Week 1 - E - Menstrual Dysfunction - Definitions, disorders, treatment, DUB

Question 1

What are the three phases of the ovarian cycle?

Answer 1

Follicular phase

Ovulation

Luteal phase

Question 2

Follicular phase FSH stimulates ovarian follicle development & granulosa cells to produce oestrogens Which two hormones cause negative feedback to inhibt the FSH production?

Answer 2

Oestrogen and inhibin inhibit the FSH production

Question 3

When is the LH surge prior to ovulation? What causes the LH surge?

Answer 3

LH surge occurs 36.5 hours prior to ovulation

Low levels of oestrogen inhibits LH and promotes FSH but high levels have a positive feedback mechanisms and therefore when increasing oestrogen is produced by the theca interna cells independent of FSH secretion in late follicular phase, the LH will increase and FSH will decrease - ovulation occurs when this LH surges

Question 4

When the oocyte is ready to be ovulated, what is the site where the oocyte buldges against the ovary ready to enter the fallopian tube?

Answer 4

This is the follicular stigma

Question 5

What happens in the luteal phase?

Answer 5

Corpus luteum is formed from the follicle cells and produces progesterone

The corpus luteum breaks down once no bHCG is produced - luteolysis and the corpus albicans is formed

Question 6

If there is bHCG production by the placenta, what happens to the progesterone production?

Answer 6

The bHCG production will maintain the corpus luteum which continues with the progesterone production which will maintain the endometrium and continue secretion

Question 7

Whilst the ovarian events are occuring in the menstrual cycle, endometrial events are also occuring (uterine cycle) Proliferation of the endometrium, secretion and eventually shedding (menstruation) (UTERINE CYCLE = menstruation, proliferation, secretion) Do FSH or LH have any direct function on the uterus? Which hormone is responsible for the growth of the endometrium and stroma in the prolferative phase?

Answer 7

FSH and LH do not have a direct effect on the endometrium

Oestrogen is response for the endometrial prolliferation and growth of stroma in the proliferative phase

Question 8

Which hormone is predominant in the secretory (luteal) phase and what produces it? What does the hormone cause?

Answer 8

Progesterone produced by the coprus luteum is the predominant hormone in the secretory phase

Progesterone is responsible for the thickening of the endometrium in preparation for the implantation of a blastocyst into the endometrial wall

Question 9

When the endometrium outgrows its blood supply in the secretory phase (due to no placenta forming to give a blood supply), what happens?

Answer 9

There is endometrial apoptosis and the straum functionalis layer of the endometrium is shed as there is no blood supply to this layer

Question 10

As the uterus sheds every month, scar tissue can form. What process prevents the formation of scar tissue in the uterus?

Answer 10

This would be fibrinolysis

Question 11

What is the average length of a normal menstrual cycle? What can a normal menstrual cycle rang between? How many days does menstruation normally occur for and which is the peak day?

Answer 11

Average menstrual cycle - approx 28 days

Ranges from 21-35 days

Menstruation normally occurs for 4-6 days with peak menstruation days 1-2

Question 12

What is the rough volume of total blood loss in menstruation? What is intermenstrual bleeding (IMB) and post-coital bleeding (PCB)?

Answer 12

Women lose less roughly 30-40mls ml of blood during menstruation

Heavy bleeding considered to be more than 60mls

IMB - this refers to vaginal bleediing (other thn post coital) at any time during the menstrual cycle other than menstruation

Post-coital bleeding - this is non-menstrual bleeding that occurs immediately after sex

Question 13

What is the definition of menorrhagia? What is metrorrhagia?

Answer 13

Menorrhagia is prolonged and increased menstrual bleeding

Metorrhagia is regular intermenstrual bleeding

Question 14

What is it known as when menses occur at less than 21 days interval between periods?

Answer 14

This is polymenorrhea

Question 15

If menorrhagia is prolonged and increased menstrual flow and polymenorrhea is menses occuring at less than a 21 day interval What is polymenorrhagia?

Answer 15

This is increased menstrual bleeding and frequency of cycle

Question 16

What is menometorrhagia?

Answer 16

This is where there is prolonged menses and regular intermenstrual bleeding

Question 17

What is amenorrhea? What is oligomenorrhea?

Answer 17

Amenorrhea is the absence of menses for greater than 6 months

Oligomenorrhea is the asbence of menses for greater than 35 days

Question 18

What is menorrhagia and metrorrhagia?

Answer 18

Menorrhagia - prolonged and increased menstrual bleeding

Metrorrhagia - regular intermenstrual bleeding

Question 19

Menorrhagia prolonged and increased menstrual flow Metrorrhagia regular intermenstrual bleeding What is: Polymenorrhea? Oligomenorrhea?

Answer 19

Polymenorrhea - menses occurring at 6 months+

Oligomenorrhea - menses at intervals >35 days

Question 20

Most people that come with heavy periods also tend to have a shortened cycle What is this known as? What is the difference between primary and secondary amenorrhea?

