Normal Menstrual Cycle

Question 1

What is the average duration of the menstrual cycle?

Answer 1

28 days +/- 7 days

Question 2

What are the three phases of the menstrual cycle?

Answer 2

1. Follicular phase
2. Ovulation
3. Luteal phase

Question 3

What is the duration of the follicular phase? (physiologically speaking)

Answer 3

Onset of menses to the LH surge

Question 4

What is the duration of the ovulation phase? (physiologically speaking)

Answer 4

Occurs within 30-36 hours of LH surge

Question 5

What is the duration of the luteal phase? (physiologically speaking)

Answer 5

Begins on the day of the LH surge, and ends with menses

Question 6

How long (in days) do the follicular and luteal phases last?

Answer 6

14 days

Question 7

True or false: with irregular menses, the duration of the luteal phase can vary, but the follicular phase stays constant

Answer 7

False–other way around–follicular phase varies, while the luteal phase remains constant

Question 8

What happens to a woman’s menstrual cycle after menarche?

Answer 8

Followed by 5-7 years of increasing regularity, and cycle shortening

Question 9

What is the usual length of flow for a woman’s menses?

Answer 9

4-6 days

Question 10

What happens in a woman’s 40s to her menstrual cycle?

Answer 10

Lengthen

Question 11

What is the normal volume of menses? Abnormal?

Answer 11

30 ml normal

more than 80 is abnormal

Question 12

Where does estrogen exert a negative feedback on the HPA axis?

Answer 12

At the level of the pituitary and the hypothalamus

Question 13

Where does estrogen exert a positive feedback on the HPA axis?

Answer 13

At the level of the pituitary

Question 14

What hormonal surge triggers ovulation?

Answer 14

LH

Question 15

What does the ovarian follicle turn into with ovulation? What is this responsible for?

Answer 15

Corpus luteum–responsible for secreting progesterone

Question 16

What chemical causes the corpus luteum to become yellow?

Answer 16

Lutein

Question 17

What is the embryology of the uterus? (cells involves, where they move, what germ layer, weeks gestation)

Answer 17

Primordial germ cells in the endoderm of the yolk sac migrate to the genital ridge by 5-6 weeks gestation

Question 18

The maximum number of oocytes is reached when?

Answer 18

16-20 weeks gestation

Question 19

What happens to the number of oocytes from gestation, birth, puberty, and reproductive years?

Answer 19

Gestational = 6 million
Birth =2 million
Puberty = 300,000
Reproductive years = Less than 500

Question 20

How many oocytes enlarge with each follicular phase?

Answer 20

Several

Question 21

What are the layers that surround each oocyte?

Answer 21

Granulosa cells and a membrane, the zona pellucida

Question 22

Follicular growth is dependent on what hormone? Where is the receptor for this hormone?

Answer 22

FSH–receptor is on the granulosa cells

Question 23

True or false: in the presence of FSH, the preantral follicle can aromatize androgens to estrogens

Answer 23

True

Question 24

What happens to the granulosa cells with FSH binding? Stromal cells?

Answer 24

Granulosa cells proliferation into multiple layers, and produce estrogen

Stromal cells differentiate into theca cells, to produce androgens

Question 25

What are theca cells derived from? Function?

Answer 25

Stromal cells derivatives--produce androgens for the granulosa cells to convert to estrogen for the developing follicle

Question 26

What is the graafian follicle?

Answer 26

Mature follicle

Question 27

What cells produce the estrogen to lay down the endometrial layer?

Answer 27

Follicular cells

Question 28

The follicles will only progress if what hormone concentrations exist?

Answer 28

FSH is elevated | LH is low

Question 29

The success of a follicle depends upon what?

Answer 29

Its ability to convert an androgen microenvironment to an estrogen one

Question 30

In the presence of (__) estrogen is the dominant substance.

Answer 30

FSH

Question 31

What happens to the oocyte if LH is prematurely elevated?

Answer 31

Androgen levels rise which antagonizes granulosa cell proliferation and promotes degenerative changes in the oocyte

Question 32

How do increased androgen levels inhibit oocyte proliferation? (2)

Answer 32

- Antagonize granulosa cell proliferation | - Increased estrogen feedback on the HPA axis

Question 33

How does LH regulate steroidogenesis?

Answer 33

Regulates the entry of cholesterol into the mitochondria

Question 34

Granulosa cells initially have receptors for what hormone? What changes as it develops? Why?

Answer 34

Initially, only has FSH receptors, but gets LH receptors to be able to respond to ovulation

Question 35

When in the follicular phase do estradiol levels begin to rise? LH

Answer 35

Estradiol - Mid Follicular phase LH - steadily rises during the late follicular phase, to stimulate androgen production in the theca cells

Question 36

What are the major preovulatory changes that occur to the follicle?

