation

Question 26

Define "oligoamenorrhea"

Answer 26

Menses at intervals of >35 days

Question 27

What is a fibroid?

Answer 27

Benign growths that develop in or around the womb (uterus)

Question 28

What is the main aetiology behind PID?

Answer 28

Chronic CHLAMYDIA infection of fallopian tubes

Question 29

What is endometriosis? How does it appear?

Answer 29

Ectopic endometrium found within the pelvis | Starts as a red lesion and turns black

Question 30

Cervical malignancy is most common in...

Answer 30

Young women

Question 31

Uteral malignancy is most common in...

Answer 31

Post-menopausal woman with bleeding

Question 32

What are the three main causes of painful menstrual bleeding?

Answer 32

Adenomyosis Pelvic inflammatory disease Endometriosis

Question 33

Name another organic cause of menorrhagia and give some examples

Answer 33

PREGNANCY | Miscarriage, ectopic pregnancy, gestational trophoblastic disease, postpartum haemorrhage

Question 34

Describe the common features of anovulatory DUB

Answer 34

Occurs at extremes of reproductive life Irregular cycle Typically obese women

Question 35

Describe the common features of ovulatory DUB. What is the pathogenesis behind it?

Answer 35

Women aged 35-45 years Regular heavy periods Due to inadequate progesterone production by corpus luteum

Question 36

List investigations used in DUB

Answer 36

``` FBC, coag screen, TSH, renal/liver function tests Cervical smear Transvaginal US scan Endometrial sampling ```

Question 37

What is the classical presentation of endometrioma?

Answer 37

Post menopausal woman (>40) with menorrhagia | Thick endometrium

Question 38

What is the first and second line line investigation for endometrioma respectively?

Answer 38

Pipelle biopsy | Transvaginal US scan

Question 39

What is the first line NSAID commonly used in menorrhagia?

Answer 39

Mefenamic acid

Question 40

What is NICE recommendation for the management of DUB?

Answer 40

2 non-surgical treatments first before surgery