Answer 20

Most people that come with heavy periods also tend to have a shortened cycle - this is polymenorrhagia

Poly where there is less than 21 day intervals and menorrhagia where there is prolonged and increased bleeding

Primary amenorrhea - periods never started

Secondary amenorrhea - started periods then absent for >6months

Question 21

Causes of menorrhagia are organic and non-organic causes What does organic mean? What is the term for non-organic causes?

Answer 21

Organic means there is the presence of pathology

Non-organic means the menorrhagia occurs in the absence of pathology - dysfunctional uterine bleeding

Question 22

Causes of menorrhagia include local, systemic and pregnancy causes of menorrhagia What is the benign tumour of the myometrium known as? Why does this cause heavy bleeding?

Answer 22

Benign tumour of myometrium - leiomyoma - fibroid

This causes heavy bleeding as the surface area of the endometrium will also be enlarged as the myometrium beneath has been enlarged

Question 23

What type of muscle do fibroids grow from? What hormone is fibroid growth driven by?

Answer 23

Fibroids ar benign smooth muscle tumours (when occuring in uterus - leiomyomas)

Fibroids are oestorgen dependent

Question 24

What is the form of endometriosis where the endometrium breaks through the myometrium and is found here?

Answer 24

This is known as adenomyosis

Question 25

What are the symptoms of adenomysosis?

Answer 25

Sympotms include menstrual cramps, heavy and more frequent periods (polymenorrhagia)

Question 26

Endometrial hyperplasia – when there is excessive proliferation of the endometrium What can this sometimes go on to cause?

Answer 26

This can sometimes cause endometrial carcinoma

Question 27

How does endometrial carcinoma usually present?

Answer 27

It usually presents as post-menopausal bleeding

Question 28

PID – an infective process going on usually in fallopian tube or ovaries – causes a lot of pain and heavy bleeding What does PID stand for? What is the main causative organism of pelvic inflammatory disease?

Answer 28

Pelvic inflammatory disease

Mainly caused by chalmydia trachomatis - infection affects the fallopian tubes mainly

Can also be caused by neisseria gonorrhea

Question 29

What is endometriosis?

Answer 29

This is when the endometrium spreads outside of the uterine cavity usually to other structures within the pelvic cavity

Question 30

Carcinomas can also cause menorrhagia Treatments for gynaecological carcinomas of the uterus are usually hysterectomy’s WHat is the most common type of hysterectomy?

Answer 30

Total hysterecotmy where the womb and cervix are removed is the most common - renders the person infertile

Question 31

Systemic causes of menorrhagia include endocrine disorders and disorders of homeostasis Which thyroid condition causes heavy periods? Which genetic disorder causing a defect in the clotting cascade can lead to increased bleeding?

Answer 31

Hypothyroidism is associated with heavy bleeding (menorrhagia)

VWD and hemophilia are different types of bleeding disorders.

VWD is caused by a problem with von Willebrand factor, whereas hemophilia is caused by a problem with another type of clotting factor (factor VIII in hemophilia A, factor IX in hemophilia B).

Question 32

Pregnancy is another cause of organic menorrhagia When is bleeding normal in pregnancy?

Answer 32

Bleeding is normal within the first trimester of pregnancy - although can be a red herring for a miscarriage

Question 33

What percentage of women with abnormal uterine bleeding is due to dysfunctional uterine bleeding? (ie non-organic causes)

Answer 33

50% of women with abnormal uterine bleeding

Diagnosis made by exclusion

Question 34

Dysfunctional uterine bleeding can be classified as ovulatory or anovulatory depending on whether ovulation is occuring or not What percentage of cases are anovulatory? What type of women is anovulatory uterine bleeding more common in?

Answer 34

85% of cases are anovulatory and are more common in obese women

Get regular heavy periods in this condition

Question 35

What is ovulatory dysfunctional uterine bleeding due to? What age group is it seen in usually?

Answer 35

It is more common in those aged 35-45

Regular heavy periods

Due to inadequate prgesterone production by the corpus luteum

Even though your are ovulating every month, most of the eggs are poorer quality by theage of 45 – poorer quality of corpus luteum therefore poorer quality of progesterone therefor regular heavier periods

Question 36

When there is dysfunctional uterine bleeding, what tests are carried out? What can hyperprolactinaemia cause?

Answer 36

Good clinical history and physical examination

Measure the LH, FSH and Prolactin

Prolactin increase can cause decrease LH and FSH leading to anovulation

Question 37

Why is a full blood count carried out in DUB? Why is TSH measured in DUB? If there is anovulatory dysfunctional uterine bleeding, what is usually the first test to consider?