Answer 36

- Granulosa cells enlarge and acquire lipids | - oocyte resumes meiosis

Question 37

Primary oocytes are arrested at which stage of meiosis?

Answer 37

diplotene stage of prophase I (the prophase of the first meiotic division)

Question 38

Estrogen levels peak how many hours prior to ovulation? Why?

Answer 38

24-36 hours to stimulate midcycle surge of LH

Question 39

What hormone promotes the luteinization of the granulosa cells? What happens when this occurs?

Answer 39

LH promotes granulosa cell luteinization, which results in progesterone production

Question 40

Prior to follicular progesterone production, the circulating level of progesterone was derived from where?

Answer 40

Adrenal gland

Question 41

When do progesterone receptors begin to appear on the granulosa cells?

Answer 41

Preovulatory follicle

Question 42

When the primary follicle grows, and the lesser follicles become atretic, the theca cells produce increased levels of androgens. What are the two major purposes of this?

Answer 42

Enhances process of atresia Increases libido

Question 43

What happens to estradiol levels with the LH surge?

Answer 43

Plunge, then abrupt fall

Question 44

What hormonal surge stimulates the LH surge?

Answer 44

Estrogen

Question 45

Levels of which hormone can be measured at about day 21 to confirm that a woman has ovulated?

Answer 45

Progesterone

Question 46

What happens to progesterone levels in the luteal phase? How long does this last for? What is the effect of this?

Answer 46

- Peak 8 days after LH surge, but stay elevated - Suppresses new follicular growth - *consistently* lasts 14 days

Question 47

How long does the corpus luteum survive for without implantation? What hormone can prevent this?

Answer 47

9-11 days hCG will prevent luteal regression

Question 48

What is the effect of hCG on the corpus luteum?

Answer 48

Maintains steroidogenesis until 9-10th weeks of gestation

Question 49

What are the three endometrial phases of the ovulatory cycle?

Answer 49

- Menstrual endometrium and proliferative phase - Ovulation - Secretory phase

Question 50

What is day 1 of the menstrual cycle?

Answer 50

First day of menstrual bleeding

Question 51

What is the role of prostaglandins in menstruation?

Answer 51

Induce uterine contractions

Question 52

What is the effect of the rise in estrogen levels in the early follicular phase?

Answer 52

Induces endometrial healing and cessation of menstruation

Question 53

What fraction of the endometrium may be lost during menstruation?

Answer 53

2/3

Question 54

What is the major layer of the endometrium that proliferates in response to estrogen?

Answer 54

Functionalis layer

Question 55

What are the hormone levels that limit growth of the endometrium during the uterine secretory phase?

Answer 55

Estrogen and progesterone

Question 56

Why are the vessels of the uterine lining coiled?

Answer 56

Progesterone limits the growth of endometrium, but estrogen encourages growth of vessels in this confined space

Question 57

What is the signal for endometrial breakdown?

Answer 57

Loss of estrogen and progesterone

Question 58

What happens to the endocervix in the menstrual cycle?

Answer 58

increased cervical mucus

Question 59

What happens to the breasts during the menstrual cycle?

Answer 59

TTP and fullness

Question 60

What happens to the vagina during the menstrual cycle?

Answer 60

Estrogen increases lubrication

Question 61

What happens to basal body temp with the menstrual cycle?

Answer 61

Progesterone increases basal body temperature just at ovulation

Question 62

Does tubal ligation have any effect on menstruation?

Answer 62

No

Question 63

What is the effect of hyper and hypothyroidism on menstruation

Answer 63

Hyper = short, quick bleeding Hypo = prolonged, full bleeding

Question 64

What are the two hormones that regulate prolactin production?

