O+G- Menstrucal Cycle + Menstrual Disorders Flashcards
The luteal phase of the ovarian cycle corresponds to which phase of the uterine cycle?
a) Secretory phase
b) Menstrual phase
c) Proliferative phase
a) Secretory phase
What is the main hormone produced by the corpus luteum?
a) LH
b) FSH
c) Progesterone
d) Oestrogen
c) Progesterone
Which cells produce FSH?
a) Granulosa cells
b) Gonadotropic cells
c) Theca cells
b) Gonadotropic cells
What is the menstrual cycle?
•The menstrual cycle is a series of natural changes that occur in a woman’s reproductive system
- The average cycle lasts __ days, with ovulation occurring at around day __
- The average age for a woman’s first menstrual bleeding (_______) is between _____ years old
- The menstrual cycle is controlled by the endocrine system via the __________, anterior pituitary, and the ______
- The menstrual cycle can be looked at as the ________ _____ (cycle of the ovum), and the ________ _____ (changes of the lining of the uterus)
- A woman is most fertile __ days before ovulation and ____ days after
- The average cycle lasts 28 days, with ovulation occurring at around day 14
- The average age for a woman’s first menstrual bleeding (menarche) is between 12-13 years old
- The menstrual cycle is controlled by the endocrine system via the hypothalamus, anterior pituitary, and the gonads
- The menstrual cycle can be looked at as the ovarian cycle (cycle of the ovum), and the uterine cycle (changes of the lining of the uterus)
- A woman is most fertile 5 days before ovulation and 1-2 days after
What is Premenstrual syndrome?
refers to the physical and emotional symptoms a woman experiences in the 5-10 days before her period
Signs and symptoms of Premenstrual syndrome
- Acne
- Breast swelling and tenderness
- Fatigue and disturbed sleeping patterns
- Abdominal cramps – usually 1-2 days before, and during menstrual bleeding
- Changes in appetite, bloating, constipation or diarrhea
- Headaches
- Mood swings, irritability, feeling anxious or upset
______ cells form part of the ovarian follicle, and ________ cells closely surround it
Theca cells form part of the ovarian follicle, and granulosa cells closely surround it
What does theca cells produce?
What does granulosa cells produce?
- Theca cells produce androgens and granulosa cells use these androgens to produce oestradiol
- After ovulation, granulosa cells produce progesterone
Where are GnRH released?
• Released by neurons in the hypothalamus
What inhibits GnRH?
• High oestrogen levels inhibit GnRH, low levels stimulate it
Where does the GnRH act on?
• Acts on the anterior pituitary
Where is FSH produced?
Produced and secreted by gonadotropic cells in anterior pituitary
Function of FSH?
- Stimulates growth of immature follicles in the ovaries, acts on granulosa cells that surround the egg to produce oestrogen
- Stimulated by GnRH, inhibited by oestrogen
Where is LH produced and secreted?
• Produced and secreted by gonadotrophin cells of the anterior pituitary
LH is inhibited by ______
LH is stimulated by _______
Inhibited by low levels of oestrogen,
stimulated by high levels of oestrogen
Surge in ____ triggers ovulation, supports increase in oestrogen by binding to ______cells
Surge in LH triggers ovulation, supports increase in oestrogen by binding to theca cells
TRUE OR FALSE
oestrogen is a steriod hormone?
TRUE
Where is oestrogen produced?
Produced primarily by granulosa cells of the ovarian follicles, which are stimulated by FSH
Function of oestrogen?
Promotes female secondary sexual characteristics, and endometrial growth
Where is progesterone produced?
Steroid hormone that is produced mainly by the corpus luteum in th
Progesterone has a _____ effect with oestrogen
synergistic
Funciton of progesterone?
“The hormone of pregnancy” – promotes endometrial development and thickens vaginal epithelium and cervical mucus so sperm can not enter the uterus, inhibits lactation until birth
The ovarian cycle can be split into……
the follicular phase, ovulation, and the luteal phase
Explain the follicular phase:
- FSH levels begin to rise causing stimulation ovarian follicles, once a follicle has matured, it produces large amounts of oestrogen to inhibit the other follicles, the mature follicle is known as the tertiary / Graafian follicle
- The oestrogen causes endometrial thickening and inhibits LH at low levels. Once oestrogen reaches a higher level, it causes a surge of LH at around day 12, which means ovulation can occur at around day 14
- The LH causes the tertiary follicle to become thinner so that it can rupture and release a secondary oocyte – this is ovulation
- This then matures into an ovum, which is released into the fallopian tube
Explain the Luteal phase:
- The pituitary hormones LH and FSH cause the remaining part of the tertiary follicle to develop into the corpus luteum
- The corpus luteum produces progesterone which maintains the endometrium, induces the production of oestrogen, and inhibits production of LH and FSH
• Inhibition of LH and FSH means that the corpus luteum atrophies, and progesterone is no longer produced, this fall in progesterone causes the endometrium to shed and therefore menstrual bleeding occurs
- The corpus luteum is broken down and forms the corpus albicans
- If an ovum is fertilised, the outer layer (syntiotrophoblasts) becomes part of the placenta, these cells produce hCG which is similar to LH and can preserve the corpus luteum, this means that progesterone levels do not drop, and menstrual bleeding does not occur
The uterine cycle has 3 phases which are?
