Tutorial 11 - Women's and Men's health - Menstrual cycle and its associated conditions Flashcards
What is the hypothalamo - pituitary - gonadal axis?
- Hypothalamus - GnRH (pulsatile release).
- Anterior pituitary - LH/FSH.
- Gonads - teses/ovaries -Testosterone/oestrogen/progesterone.
What does FSH and LH do in the male?
- FSH - acts on the Sertoli cells. Spermatogenesis and inhibin.
- LH - acts on the Leydig cells. Testosterone and helps negative feedback on hypothalamus.
What does FSH and LH do in the female?
- FSH - acts on granulosa cells. Aids in follicular development, production of oestrogen from androgens and release of inhibin.
- LH - acts on the theca International cells. Release androgens (which are converted to Oestrogens by granulosa cells).
What is the effect of:
A. Moderate oestrogen on GnRH (+LH/FSH).
B. High oestrogen on GnRH (+LH/FSH).
C. progesterone on oestrogen.
A. Moderate oestrogen inhibits GnRh
B. High oestrogen increases GnRH
C. Progesterone exacerbates inhibitory effects on Low oestrogen and inhibits stimulatory effects of high oestrogen.
What is the link between stimulation of the GnRH receptor and prostate cancer?
- When GnRH released, the receptors for it in the anterior pituitary become internalised and destroyed.
- Thus, continuous stimulation degrades GnRH receptors, meaning less LH/FSH released, thus less testosterone.
- Testosterone helps prostate cancer grow, so by medically castrating a male - can reduce spread of prostate cancer.
Describe what happens in the ovarian cycle.
- The ovarian cycle is split into the follicular and luteal phase.
- Ovarian phase: Initially there is little steroid hormone, so there is little FSH/LH negative feedback. Leading to increased oestrogen production and follicular development. As oestrogen increases, the negative feedback inhibits the FSH/LH so only one follicle develops. BUT as oestrogen hits a high threshold, it initiates positive feedback on GnRH - which leads to an increase in LH (not FSH - due to Inhibin production) - which promotes ovulation.
- Ovulation - Follicle ruptures, oocyte released, enters Fallopian tube - aided by fimbria.
- Luteal phase - Remainder of follicle is now known as the corpus lutieum. This secretes both oestrogen and progesterone as well as inhibin. If there is no fertilisation - regresses - resetting negative feedback - allowing new cycle to occur. If fertilisation occurs - syncytiotrophoblasts of embryo produce HCG which maintains the release of hormones.
Describe what happens in the uterine cycle.
- The uterine cycle coincides with the ovarian cycle. It is split into the proliferative, secretory and menses phase.
- Proliferative phase - Coincides with the follicular phase. Oestrogen stimulates the endometrium myometrium grow and thicken. Thin alkaline cervical mucus released.
- Secretory phase - Coincides with the luteal phase. progesterone causes further thickening of the endometrium and myometrium. Release of thick acidic cervical mucus.
- Menses - End of luteal phase. No fertilisation. No hormones to maintain lining of endometrium. Shed. Bleeding.
How long should a normal menstrual cycle be?
- 21 - 40 days
- Variations often due to follicular phase fluctuations.
What is primary amenorrhoea and what can cause it?
- 16 yrs + normal secondary sexual characteristics
- Causes:
- Often structural genito-urinary abnormalities(as there are normal secondary sexual characteristics)
- imperforate hymen (thin membrane covers the vaginal opening)
- absent vagina
- absent uterus.
- 14 yrs + no sign of secondary sexual characteristics.
- Causes:
-Due to the absence of secondary characteristics, its likely to be a hormonal/chromosome related issue.
-Turners syndrome (45XO, high FSH/LH, low oestrogen - poor great development, short stature, low hairline. ) - Complete androgen sensitivity.
- Idiopathic hypogonadotrophic hypogonadism - with anosmia presentation - kallman’s syndrome.
What is secondary amenorrhoea and what can cause it?
- Lack of menstruation for 6 months in a women who has had normal menstruations before.
- lack of menstruation for 12 months in a women who previously had oligomenorrhoea.
- Causes:
- Asherman’s syndrome (scarring, intrauterine adhesions, post uterine surgery).
- Primary ovarian insufficiency syndrome (oocytes deplete before age of 40).
- PCOS (presents with menstrual irregularity + androgen excess + obesity).
- Thyroid disease.
- Sheehans syndrome (damage to pituitary gland - postpartum - due to severe hypotension).
- Functional hypothalamus amennorhea - weight loss, excessive exercise, emotional stress.
When is amenorrhea normal?
- Pregnancy.
- Menopause.
What is oligomenorrhoea and what can causes i?
- Infrequent menstruation below 6-8 menstruations a year.
- Causes:
- PCOS
- primary ovarian insufficiency syndrome
- Thyroid problems
- Excessive exercise
- Peri - menopause
What is menorrhagia?
- Menorrhagia is abnormal uterine bleeding:
- Bleeding > 8 days.
- > 80 ml a cycle.
- Occurs more frequently than 24 days/less frequently than 38 days.
- Bleeding within menstrual cycle.
- Post coital bleeding.
- Absence of menses.
What causes menorrhagia?
- PALM - COEIN
P - Polyps
A - Adenomyosis
L - leiomyoma (fibroid) (benign tumour of the myometrium - can cause HMB and IMB. )
M - Malignancy
C - Coagulopathy
O - Ovulatory dysufunction
E - Endometrial
I - Iatrigenic
N - Not classified bleeding
A. What is dysmenorrhea and what can cause it?
B. How would you manage dysmenorrhea?
A. - Painful menstruation - cramp like and intermittent, or continuously dull.
- Begins 1-2 day before or on onset of menses, usually resolves within 72 hours.
- Primary - since menarche, secondary - recent onset
- Endometriosis
B. COCP pill, GnRH analoge, surgery, analgesia.
How does menopause affect a women?
- Symptoms all arise due to lack of oestrogen.
- Vasomotor system (blood vessel vasodilation driven hHOT FLUSHES)
- GI tract - Motor activity diminished - sluggish - CONSTIPATION.
- Urinary system - tissue lining the urethra and bladder becomes thinner - causing urinary incontinence, increased frequency, and increased tendency of UTI’s.
- Musculoskeletal system - increased osteoclast activity leading to osteoporosis and increased fracture risk.
- Reproductive system - Cervix becomes smaller and flush with vagina. Fat in labia majora lost. Pubic hair loss. Breast becomes flat/shrivelled or flabby/pendulous depending if women thin or fat.
- Cardiovascular - Abnormal metabolism of cholesterol - increased cholesterol - hyperlipidemia - increased risk of stroke/MI.
- General appearance - skin becomes thin(loss of elastin), weight increase(mood swings - food habits related?), thin hair, hoarse voice.
- Other - Exacerbated psoriasis, insomnia, bloating, mood disorders/mood swings and diminished sex interest due to dry vagina.
Outline potential management if a menopausal patient.
Non - hormonal interventions:
- Dressing lightly , avoiding caffeine, alcohol and spicy foods - van help alleviate hot sweats.
- Reducing dietary fat/exercising - can help with weight gain.
Hormonal interventions:
- Oral
- Patch
- Vaginal
- All aim to replace oestrogen.
What are the red flag symptoms for ovarian cancer?
- BEAT:
- B - Bloating
- E - Eating difficulty / early satiety
- A - Abdominal / pelvic pain
- T - Toilet changes (urinary/GI)
