Menstruation & Uterine Pathology Flashcards
Name four hormones involved in the menstrual system
- oestrogen
- progesterone
- LH
- FSH
When is the primary follicle formed?
Day 5
What is produced by the primary follicle at day 5?
Inhibin - causes FSH to fall and oestrogen to rise
What does the oestrogen rise at day 5 stimulate?
Proliferative phase in the uterus
Describe the events leading up to ovulation
Oestrogen reaches threshold and changes to positive feedback leading to an LH surge and rise in FSH
What does the LH surge cause?
Ovulation, oocyte released into the uterine tubes and secretory phase in the uterus
What is left of the follicle after the oocyte has been released?
Corpus luteum - produces progesterone causing a progesterone and oestrogen to rise
What happens if implantation occurs?
Placenta produces HCG - this maintains the corpus luteum
What happens if no implantation occurs?
Corpus luteum will breakdown causing a fall in oestrogen and progesterone
What is the result of the oestrogen and progesterone fall?
Menstruation in the uterus
Describe the proliferative phase
Stratum basalis proliferates and increases the thickness of the endometrium - pseudostratified columnar epithelium is relatively straight
Describe the secretory phase
Glands become coiled with corkscrew appearance and secrete glycogen
Describe the menstrual phase
Arterioles in SF constrict causing ischaemia, tissue breakdown and bleeding
What are the two methods of uterine sampling?
Pipette
Dilatation and curettage
How thick should the endometrium be?
Premenopausal <16mm
Postmenopausal <4mm
What are the indications for uterine sampling?
Abnormal uterine bleeding Infertility investigation Pregnancy loss Endometrial ablation Prior to hysterectomy Incidental finding of thickening Cancer screening in high risk cases
Define menorrhagia
Prolonged and increased menstrual flow
State the local causes of menorrhagia
Fibroids Adenomyosis Polyps Cervical eversion Endometrial hyperplasia IUCD Pelvic Inflammatory Disease (Chlamydia) Endometriosis Malignancy Hormone producing tumours Endometrial carcinoma
State the systemic causes of menorrhagia
Endocrine - thyroid, diabetes mellitus, adrenal disease
Disorders of homeostasis
Liver/renal disorders
Drugs - anticoagulants
What are the symptoms of PCOS?
Oligomenorrhoea/amenorrhoea
Weight gain
Facial hirsutism/acne
Hair loss/thinning
What diseases are associated with PCOS?
T2DM (insulin resistance), hypercholesterolaemia, hypertension, sleep apnoea (obesity), higher risk of endometrial carcinoma due to high oestrogen
Describe the diagnostic criteria for PCOS?
- Oligo/amenorrhoea
- Polycystic ovaries (scan appearance)
- Clinical and/or biochemical signs of hyperandrogenism
Describe the management of PCOS
Lifestyle, statin, COCP, mirena coil, ovarian drilling, metformin
Define disordered uterine bleeding
Irregular uterine bleeding that reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining
What are the two types of DUB?
Anovulatory
Luteal Phase
Describe anovulatory cycle
Corpus luteum does not form as secondary oocyte is not released - lack of control of proliferation leads to irregular breakdown
Describe luteal phase deficiencies
Insufficient progesterone or poor response by endometrium. Abnormal follicular development leads to poor corpus luteum
What investigations are done in DUB?
FBC, cervical smear, TSH, coagulation, LFT/renal function, transvaginal ultrasound, endometrial sampling
What are the treatment options for DUB?
Medical
Mirena Coil
Endometrial resection/ablation
Hysterectomy (total or subtotal)
What is the medical management of DUB?
Progestogens COCP Synthetic testosterone GnRH analogues NSAIDs Anti-fibrinolytics Transexamic acid (taken while bleeding)
What medication is required after endometrial resection and hysterectomy?
Endometrial resection - combined HRT
Hysterectomy - oestrogen only HRT
What is endometritis?
Abnormal pattern of inflammatory cells (plasma cells in the stroma)
What makes the endometrium resistant to infection?
Cervical mucous plug protects the endometrium from ascending infection in addition to cyclical shedding
State the infectious causes of endometritis
Neisseria Chlamydia TB/CMV HSV Actinomyces
State the inflammatory causes of endometritis
IUD Postpartum/post arbortal Post curettage Chronic endometritis NOS Granulomatous Associated leiomyomata or polyps
When do endometrial polps most commonly occur?
Around/after menopause
What are the products of conception after miscarriage?
Chorionic villi
Trophoblast
Foetal RBCs
Black nucleus - <12 weeks
Define molar pregnancy
Abnormal pregnancy where a non-viable fertilised egg implants in the uterus
What disease is a molar part of?
Gestational Trophoblastic Disease
Describe gestational trophoblastic disease
A mass grows with characteristic swollen chorionic villi and proliferating trophoblasts
Describe a complete mole
One or two sperm combine with an egg that has lost DNA to form a egg with 46 chromosomes all of paternal DNA as sperm replicates
Describe a partial mole
Egg fertilised by two sperm or one perm with reduplicates to yield 69 chromosomes
What is the risk of molar pregnancy?
They can invade the myometrium and risk of transformation into choriocarcinoma
What is an adenomyosis?
Presence of endometrial glands and stroma in the myometrium leading to menorrhagia/dysmenorrhoea
What is leiomyoma?
Benign tumour of smooth muscle - Fibroid
How may fibroids present?
Menorrhagia, infertility, mass effect, pain
What hormone stimulates fibroid growth?
Oestrogen
Name the malignant subtype of leiomyoma
Leiomyosarcoma - pleomorphism, necrosis, proliferation
Define metrorrhagia
Regular intermenstrual bleeding
Define polymenorrhoea
Menses occurring at <21 day interval
Define polymenorrhagia
Increased bleeding and frequent cycle
Define menometrorrhagia
Prolonged menses and intermenstrual bleeding
Define amenorrhoea
Absence of menstruation >6 months
Define Oligomenorrhoea
Menses at intervals >35 days
