Week 1-menstrual disorders Flashcards
Describe the follicular phase of menstruation
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.
Describe ovulation
Luteinising hormone surge just before ovulation.
Dominant follicle ruptures releasing oocyte.
Describe the luteal phase of menstruation
Formation of corpus luteum
Progesterone production
Describe the endometrial lining in the proliferative phase of menstruation?
Oestrogen induced growth of endometrial glands and stroma.
Describe the endometrial lining in the luteal phase of menstruation?
Progesterone induced glandular secretory activity.
Decidualisation (changes in the endometrial lining in preparation for pregnancy).
Endometrial apoptosis and subsequent menstruation
Describe the endometrium during menstruation?
Arteriolar construction and shredding of the functional endometrial layer.
Fibrinolysis inhibits scar tissue formation.
At what day in the cycle does 1- ovulation and 2-menstruation occur?
1- 14 days
2- day 1-6.
How long is a normal menstrual cycle?
28 days +/- 7 days
Menorrhagia
Heavy periods (prolonged and increased menstrual flow)
Metrorrhagia
Regular intermenstrual bleeding
Polymenorrhoea
Periods occur at less than a 21 day interval
Polymenorrhagia
Increased bleeding and frequent cycle
Menometrorrhagia
Prolonged heavy periods and intermenstrual bleeding
Amenorrhoea
Absence of menstruation >6 months.
Oligomenorrhoea
Periods at intervals of greater than 35 days.
What are the causes of menorrhagia?
Can be organic- caused by pathology
Or non-organic- absence of pathology
What is non-organic menorrhagia also known as?
Dysfunctional uterine bleeding.
What local disorders can cause organic menorrhagia?
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
What are fibroids?
Why are they associated with heavy periods?
Do they cause symptoms?
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.
What is adenomyosis?
Does it cause symptoms?
Lining of the uterus (endometrium) is present in the myometrium (muscle layer). Meaning blood can’t escape.
Can be quite painful.
What is cervical eversion?
Why does it cause bleeding?
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.
Why do intrauterine contraceptive devices cause menorrhagia?
If its copper it causes bleeding.
What systemic disorders can cause menorrhagia?
Endocrine disorders- hyper/hypothyroidism
Diabetes
Adrenal disease
Prolactin disorders
Disorders of haemostasis- Von willebrands disease ITP Liver disorders Renal disease Drugs- anticoagulants.
How would you diagnose dysfunctional uterine bleeding?
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.
What investigations would you do into dysfunctional uterine bleeding?
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
What is the general rule for treatment of DUB?
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.
What medical options are there for treatment of DUB?
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
What surgical management can be offered for DUB?
Endometrial resection/ablation
Hysterectomy
Describe the pro’s and cons of treatment of DUB using surgical and medical management
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.
Compare endometrial ablation and hysterectomy for treatment of DUB
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