Answer 64

``` Positive = TSH Negative = dopamine ```

Question 65

What is the effect of prolactin on GnRH release?

Answer 65

Inhibits--therefore a prolactinoma will decrease estrogen/testosterone levels and interfere with menstruation

Question 66

What is the average duration of flow for menstruation? How much blood is lost? How much Fe is lost?

Answer 66

4 days 30 ml 13 mg

Question 67

What percent of blood loss during menstruation occurs within the first 2 days?

Answer 67

70%

Question 68

What is amenorrhea?

Answer 68

Absence of menstruation for 6 months

Question 69

What is polymenorrhea?

Answer 69

Uterine bleeding occurring at regular intervals of less than 21 days

Question 70

What is oligomenorrhea?

Answer 70

Cycle frequency of greater than 40 days, but less than 6 months

Question 71

What is primary amenorrhea?

Answer 71

Young woman who has never menstruated by age 13

Question 72

What is secondary amenorrhea?

Answer 72

Previously menstruating woman has not menstruated for 3-6 months

Question 73

What is menorrhagia?

Answer 73

Prolonged (greater than 7 days) of bleeding

Question 74

What is hypomenorrhea?

Answer 74

Cycle length of 2 days of less or reduction in flow

Question 75

What is intermenstrual bleeding?

Answer 75

Bleeding of variable amounts between regular periods

Question 76

What is metrorrhagia?

Answer 76

Bleeding at irregular, but frequent intervals of variable amount

Question 77

What is menometrorrhagia?

Answer 77

Frequent bleeding that is excessive and irregular in amount and duration

Question 78

What is the most common cause of amenorrhea?

Answer 78

Prego

Question 79

What are the functional causes of amenorrhea?

Answer 79

Excessive exercise or obesity

Question 80

True or false: most causes of amenorrhea (not 2/2 prego) are functional

Answer 80

True

Question 81

How do you assess for HPA axis dysfunction causing amenorrhea?

Answer 81

Measure FSH, LH, and prolactin levels

Question 82

What is the most common adenoma of the pituitary?

Answer 82

Prolactinoma

Question 83

Low FSH, LH, and estrogen/progesterone levels, suggests there is a dysfunction of what part of the HPA axis?

Answer 83

Hypothalamus or pituitary--check GnRH to see

Question 84

High FSH/LH, but low estrogen/progesterone suggests there is a dysfunction of what part of the HPA axis?

Answer 84

Ovaries

Question 85

Turner's syndrome can have what effect on the HPA axis?

Answer 85

Ovaries will not function correctly--streak ovaries

Question 86

What is asherman syndrome?

Answer 86

a condition characterized by adhesions and/or fibrosis of the endometrium particularly but can also affect the myometrium. It is often associated with dilation and curettage of the intrauterine cavity Can cause amenorrhea

Question 87

What is the most frequent *anatomic* cause of secondary amenorrhea?

Answer 87

Asherman syndrome

Question 88

What is the treatment for Asherman's syndrome

Answer 88

Surgical lysis of adhesions by hysteroscopy

Question 89

What is the hormone that heals the uterine lining?

Answer 89

Estrogen

Question 90

What is the thinking behind the progesterone challenge test for assessing amenorrhea?

Answer 90

1. Assess if pt has adequate estrogen, competent endometrium, and genital outflow tract. 2. Induce progesterone withdrawal bleed within one week of oral progesterone 3. If bleeding occurs, pt anovulatory. If no bleeding, hypoestrogenic or anatomic

Question 91

What are the s/sx of a prolactinoma?

Answer 91

- Galactorrhea | - Amenorrhea

Question 92

What is the medical treatment for a prolactinoma? MOA?

Answer 92

Bromocriptine--Dopamine agonist

Question 93

How can ovulation be induced if a patient has amenorrhea?

Answer 93

- Clomiphene citrate - Human menopausal gonadotropins - Pulsatile GnRH - Aromatase inhibitors

Question 94

How will aromatase inhibitors cause ovulation?

Answer 94

Increases in estrogen levels will cause lH surge etc

Question 95

What causes the abnormal bleeding with anovulatory patients?

Answer 95

Continued release of estrogen builds up uterine lining, but there is no pause in estrogen to stop it

Question 96

What causes the abnormal bleeding with patients who have a luteal phase defect?

Answer 96

Corpus luteum does not produce enough progesterone to maintain the uterine lining. Results in shortened luteal phase, and infertility

Question 97

What is midcycle spotting? Is this concerning?

Answer 97

Bleeding at the time of ovulation--in the absence of other pathology, then is a self-limited benign condition

Question 98

When should you suspect AUB?

Answer 98

Irregular, unpredictable, and not associated with PMS s/sx

Question 99

What are the conditions that you must exclude with AUB?

Answer 99

- Neoplasia - pregnancy - Anatomical issues of vagina

Question 100

How do you diagnose AUB caused by unopposed estrogen stimulation?

Answer 100

endometrial bx

Question 101

What is the treatment for AUB? (2)

Answer 101

- Progestin for 10-14 days to mimic withdrawl of progesterone - Combination oral contraception

Question 102

What is the MOA of oral combination contraceptives in treating AUB?

Answer 102

Suppresses the endometrium and also establishes a regular withdrawal cycle

Question 103

What is the MOA of progestin for treating AUB?

Answer 103

10-14 days of progestin mimic the fall of progesterone, causing uterine lining shedding

Question 104

What is the medical treatment for acute, heavy abnormal bleeding?

Answer 104

HIgh dose estrogen and/or progesterone, follow by preventative management with oral contraceptives

Question 105

What should be done if medical treatment for acute heavy AUB fails?

Answer 105

D and C