Physiology - Menstruation

Question 1

What are the three hormonal phases of menstruation?

Answer 1

1. Follicular phase
2. Ovulation
3. Luteal phase

Question 2

What pituitary hormones are involved in menstruation?

Answer 2

FSH

LH

Question 3

What ovarian hormones are involved in menstruation?

Answer 3

Oestrogen

Progesterone

Question 4

What happens during the follicular phase?

Answer 4

1. FSH stimulates ovarian follicle development and granulosa cells to produce oestrogen.
2. Oestrogen and inhibin from dominant follicle inhibits further FSH
3. Declining FSH then causes atresia except for dominant follicle

Question 5

What stimulates ovulation?

Answer 5

LH surge at day 12

Question 6

What occurs during the Luteal Phase?

Answer 6

Formation of Corpus Luteum
Progesterone production (peak at day 21)
Second Oestrogen peak
Luteolysis (~14 days post ovulation)

Question 7

What are the endometrial phases of the menstrual cycle?

Answer 7

Proliferative
Luteal
Menstruation

Question 8

What occurs during the proliferative phase at the endometrium?

Answer 8

Oestrogen induced growth of endometrial glands and stroma

Question 9

What happens at the endometrium during the luteal phase?

Answer 9

Progesterone induced glandular secretory activity
Decidualisation in later secretory phase
Endometrial apoptosis for subsequent menstruation

Question 10

What occurs to the endometrium during menstruation?

Answer 10

Arteriolar constriction and shedding of functional endometrial layer
Fibrinolysis inhibits scar tissue formation

Question 11

What is the normal loss associated with menstruation?

Answer 11

4-6 days
Peak flow in days 1-2
<80mls per menstruation
No clots or flooding

Question 12

What is the average length and range for menstrual cycles?

Answer 12

Average - 28 days
Range - 21-35 days

No IMB or PCB

Question 13

What is Menorrhagia?

Answer 13

Prolonged and increased menstrual flow

Question 14

What is Metorrhagia?

Answer 14

Regular intermenstrual bleeding

Question 15

What is Polymenorrhoea?

Answer 15

Menses <21 day interval

Question 16

What is Polymenorrhagia?

Answer 16

Increased bleeding and frequent cycle i.e. menorrhagia + polymenorrhoea

Question 17

What is Menometrorrhagia?

Answer 17

Prolonged menses and intermenstrual bleeding

Question 18

What is Amenorrhoea?

Answer 18

Absence of menstruation > 6 months

Question 19

What is Oligomenorrhoea?

Answer 19

Menses at intervals of > 35 days

Question 20

What local disorders can result in menorrhagia? (x 11)

Answer 20

Fibroids 
Adenomyosis 
Endocervical or endometrial polyp 
Cervical eversion 
Endometrial hyperplasia 
PID 
Endometriosis 
Malignancy (cervix or uterus) 
Hormone producing tumours 
Trauma 
Malformations

Question 21

What systemic disorders can cause menorrhagia?

Answer 21

Endocrine - hyper/hypothyroidism, diabetes, adrenal disease, prolactin disorders
Haemostasis - VW, ITP, Factor II, V, VII and XI deficiencies
Liver disorders
Renal Disease

Question 22

What are causes of menorrhagia during pregnancy?

Answer 22

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Postpartum haemorrhage

Question 23

What are the two categories of dysfunctional uterine bleeding, and which is most common?

Answer 23

Anovulatory - irregular cycles (most common)

Ovulatory - regular but heavy

Question 24

What I for dysfunctional uterine bleeding?

Answer 24

FBC 
Smear
Renal and LFTs 
If indicated - TSH or coagulation screen 
Transvaginal US 
Endometrial sampling if indicated

Question 25

What are the options for medical management of dysfunctional bleeding?

Answer 25

Progestogens 
COCP 
Danazol 
GnRH analogues 
NSAIDs 
Anti-fibrinolytics 
Capillary wall stabilisers
IUCD

Question 26

What are the surgical management options for dysfunctional bleeding?

Answer 26

Endometrial resection or ablation

Hysterectomy (subtotal or total, vaginal…)