Disorders of Menstruation

Question 1

Where is GnRH secreted from and what role does it play?

Answer 1

GnRH is released from the hypothalamus.

It stimulates the release of FSH and LH.

Question 2

What is the role of FSH?

Answer 2

Stimulates follicular growth.

Question 3

What secretes progesterone?

Answer 3

Corpus luteum

Question 4

What chemicals are released to cause uterine spiral arterioles to constrict, shedding the endometrium as a period?

Answer 4

Prostaglandins

Question 5

Which layer of the endometrium is cast out as a period?

Answer 5

Stratum functionalis - the other layer (stratum basalis) remains.

Question 6

What are pre-menstrual disorders?

Answer 6

Normal menstrual symptoms that inhibit daily function.

They are cyclical, occuring in the luteal phase.

Question 7

How are pre-menstrual disorders treated?

Answer 7

Combined OC or GnRH agonist - the aim is to suppress ovulation.

SSRIs can also help.

Question 8

What may result from solitary oestrogen therapy?

Answer 8

Endometrial hyperplasia (this is a pre-cancerous state).

Question 9

What is the first-line treatment for heavy menstrual bleeding?

Answer 9

Mirena coil

Question 10

If mirena coil is unsuccessful in preventing heavy menstrual bleeding what is given?

Answer 10

Give tranexamic acid or combined OC.

If still persists, give PO pill.

Surgery is the last-line of therapy.

Question 11

What is premenstrual syndrome?

Answer 11

A complex of symptoms experienced in the days immediately prior to menstruation.

Causes a wide range of symptoms.

Question 12

What is the difference in PMS symptoms compared to normal period?

Answer 12

The key to diagnosis is the severity of impact experienced on normal life.

Question 13

If conception does not occur, what happens?

Answer 13

Progesterone and oestrogen levels drop, allowing menstruation to occur.

Question 14

What is suggested as the cause of PMS?

Answer 14

Sensitivity to progesterone.

Not yet fully understood.

Question 15

How is PMS diagnosed?

Answer 15

Symptom diary over 2 cycles.

Question 16

What is first-line treatment for PMS?

Answer 16

Exercise
CBT
Vitamin B6 supplementation
Combined OC pill
Continuous/Luteal phase only SSRI

Question 17

What is second-line for PMS?

Answer 17

Estradiol patches
Microionised progesterone (this is aimed at protecting the endometrium).
Increased dose SSRIs (can be continuous or luteal phase only).

Question 18

What is third-line for PMS?

Answer 18

GnRH analogues and HRT.

Question 19

What is the aim of PMS treatment?

Answer 19

To suppress progesterone/ovulation.

Treat continuously rather than cyclically.

Question 20

Is estradiol/HRT a contraceptive?

Answer 20

No, need a contraceptive alongside this.

Question 21

Which hormone stimulates the growth of the endometrium?

Answer 21

Oestrogen

Question 22

What is the risk of suppressing progesterone?

Answer 22

Oestrogen will now be unopposed. Risk of cancer.

Give mirena coil/microionised progesterone to counteract this.

Question 23

What must be given alongside GnRH antagonists?

Answer 23

Contraception as it can virilise a female foetus.

Question 24

When are GnRH analogues used in PMS?

Answer 24

Severe disease or for diagnosis only.

They are very effective but affect bone mass density significantly.

If necessary to give these, then perform DEXA scan each year.

Question 25

What surgery options are available in PMS?

Answer 25

Hysterectomy
Bilateral oophorectomy

Only considered if medical management fails.

Question 26

What is recommended if GnRH analogues effectively manage symptoms?

Answer 26

Surgery

Question 27

What is dysfunctional uterine bleeding?

Answer 27

Irregular uterine bleeding that reflects disruption of the normal menstrual cycle.