the proliferative, secretory & menstrual phases
Which phase does this describe?
- Corresponds to the second half of the follicular phase of the ovarian cycle
- Endometrium is repaired and grows due to rising levels of oestrogen
• The proliferative phase:
Which phase does this describe?
- This phase begins once ovulation has occurred (luteal phase in ovarian cycle)
- Progesterone produced by the corpus luteum maintains the endometrium and causes secretions from endometrial glands to prepare the uterus for embryo implantation
The secretory phase:
Which phase does this describe?
- Corresponds to the first half of the follicular phase
- Occurs if no implantation occurs, loss of corpus luteum causes decrease in progesterone so the functional endometrium sheds
Menstrual phase:
Which is an example of a menstrual disorder?
a) Polycystic Ovarian Syndrome
b) Premature Ovarian Failure
c) Menorrhagia
d) Endometriosis
c) Menorrhagia
The others are examples of menstrual disorder causes
What is Menorrhea?
refers to the flow of blood at menstruation
What is amenorrhea?
a) Painful periods
b) Lack of periods
c) Infrequent periods
d) Heavy periods
b) Lack of periods
What is an example of Premenstrual Syndrome symptom?
a) Abdominal pain
b) Vaginal discharge
c) Bloating
d) Emotional lability
d) Emotional Lability
This is very common and experienced by the majority of women before onset of the menses
Menstrual Disorders
What is it?
Menstrual disorder is an umbrella term used to describe abnormal conditions that occur within a woman’s menstrual cycle.
Examples of Menstrual disorders?
- Amenorrhea
- Dysmenorrhea
- Oligomenorrhoea
- Menorrhagia
- Premenstrual syndrome
What is Primary Amenorrhea?
Primary amenorrhea is a failure of menses to occur by either:
- Age 16 or 2 years after the onset of puberty
- Age 14 in girls who have not gone through puberty
If by age 13 menses has not occurred and there is no onset of puberty a workup for primary amenorrhea should begin
Causes of primary amenorrhea (ovulatory) include:
• Chromosomal or genetic abnormalities: Turner syndrome, Kallmann syndrome, Obstructive abnormalities i.e. Vaginal/Uterine Aplasia
• Problems with the hypothalamus or pituitary gland: Eating disorders, Excessive exercise, Extreme stress
What is Secondary Amenorrhea?
Secondary amenorrhea is the cessation of the menses after they have begun:
• If they have been absent for ≥ 3 months or ≥ 3 typical cycles
There is disruption in the gonadotrophin stimulated oestrogen production which results in changes in the endometrial cycle causing anovulatory amenorrhea.
Common causes of secondary amenorrhea include
• Natural causes: Pregnancy
• Medications and therapies: Contraception, Antidepressants, Chemotherapy
• Gynecological causes: Polycystic Ovarian Syndrome, Premature Ovarian Failure
• Thyroid Problem
• Pituitary tumors
How do you diagnose amenorrhea?
- History including whether the menses have ever occurred, how old the patient was at menarche, if the periods were regular, LMP, how long and heavy menses is, any accompanying symptoms with menses, cyclic breast changes and mood changes and were certain growth and development milestones reaches
- Review of Systems
- Physical examination including pelvic examination to detect anatomic genetic abnormalities, evidence of virilization i.e. hirsutism, temporal balding, acne, voice deepening, increased muscle mass and feminization
- Measure FSH, LH, Testosterone/DHEAS, prolactin and Karyotype the patient
Treatment for amenorrhea?
- Treat the underlying disorder
- Treat the symptoms and long term effects of oestrogen deficiency/excess
- Minimize hirsutism and long term effects of androgen excess
What is Dysmenorrhea
Dysmenorrhea is uterine pain around the time of the menses:
- Pain may occur with menses
- Or precede menses by 1 to 3 days
Pain tends to peak 24 hours after onset of menses and subside after 2 -3 days.
