Menstrual Disorder

Question 1

Pituitary and ovarian events of menstrual cycle

Answer 1

Follicular phase: FSH stimulates ovarian follicle development & granulosa cells to produce oestrogens
Raising oestrogen & inhibin by dominant follicles inhibit FSH production
Declining FSH levels cause atresia of but dominant follicle

Ovulation
Prior LH surge
Dominant follicle ruptures and releases oocyte

Luteal phase
Formation of corpus luteum
Progesterone production
Luteolysis 14 days post-ovulation

Question 2

Endometrial events of menstrual cycle

Answer 2

Proliferative phase
Oestrogen-induced growth of endometrial glands and stroma
Luteal phase
Progesterone-induced glandular secretory activity
Decidualisation in late secretory phase
Endometrial apoptosis and subsequent menstruation
Menstruation
Arteriolar constriction and shedding of functional endometrial layer
Fibrinolysis inhibits scar tissue formation

Question 3

Normal menstruation and menstrual cycle

Answer 3

Menstrual loss
Menstrual loss usually lasting 4 -6 days
Menstrual flows peaks day 1-2
< 80 ml per menstruation
No clots/ flooding- indicates period is heavier than normal

Normal Menstrual cycle
Average 28 day cycle
Between 21 to 35 days cycle
No IMB or PCB

Question 4

Classification of causes of menorrhagia (prolonged and increased menstrual flow)

Answer 4

organic: presence of pathology
- systemic
- local
- pregnancy

Non organic: absence of pathology, also known as dysfunctional uterine bleeding (DUB) , very common (50%)

Question 5

Local disorders as a cause of organic menorrhagia (11)

Answer 5

Fibroids- benign growth of the uterus

Adenomyosis – ectopic endometrium present in the myometrium, presents with pain in addition to menorrhagia

Endocervical or Endometrial polyp

Cervical eversion – endocervical glandular epithelium pouches up in the ectocervix (benign)

Endometrial hyperplasia

Intrauterine contraceptive device (IUCD)

Pelvic inflammatory disease (PID)

Endometriosis

Malignancy of the cervix or uterus

Hormone producing tumours

Trauma

Others e.g. arteriovenous malformations

Question 6

Systemic disorders as a cause of organic menorrhagia

Answer 6

Endocrine disorders - Hyper/hypothyroidism, DM, Adrenal hyperplasia, prolactin disorders

Disorders of hemostasis - Von willebrand’s disease, ITP, Factor II,V,VII and XI def

Liver disorders - chronic liver disease, liver cirrhosis

Renal disease

Drugs - anticoagulants

Question 7

Pregnancy as a cause of organic menorrhagia

Answer 7

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Postpartum haemorrhage

Question 8

Subdivisions of DUB

Answer 8

Anovulatory

• 85% of all DUB
• at extremes of reproductive life (menarche and menopause)
• more common in obese women

Ovulatory

• more common in women aged 35-45
• regular, heavy periods
• due to inadequate progesterone production by corpus luteum

Question 9

Investigation of DUB

Answer 9

Full blood count - interested in Hb levels

Cervical smear - in UK smears are done regularly, hence just ask in history

TSH

Coagulation screen

Renal/Liver function tests

Transvaginal ultrasound scan

• Endometrial thickness
• Presence of fibroids and other pelvic masses

Endometrial sampling (endometrium >4mm)

• Pipelle biopsies
• Hysteroscopic directed
• Dilatation & curettage (D & C)

Question 10

In which situations are transvaginal scans indicated?

Answer 10

1. Pathological finding on clinical examination
   - eg. pelvic mass on palp of abdo (rule out fibroid or endometriosis)
2. To measure endometrial thickness (exclude other pathologies causing DUB including endometrial carcinoma)

Question 11

Non surgical methods for management of DUB

Answer 11

1. Medical therapy

2. Progesterone releasing IUCD - Mirena IUS

Question 12

Drugs used in medical therapy for DUB

Answer 12

Progestogens - synthetic, progesten analogue

Combined oral contraceptive pill

Danazol

GnRH analogues (uncommon)

Non-steroidal anti-inflammatory drugs (NSAIDs)

Anti-fibrinolytics

Capillary wall stabilisers

Question 13

Features of Mirena IUS

Answer 13

lifespan of 5years

contains the same drug as oral progestogen, except delivers the drug locally

Less SE and better compliance

Question 14

When to use hormonal and non-hormonal treatment?

Answer 14

Regular cycle with heavy periods - non-hormonal treatment

Irregular cycle with heavy periods - hormonal

Question 15

Surigcal methods for management of DUB

Answer 15

1. Endometrial ablation - burn the endometrium (simpler and lower complications)
2. Hysterectomy - remove uterus

Question 16

Medical vs Surgical treatment of DUB

Answer 16

MEDICAL

• cheaper
• No waiting
• No anaesthetic risk
• May not work
• Fertility can be retained

SURGERY

• Expensive
• Waiting list
• Anaesthetic risks present
• Complications present
• Very effective (amenorrhea with hysterectomy)
• Fertility is lost