Physiology of the Mentrual Cycle Flashcards by Ravi Kana

What are the 3 phases of the normal menstrual cycle?

Follicular Phase
Ovulatory Phase
Luteal Phase

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What cells make up the ovarian follicle?

Theca cells (externa and interna)
Granulosa cells
Oocyte

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Describe the endocrinology of the Follicular phase of the menstrual cycle.

Low FSH stimulates Hypothalamus to release GnRH
GnRH stimulates the anterior pituitary to release more LH and FSH
LH stimulates Theca cells to produce androstendione
FSH stimulates granulosa cells to make Aromatase
Aromatase converts androstendione to oestrogen

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Describe the endocrinology of the Ovulatory phase.

Rising oestrogen reaches a critical level causing positive feedback to the hypothalamus via the kisspeptin system resulting in increased GnRH secretion and LH surge.
LH surge causes follicle to rupture releasing oocyte

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Describe endocrinology of the Luteal phase.

Ruptured follicle is called the Corpus Luteum

1. Corpus Luteum is stimulated by LH to secrete progesterone

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What is the role of Oestrogen in the Luteal phase?

Stimulates proliferation of the lining of the uterus, cervix, and vagina
Increases breast progestogen receptors
Thickens cervical mucus

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What is the role of Progesterone in the Luteal phase?

Builds up lining of the uterus causing it to enter the secretory phase
Stops pituitary from secreting more LH

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How do you define Primary and Secondary, Amenorrhoea and Oligomenorrhoea

Primary: no menstruations before 16 years
Secondary: occurring after normal menses have begun.

Amenorrhoea: >6 months between periods
Oligomenorrhoea: 6 weeks-6 months between periods

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What are the WHO classifications of Anovulation?

WHO I - Hypothalmic Pituitary failure
WHO II - Hypothalmic-Pituitary Ovarian failure (predominantly as a result of PCOS)
WHO III - Ovarian failure (old age)

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What is the definition of Menorrhagia?

heavy menstrual loss as excessive blood loss that interferes with a woman’s physical, social, emotional and/or quality of life (NICE)

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What is the difference between Menorrhagia and Dysfunctional Uterine Bleeding?

DUB is Menorrhagia without a known cause

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What are the causes of Menorrhagia?

Pelvic Pathology

Fibroids
Endometrial polyps
Endometriosis, PID, PCOS

Systemic diseases

Coagulation disorders (e.g. Von Willebrands)
Hypothyroidism

Iatrogenic

Anticoagulant treatment
IUD

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What are the treatments for Dysfunctional Uterine Bleeding?

1st - Mirena Coil - Levonorgestrel releasing IUD
2nd - Tranexamic acid - Antifibrinolytic (Risk of thrombosis), NSAID’s (antiplatelet)
3rd - Progestogens
Short acting - Northisterone tablets
Long acting - Depot-Provera

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What are fibroids?

Benign smooth muscle cell tumours in the myometrium

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What is the Rotterdam criteria for PCOS diagnosis?

2 out of 3 of the following:

Oligo-anovulation or anovulation
Clinical +/- biochemical signs of hyper-androgenism
Polycystic ovaries: the presence of 12 or more follicles in one or both ovaries +/- increased ovarian volume (>10ml)

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What is the cause of PCOS?

Multi factorial
Excess androgens produced by Theca cells of the developing follicle
Insulin resistance which causes increased androgen production - which cause

What is the criteria for Clinical Hyper-Androgenism

Hirsutism
Acne
Male pattern alopecia

What tool is used to define Hirsutism?

Ferriman-Gallway Scale
9 body areas rated from 0-4
Total score of 6-8 defines Hirsutism

How do you treat Hirsutism?

Spironolactone
Aldosterone and androgen receptor antagonist
Cyproterone acetate
Progestogen with anti-androgen properties, combined with an Oral contraceptive pill
Flutamide
Androgen receptor antagonist

Define infertility and subfertility

Infertility:
Unable to conceive at all

Subfertility:
More than 12 months without conceiving despite
unprotected intercourse. Lower chance per month of
conceiving in a given month than normal (± 20% per cycle)

What are some the basic investigations for infertility?

Basic Investigations
In there an egg?: Mid-luteal phase progesterone
Is there sperm?: Semen analysis
Can they meet?: Tubal patency test, Hysterosalpingogram, Diagnostic Laparoscopy

What fertility treatment is available for Anovulation?

Ovulation Indution

What types of medication is available for Ovulation Induction?

Oestrogen inhibitors - Clomid - 80% ovulation, 10-15% chance of conceiving per cycle

Gonadatrophins (LH and FSH) - 90% ovulation, cumulative pregnancy chance - 50%

What is the risk of multiple pregnancy in Gonadatrophin Ovulation Induction?

20%

What fertility treatment is available for sperm defects or unexplained infertility?

Intra-uterine-insemination Sperm washed and injected into uterus Chance per cycle 8%

When is IVF considered?

Tubal blockage Unsucessful OI or IUI Severe male factor Long term unexplained infertility

What is the most serious disorder that can arise following IVF/OI?

Ovarian Hyperstimulation Syndrome

What is the pathologenesis of Ovarian Hyper Stimulation Syndrome?

Ovariese form 20+ follicles and swell up. Vasoactive mediators are released from swollen ovaries, increasing capillary permeability Fluid shifts into the third space compartments causing effusions, increased risk of thrombosis, and liver/kidney dysfunction.

What are the symptoms of OHSS?

``` Abdominal bloating Abdo bain Nausea vomiting Adult respiratory distress syndrome Thromboembolism ```

What is the management of OHSS?

With-hold HCG Analgesia Antiemetics Thromboprophylaxis

What are the 6 types of pelvic pain?

``` Cyclical (usually gynaecological) Non-Cyclical (may or may not be gynaecological) Dysmenorrhoea (painful periods) Dyspareunia (pain during sex) Dyschesia (pain whe passing stool) Dysuria (pain when passing urine) ```

What are the 4 gynaecological causes of cyclical pelvic pain?

Endometriosis Adenomyosis PID Primary dysmenorrhoea

What are the non-cyclical causes of pelvic pain?

Gynaecological: Adhesions, Hydrosalpinges, Tumours IBS Urological: Recurrent UTIs, Interstitial Cystitis Neurological: Nerve injury/entrapment Musculoskeletal: Myofascial pain

What is the definition of Endometriosis?

The presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction

What are the common sites of endometriosis?

Ovaries Utero-sacral ligaments Pouch of Douglas Broad ligament

What is the most common gynaecological pelvic pain referral?

Endometriosis 20% of all gynae consultations

What is the gold standard for endometriosis diagnosis?

Laparoscopy and histological diagnosis

What treatment is available for endometriosis?

Simple analgesia Hormonal: - Progestogens - Combined oral contraceptive - Mirena - Gonadotrophin releasing hormone agonists +/- add back HRT

What are the 4 stages of endometriosis?

Stage I: Minimal In minimal endometriosis, there are small lesions, or wounds, and shallow endometrial implants on your ovary. There may also be inflammation in or around your pelvic cavity. Stage 2: Mild Mild endometriosis involves light lesions and shallow implants on an ovary and the pelvic lining. Stage 3: Moderate Moderate endometriosis involves deep implants on your ovary and pelvic lining. There can also be more lesions. Stage 4: Severe The most severe stage of endometriosis involves deep implants on your pelvic lining and ovaries. There may also be lesions on your fallopian tubes and bowels.