Answer 37

Full blood count carried out to check if patient is anaemic

TSH carried out to see if there is any hypo/hyper thyroidism

Carry out a pregnancy test initially - bHCG levels in urine

Question 38

TVUS – only done if suspection of a pelvic mass ie endometrial thickening (thickening of the endometrium is more likely that the patient has endometrial carcinoma) – must be confirmed by endometrial sampling When is endometrial carcinoma presentation more common? If TVUS (transvaginal ultrasound) is carried out and endometrial thickening is confirmed, what thickness must the endometrium be?

Answer 38

Endometrial carcinoma is more common in post-menopausal women with vginal bleeding

Endometrial thickness on TVUS

•  Post menopausal = >4mm is worrying so biopsy
•  Pre menopausal = >16mm is worrying, so biopsy

Question 39

Endometrial sampling – uses a speculum inseted into cervix, through into the uterus, widhdraw the piston in the catheter (speculum) and this created a vacuum which will shear part of the endometrium ready for biopsy What is the main type of biopsy used for endometrial sampling known as?

Answer 39

This is a Pippele biopsy

This is the name of the procedure which takes a small sample of tissue from the lining of the womb (endometrium).

This sample is then sent off to the laboratory to check if you have any cancer or other abnormal cells in the lining of your womb.

Question 40

Does endometrial or cervical cancer affect younger women? How often is screening in which type of cancer?

Answer 40

Endometrial cancer tends to affect post-menopausal women

Cervical cancer tends to affect younger menopausal women

Screening in cervical cancer

• Women aged 25-49 are offered screening every 3 years
• Women aged 50-64 are offered screening every 5 years
• Women aged 65 and above are usually not offered screening

Question 41

There are many different treatment options for dysfucntional uterine bleeding Remember dysfucntional uterine bleeding is usually intermenstrual bleeding and can be quite heavy so want to achieve a regular menstrual cycle with normal periods

What is the 1st line treatment in DUB? (oral and intrauterine)

Answer 41

Levenogestrel - LVG-IUS

This intrauterine drug is known as mirena

Question 42

Mirena is the brand name for the intrauterine system It is a Tshaped contraceptive device that prevents sperm from reaching the egg amongst other things WHat hormone does the brand name mirena treatment release into the uterus? How does it work?

Answer 42

Releases levenogestrel

This inhibits ovulation and also thickens the cervical mucus to prevent sperm entry

Question 43

How long does the T shaped plastic device (mirena) last for?

Answer 43

Can last for 3-5years

Question 44

What is the second line treatment of DUB? Three options are given for 2nd line treatment

Answer 44

2n line - Tranexamic acid would be prescribed for the patient - this is an antifibrinolytic used to reduce bleeding (the degradation of fibrin in blood clots would be termed fibrinolysis)

NSAIDs or Combined contraceptive pill: thins the lining of the womb, thickens the mucus in the neck of the womb.

Take for 21 days then 7 day break.

Contains oestrogen and progesterone.

Question 45

What is the third line treatment for DUB?

Answer 45

Oral progestogens - Norethisterone

Question 46

When hysterectomy is advised, will the woman remain fertile afterwards?

Answer 46

The women will not be fertile and must be advised of this

Question 47

What is the medication treatment of DUB? 1st second and third line

Answer 47

1st line - give levenogestrel intrauterine system (LVG - IUS)

2nd line - Antifibrinolytics , (Tranexamic acid), NSAIDs or combined OCP

3rd line- oral pregestogens, norithesterone

Question 48

If medication treatments fail to work to treat the dysfunctional uterine bleeding , what can be attempted?

Answer 48

Endometrial ablation/resection

Question 49

What is the last line treatment for DUB?

Answer 49

The last line treatment for DUB is hysterectomy

Question 50

What are the names of the four different types of hysterectomy?

Answer 50

Total hysterectomy

Sub-total hysterectomy

Total hysterectomy with bilateral salpingo-oopherectomy (salpingectomy - fallopian tubes, oopherectomy - ovaries)

Radical hysterectomy

Question 51

What are the four different types of hysterectomy?

Answer 51

Total hysterectomy - the womb and cervix (neck of womb are removed)

Subtotal hysterectomy - the body of womb is removed leaving the neck of the cervix in place

Total hysterectomy with bilateral salpingo-oophorectomy - the womb, cervix, fallopian tubes and ovaries are removed

radical hysterectomy – the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue

Question 52

Adverse effects of medical treatments are not permanent and main downside is they may not work Endometrial ablation is preferred to hysterectomy as there is fewer complications and faster recovery What HRT is required in both?

Answer 52

Endometrial ablation requires combined hormone replacement therapy (HRT)

Hysterectomy only requires oestrogen (HRT)

Question 53

What are the three categories of procedure to carry out a hysterectomy?

Answer 53

• vaginal hysterectomy – where the womb is removed through a cut in the top of the vagina
• abdominal hysterectomy – where the womb is removed through a cut in the lower abdomen
• laparoscopic hysterectomy (keyhole surgery) – where the womb is removed through several small cuts in the abdomen