Menstruation

Question 1

What does the menstrual cycle involve?

Answer 1

The interaction of many endocrine glands, as well as a responsive uterus

Question 2

What interacts in the menstrual cycle?

Answer 2

• The central nervous system; the hypothalamus and pituitary
• The ovaries

Question 3

What does the interaction between the CNS and the ovaries result in?

Answer 3

Cyclic and ordered sloughing of the uterine endometrial lining

Question 4

What are the key hormones in the control of the menstrual cycle?

Answer 4

• Gonadotrophin releasing hormone (GnRH)
• Follicle stimulating hormone (FSH)
• Luteinising hormone (LH)
• Estradiol
• Progesterone

Question 5

What are the stages of the menstrual cycle?

Answer 5

• Proliferative stage
• Ovulation
• Secretory phase

Question 6

When does the proliferative stage of the menstrual cycle begin?

Answer 6

At the onset of menses

Question 7

When does the proliferative phase end?

Answer 7

When ovulation takes place

Question 8

What takes place during the proliferative phase of the menstrual cycle?

Answer 8

Folliculogenesis

Question 9

What happens in folliculogenesis?

Answer 9

A dominant follicle is selected from a pool of growing follicles that will be destined to ovulate

Question 10

What does the growth of follicules during the proliferative stage depend on?

Answer 10

Pituitary hormones

Question 11

What does the growth of a follicle during the follicular phase lead to?

Answer 11

Production of estradiol from the layers of the granulosa cells surrounding it

Question 12

What is estradiol responsible for in the proliferative phase?

Answer 12

The proliferation of the endometrial lining of the uterus

Question 13

When does ovulation occur?

Answer 13

At the peak of follicular growth

Question 14

What does ovulation occur in response to?

Answer 14

LH surge

Question 15

What size to follicles grow to prior to ovulation?

Answer 15

Sizes greater than 20mm in average diameter

Question 16

By what mechanism is LH released following follicular growth?

Answer 16

In a positive feedback mechanism from the anterior pituitary, due to prolonged exposure to estradiol

Question 17

What levels of estradiol are required for positive feedback to take place?

Answer 17

Above 200pg/mL for approximately 50 hours

Question 18

What is required for the oocyte to be released from the follicle in ovulation?

Answer 18

Several proteolytic enzymes and prostaglandins are activated, leading to digestion of the follicle wall collagen

Question 19

What happens once an oocyte has been released in ovulation?

Answer 19

The fallopian tube is responsible for picking it up to await fertilisation

Question 20

What happens during the secretory phase?

Answer 20

The remaining granulosa cells that are not released within the oocyte during the ovulation process enlarge and acquire lutein

Question 21

What colour is lutein?

Answer 21

Yellow

Question 22

What are the granulosa cells that have acquired lutein called?

Answer 22

Corpus luteum

Question 23

What does the corpus luteum do?

Answer 23

Predominantly secretes progesterone

Question 24

When is peak progesterone production noted?

Answer 24

1 week after ovulation takes place

Question 25

What does the life span of the corpus luteum, *and hence progesterone production,* depend on?

Answer 25

Continued LH support from the anterior pituitary

Question 26

What happen to the corpus luteum if pregnancy takes place?

Answer 26

hCG (human chorionic gonadotrophin) will maintain the corpus luteum

Question 27

What happens to the corpus luteum if pregnancy fails to happen?

Answer 27

Luteolysis takes place, and the corpus luteum is converted to a white scar, the corpus albicans

Question 28

Draw a diagram illustrating the blood supply of the endometrium

Answer 28

Question 29

What happens to the radial arteries as menses occur?

Answer 29

They shrink and compress, so blood supply to the innermost layer of the womb is affected

Question 30

What happens to the innermost layer of the womb after the radial arteries have been compressed?

Answer 30

It dies and gets sloughed off

Question 31

How long does mensturation last?

Answer 31

24-32 days, *but variable*

Question 32

When is regularity of menstruation best?

