Week 1-menstrual disorders

Question 1

Describe the follicular phase of menstruation

Answer 1

FSH stimulates ovarian follicle to develop and the granulosa cells produce oestrogen. Rising oestrogen levels then subsequently inhibit FSH production.
Declining FSH levels cause atresia in all but one dominant follicle.

Question 2

Describe ovulation

Answer 2

Luteinising hormone surge just before ovulation.

Dominant follicle ruptures releasing oocyte.

Question 3

Describe the luteal phase of menstruation

Answer 3

Formation of corpus luteum

Progesterone production

Question 4

Describe the endometrial lining in the proliferative phase of menstruation?

Answer 4

Oestrogen induced growth of endometrial glands and stroma.

Question 5

Describe the endometrial lining in the luteal phase of menstruation?

Answer 5

Progesterone induced glandular secretory activity.
Decidualisation (changes in the endometrial lining in preparation for pregnancy).
Endometrial apoptosis and subsequent menstruation

Question 6

Describe the endometrium during menstruation?

Answer 6

Arteriolar construction and shredding of the functional endometrial layer.
Fibrinolysis inhibits scar tissue formation.

Question 7

At what day in the cycle does 1- ovulation and 2-menstruation occur?

Answer 7

1- 14 days

2- day 1-6.

Question 8

How long is a normal menstrual cycle?

Answer 8

28 days +/- 7 days

Question 9

Menorrhagia

Answer 9

Heavy periods (prolonged and increased menstrual flow)

Question 10

Metrorrhagia

Answer 10

Regular intermenstrual bleeding

Question 11

Polymenorrhoea

Answer 11

Periods occur at less than a 21 day interval

Question 12

Polymenorrhagia

Answer 12

Increased bleeding and frequent cycle

Question 13

Menometrorrhagia

Answer 13

Prolonged heavy periods and intermenstrual bleeding

Question 14

Amenorrhoea

Answer 14

Absence of menstruation >6 months.

Question 15

Oligomenorrhoea

Answer 15

Periods at intervals of greater than 35 days.

Question 16

What are the causes of menorrhagia?

Answer 16

Can be organic- caused by pathology

Or non-organic- absence of pathology

Question 17

What is non-organic menorrhagia also known as?

Answer 17

Dysfunctional uterine bleeding.

Question 18

What local disorders can cause organic menorrhagia?

Answer 18

Fibroids
Adenomyosis
Endocervical or endometrial polyp
Cervical eversion
Intrauterine contraceptive device
Pelvic inflammatory disease
Endometriosis
Malignancy of the cervix or uterus
Hormone producing tumours 
Trauma

Question 19

What are fibroids?
Why are they associated with heavy periods?
Do they cause symptoms?

Answer 19

Benign tumour of the myometrium. Usually results in the uterus being much larger than normal.
Associated with heavy periods because the surface endometrium is also enlarged.
Non- painful unless they are so enlarged they cause pressure symptoms.

Question 20

What is adenomyosis?

Does it cause symptoms?

Answer 20

Lining of the uterus (endometrium) is present in the myometrium (muscle layer). Meaning blood can’t escape.
Can be quite painful.

Question 21

What is cervical eversion?

Why does it cause bleeding?

Answer 21

Endocervical epithelium (columnar) of the cervical canal is pouched out into the ectocervix (squamous). The columnar epithelium tends to be more vascular so causes more bleeding.

However eventually the columnar epithelium undergoes metaplasia when exposed to the vaginal acidity, so the problem sorts itself out.

Question 22

Why do intrauterine contraceptive devices cause menorrhagia?

Answer 22

If its copper it causes bleeding.

Question 23

What systemic disorders can cause menorrhagia?

Answer 23

Endocrine disorders- hyper/hypothyroidism
Diabetes
Adrenal disease
Prolactin disorders

Disorders of haemostasis- Von willebrands disease
ITP
Liver disorders
Renal disease
Drugs- anticoagulants.

Question 24

How would you diagnose dysfunctional uterine bleeding?

Answer 24

Anovolutary- 85%. Occurs at the extremes of reproductive life. Irregular cycle. More common in obese women
Ovulatory -15%. Regular heavy periods. Due to inadequate progesterone productive by corpus luteum. More common in women age 35-45.

Question 25

What investigations would you do into dysfunctional uterine bleeding?

Answer 25

FBC- measure haemoglobin to exclude anaemia
Cervical smear
TSH
Coagulation screen
Renal/liver function tests

Important ones

• Transvaginal ultrasound- measure endometrial thickness. The thicker the endometrium the more likely you are to have endometrial carcinoma.
• Endometrial sampling-pipelle biopsies. Uses a hysteroscope- an endoscope through the cervix however needs general aneasthetic

Question 26

What is the general rule for treatment of DUB?

Answer 26

If irregular cycle- treat with hormonal manipulation e.g. progestogens and combined OCP
If regular cycle- treat with drugs.
Combination of heavy periods and shortened cycle- use both.

Question 27

What medical options are there for treatment of DUB?

Answer 27

Progestrogen replacing therapies- mirena coil is 1st line
2nd line are anti-fibrinolytics- tranexamic acid
or antiprostaglandins (NSAIDs)- mefenamic acid
The combined oral contraceptive pill is also affective
3rd line- progestogens IM

Question 28

What surgical management can be offered for DUB?

Answer 28

Endometrial resection/ablation

Hysterectomy

Question 29

Describe the pro’s and cons of treatment of DUB using surgical and medical management

Answer 29

Medical treatment

• cheaper
• No waiting list
• No anaesthetic risks
• Side effects temporary
• Fertility retained
• may not be effective

Surgical treatment

• more expensive
• Waiting list
• Anaesthetic risks
• Fertility lost
• completely effective.

Question 30

Compare endometrial ablation and hysterectomy for treatment of DUB

Answer 30

Endometrial ablation-

• day case
• shorter operating time
• shorter recovery
• fewer complications
• requires cervical smears and HRT therapy

Hysterectomy

• Major operation
• longer operating time
• longer recovery time
• more complications
• No cervical smears
• Oestrogen only HRT