DUB, Ovarian Function and Anovulation (7.2)

Question 1

State the 2 main functions of the ovary

Answer 1

1. Ovulation: To perform the maturation and release (through ovulation) of the oocyte
2. Endocrine: To secrete oestradiol and progesterone

Question 2

Outline the HPO axis

Answer 2

Question 3

Outline the process of ovulation

Answer 3

The ovulatory cycle:

1. Recruitment: Around 5 follicles per follicular phase
2. Selection: The most dominant tertiary follicle is selected following the FSH window (5 days)
3. Atresia

⋆ FSH window: [FSH] above the threshold level. Allows for the development and selection of the most domiannt follicle.

Question 4

Outline the process of folliculogenesis

Answer 4

• Takes 3 ovarian cycles for complete maturation of the follicle - see wikipedia image

Question 5

Define anovulation and its possible mechanisms

Answer 5

Anovulation: Failure to release a mature ovum, in preparation for fertilisation, through ovulation

Possible mechanisms:

Ovulatory failure: Failure to ovulate

Ovulatory dysfunction: Irregular ovulation. Failure of the oocyte to mature and undergo ovulation

Ovarian failure: Depletion of oocytes

Question 6

Outline the WHO classification of anovulation

Answer 6

Question 7

Define NUB (normal uterine bleeding) and its mechanism

Answer 7

Cyclical shedding of the endometrial lining, under hormonal control. Occuring approximately every 28 days.

Oestrogen release, triggered by FSH, causes proliferation of the endometrial lining. Oestrogen creates a positive feedback loop, causing a mid-cycle surge in LH, allowing for ovulation and subsequent menses.

Mechanism:

• Shedding of the endometrial stratum functionalis
• The endometrial stroma ‘shrink’
• Spiral arterioles vasoconstrict (as vasodilatory progesterone is lost) and hypoxia follows. Prostaglandin synthesis and inflammation result → dysmenorrhoea.

Duration: 3-5 days

Amount: 40 ml on average

Question 8

AUB: State the ‘regular’ variations

Answer 8

Menorrhagia - heavy/prolonged menses (heavy = > 80 ml)

Oligomenorrhea - light/infrequent menses

Polymenorrhea - Short cycle length

Amenorrhea - Absence of menses

Question 9

AUB: State the ‘irregular’ variations

Answer 9

Metrorrhagia - Frequent and irregular (between menstrual periods)

Intermenstrual

Postcoital

Post-menopausal

Question 10

AUB: State the possible causes

⋆ Structural: PALM

⋆ Functional: COIN

Answer 10

Structural: PALM

Polys

Adenomyosis

Leiomyoma (fibroids)

Malignancy

Functional: COIN

Coagulopathy

Ovulatory (endocrine)

Idiopathic

Not yet classified

Question 11

Outline the assessment/diagnosis of AUB

Answer 11

1. Symptomatology:

Pattern & severity: Menstrual diary

Impact on health & QOL

Associated symptoms: Pelvic pain, anaemia, weight loss, urinary/bowel symptoms

2. Underlying pathology

Nature, extent/severity

3. Patient’s circumstances

Demographics: Age, social, fertility

Medical background: DM, obesity, PCOS, BP, thyroid disease

Drug Hx: Iron, anti-coagulants

Examination

• Check for pelvoc:abdominal mass
• Check cervix (polyps), uterus and adnexa

Investigations

Imaging: USS (ultrasound scan), MRI

Hysteroscopy: Used for polyps and suspected uterine pathology

Endometrial biopsy

Question 12

Outline possible management strategies for AUB

Answer 12

Structural causes:

• Medical
  
  • Adenomyosis:

Non-hormonal: NSAIDs, transexamic acid

Hormonal: COCP, progestogens, Mirena IUS, GnRH agonist

• Surgical:
  
  • Fibroids: Removal or uterine artery embolization (stops growth of the mass)

Functional causes:

• Non-hormonal: NSAIDs, tranexamic acid (anti-fibrinolytic)
• Hormonal: COCP, progestogens, Mirena IUS, GnRH agonist
• Treat cause: Applicable for thyroid disease, blood disorders, fibroids, anaemia
• Endometrial ablation: Can be used if conservative treatment is unsuccessful. May use novasure (scrape), thermal balloon or hyrothermal ablation.
• Hysterectomy

Question 13

AUB: Outline the mechanism of ovulatory AUB

Answer 13

Anovulation → Lack of progesterone (no corpus luteum) → Excessive endometrial proliferation which eventually exceeds the structural support matrix → Endometrium breaks down → heavy menses (?)

Question 14

AUB: State coagulopathies which may lead to AUB

Answer 14

Bleeding may be increased due to:

• Von Willebrand disease ⇒ less coagulation and more bleeding
• Thrombocytopenia (low platelet levels)
• Vitamin K deficiency (dependent clotting factors)
• NSAIDs, penicillin
• Anti-coagulant treatments

Question 15

Structual causes of AUB: State the risk factors for malignancy

Answer 15

• PCOS
• > 45 years
• Obesity
• Hypertension
• Diabetes

Question 16

Structural AUB: Outline how polys may cause AUB

Answer 16

May cause excessive menstrual bleeding, post-coital bleeding or intramenstrual spotting

Question 17

Structural AUB: Outline adenomyosis and its symptoms

Answer 17

Adenomyosis: Growth of endometrial tissue within the myometrium of the uterus

Symptoms:

• Heavy, painful and irregular periods
• Pre-menstrual pelvic pain
• ‘Fullness’ in the pelvis

Question 18

Structural AUB: Outline leiomyoma and its symptoms

Answer 18

Leiomyoma: Growths of smooth muscle and fibrous tissue

Symptoms

• Menorrhagia
• Intermenstrual and post-coital bleeding
• Abdominal pain
• Pain during intercourse

Question 19

Define Chronic Pelvis Pain (CPP) and the associated risk factors

Answer 19

Pelvic pain persisting for > 6 months

Aetiology:

• May be resultant of limbic lobe dysregulation
  
  • The psychological effects of physical abuse lead to disregulation of the cingulate gyrus, amygdala and insular cortex
• Centrally mediated allodynia (pain from a non-noxious stimuli) without end-organ pathology

Risk factors:

• Single, separated, divorced
• PID
• Pregnancy
• Endometriosis
• Previous CS
• Hx of sexual abuse
• Hx of drug/alcohol abuse

Question 20

Outline the possible causes of CPP

Answer 20

Gynaecological:

• Endometriosis
• Adhesions
• Ovarian Cyst
• Fibroid

Non-gynaecological

• Bowel
• Urinary
• MSK
• Neuropathic
• Psychological

Unexplained

Question 21

Define endometriosis, possible theories and its pathology

Answer 21

Endometriosis: Ectopic growth of endometrial stroma/glands outside of the uterine cavity

Possible theories:

• Retrograde menstruation and perineal implantation

Pathology: Ectopic growth of the oestrogen sensitive tissue leads to bleeding in these areas. Inflammation leads to scarring and adhesions. This may then cause CPP.

Inflammation → fibrosis → adhesions → CPP

Question 22

Outline the symptoms associated with endometriosis

Answer 22

• Dysmenorrhoea (62 %)
• Dyspareunia
• Non-cyclic pain

Associated non-gynaecological symptoms:

• Urinary: Haematuria and dysuria
• Bowel disturbances: Dyschezia, tenesmus
• Pain/symptoms worsen around period

All pain and symptoms worsen around the time of menses

Question 23

Outline the management of endometriosis

Answer 23

Pain management: Paracetamol, NSAIDs

Hormonal treatment:

• Pseudopregnancy: Progesterone (POP), COCP
• Pseudomenopause: GnRH analogues

Surgery:

• Conservative: Ablation, cystectomy (removal of ‘chocolate’ cysts)
• Radical: Hysterectomy