Answer 32

Between 20 and 40 years

Question 33

How does the length of the menstrual cycle change depending on age?

Answer 33

* Longer in menarche * Shorter in pre-menopause

Question 34

What is the median blood loss per menstrual cycle?

Answer 34

37-43ml

Question 35

When does most of the blood loss during menses occur?

Answer 35

In the first 48 hours

Question 36

What % of women loose \>80ml per cycle?

Answer 36

9-14%

Question 37

What % of those who loose \>80ml/cycle are anaemic due to significant blood loss?

Answer 37

60-70%

Question 38

What is menorrhagia?

Answer 38

Heavy periods

Question 39

What are the causes of menorrhagia?

Answer 39

* Abnormal clotting * Fibroids * IUCD * Cancer

Question 40

What are fibroids?

Answer 40

Benign growths found in the uterine cavity

Question 41

What are fibroids often present with?

Answer 41

Heavy periods

Question 42

What can very large fibroids present as?

Answer 42

Pregnancy/tumour

Question 43

In what locations are fibroids found?

Answer 43

* Intracavity * Subserosal * Submucosal * Intramural * Pedunculated (on a stalk)

Question 44

What kind of cancer can cause heavy periods?

Answer 44

Endometrial cancer

Question 45

What is the problem with endometrial cancer?

Answer 45

Low detection rate

Question 46

Why does endometrial cancer have a low detection rate?

Answer 46

* A lot of male doctors are reluctant to ask questions, or to follow up * Political correctness * Problems obtaining chaperones

Question 47

How can endometrial cancer be detected?

Answer 47

* Ultrasound scan * Hysteroscopy * Pelvic MRI

Question 48

What % of cases of heavy periods are caused by dysfunctional uterine bleeding?

Answer 48

60%

Question 49

What is dysfunctional uterine bleeding?

Answer 49

No recognisable pelvic pathology, pregnancy, or general bleeding disorders. *No cause has been found to account for heavy periods*

Question 50

What may a person opt for in the case of dysfunctional uterine bleeding?

Answer 50

Hysterectomy

Question 51

What can cause irregular bleeding?

Answer 51

Hormone contraceptives

Question 52

When is bleeding between periods common with hormone contraceptives?

Answer 52

During the first three months

Question 53

What hormonal contraceptives can lead to irregular bleeding?

Answer 53

* Combined oral contraceptive pill * Progesterone only pill Contraceptive patch (transdermal patch) * Contraceptive implant or injection * Intrauterine system (IUS)

Question 54

When are menstrual problems with hormone contraceptives possible?

Answer 54

* Missed combined pills/progesterone only pills * If certain prescription medicines or St John's Wort are taken when using the pill, patch, ring, or implant * When have vomiting/diarrhoea whilst on COCP

Question 55

Why does missed combined pills/progesterone-only pills cause menstrual problems?

Answer 55

Disrupts control of periods

Question 56

Why can vomiting/diarrhoea cause menstrual problems when taking the pill?

Answer 56

Causes a dip in hormone levels in the blood

Question 57

How can heavy periods be treated?

Answer 57

Endometrial ablation of the endometrium

Question 58

What happens in endometrial ablation of the endometrium?

Answer 58

Use a Nd-YAG laser to burn the lining of the endometrium to reduce the thickness of the layer

Question 59

How effective is endometrial ablation of the endometrium?

Answer 59

Relatively good success rate. Sometimes works, sometimes needs repeating

Question 60

What is amenorrhea?

Answer 60

No period

Question 61

What are the causes of amenorrhea?

Answer 61

* Pre-pubertal * Pregnancy * Menopause * Uterine/endometrial * Ovarian * Pituitary * Hypothalamic

Question 62

What are the physical impacts of menstrual disorders?

Answer 62

* Tiredness * Anaemia

Question 63

What is the psyschological impact of menstrual disorders?

Answer 63

* Depression * Irritability * Mood swings * Anxiety

Question 64

What is the social impact of menstrual disorders?

Answer 64

Impact on ability to socialise/swim/perform sports