Other symptoms of Dysmenorrhea?
Other common symptoms include: Headache, nausea, constipation or diarrhea, lower back pain, urinary frequency.
What is the difference between primary and secondary dysmenorrhea?
- Primary symptoms cannot be explained by structural gynecologic disorders
- Secondary symptoms are due to pelvic abnormalities i.e. endometriosis, uterine adenomyosis and fibroids
Treatment for dysmenorrhea
Treat underlying disorders
WHat is Oligomenorrhea?
Condition with infrequent menstrual periods, who regularly go more 35 days without menstruating
• Oligomenorrhoea occurs after more than 90 days without a period
Causes of Oligomenorrhea?
- Side effect of hormonal birth control
- Participate in sports or engage in heavy exercise
- Eating disorders
- Diabetes or thyroid problems
- High blood levels of prolactin
How do you diagnose Oligomenorrhea
Usually diagnosed as a review of your menstrual history
Treatment for Oligomenorrhea?
- It is not a serious condition on its own
- Menstrual periods can be adjusted with a change in hormonal control or progestin
What is Menorrhagia?
Menorrhagia is excessive menstrual blood loss that occurs regularly and interferes with a women’s physical, emotional, social and material quality of life.
- Quantified as loss of 80ml or more with a duration of more than 7 days
- It can also be defined as the need the change menstrual products every one to two hours, passage of clos greater than 2.54cm or “very heavy” periods as reported by woman
Can occur alone or in combination with other symptoms
Causes of Menorrhagia
- 50% of women with menorrhagia have no known cause
- Uterine and Ovarian pathologies
- Systemic disorders
- Iatrogenic
Complications of Menorrhagia
Affects quality of life, iron deficiency anaemia, endometrial hyperplasia
Diagnosis of Menorrhagia
- History and examination (Abdominal and Bimanual examination as well as speculum)
- Blood tests (iron deficiency anaemia and underlying systemic disorders i.e. TFTs)
- Referral to gynecology
Treatment for Menorrhagia
- Levonorgestrel intrauterine system
- NSAIDs or Combined Oral Contraceptives
What is Premenstrual Syndrome
PMS is characterised by irritability, anxiety, emotional lability, depression, oedema, breast pain and headaches, occurring during the week before onset of the menses
Premenstrual Syndrome
common symptoms?
Common symptoms include: irritability, anxiety, anger and agitation, insomnia, difficulty concentrating and fatigue.
PMS is diagnosed……
- based on physical symptoms.
- by symptoms, women must have 5 or more symptoms for most of the week before the menses that subside following the onset of the menses.
PMS treatment?
- General: Symptomatic treatment, adequate sleep, regular exercise and relaxing activities.
- NSAIDs: Relieve aches, pains and dysmenorrhea
- SSRI:s Provide relief for the anxiety, irritability and other emotional symptoms
OSCE tips
gynae history?
- Onset, duration, severity, course, intermittent/continuous, precipitating factors, relieving factors, associated features and previous episodes
- Use SOCRATES to explore the pain (particulary in dysmenorrhea)
- Menstrual history (Duration, frequency, menstrual blood flow, date of LMP, age of menarche)
- Contraception (If currently used or any reproductive plans)
- Any abnormal bleeding (post – coital, intermenstrual)
- Vaginal discharge (Volume, colour, consistency, smell)
- Dyspareunia
- Any other relevant symptoms
- Any other gynecological past history and cervical screening, Family History - Obstetric history
When should amenorrhea be investigated?
a) Failure of the menses before the age of 13 with no puberty onset
b) Failure of the menses before the age of 14 with puberty onset
c) Failure of the menses for two consecutive cycles
d) Failure of the menses after 16 years of ag
a) Failure of the menses before the age of 13 with no puberty onset
What is secondary dysmenorrhea?
: Dysmenorrhea is pain around the time of the menses
a) Dysmenorrhea caused by structural gynecological abnormalities
b) Dysmenorrhea with no known cause
c) Dysmenorrhea that is constant throughout the cycle
d) Dysmenorrhea not caused by structural gynecological abnormalities
d) Dysmenorrhea caused by structural gynecological abnormalities
Primary dysmenorrhea has no known structural gynecological cause and so is treated symptomatically
What is the first line treatment for Menorrhagia?
a) Combined Oral Contraceptives
b) Nonsteroidal Anti – Inflammatory Drugs
c) Levonorgestrel Intrauterine System
d) Tranexamic Acid
c) Levonorgestrel Intrauterine System
ALL of these treatments can be explored before referring to the Gynaecologist
