Menstrual Cycle/Menstrual Problems

Question 1

Endometrial effects in proliferative phase?

Answer 1

Endometrium thickens ↑ stromal cells, ↑ glands, blood vessels.
By ovulation endometrium 2-3mm thick.

Question 2

Endometrial effects in secretory phase?

Answer 2

↑secretion, ↑lipids and glycogen, ↑blood supply
Endometrium 4-6mm thick
Optimal condiitons for implantation of fetilised egg

Question 3

What happens to endometrium if no fertilisation?

Answer 3

Vasodilation (vasospasm) –> necrotic layers of endometrium separate from uterus –> uterine contractions –> menstruation

Question 4

Cervical effects of menstrual cycle?

Answer 4

• Mucus production from columnar glands
• Stringy and runny midcycle (spinnbarkeit) –> facilitates sperm access at ovulation
• Tenacious and inelastic in luteal phase (moderated by progesterone)

Question 5

Definition of abnormal menstrual bleeding (AUB)?

Answer 5

Any menstrual bleeding that is either:
o Abnormal in volume (excessive duration or heavy)
o Abnormal in regularity, timing (delayed or frequent)
o Non-menstrual (IMB, PCB, PMB)

Question 6

Structural causes of AUB?

Answer 6

PALM

Polyps (endometrial/cervical)
Adenomyosis
Leimyoma
Malignancy/pre-malignancy

Question 7

Non-structural causes of AUB?

Answer 7

COEIN

Coagulopathy
Ovulatory dysfunction (PCOS, hypoT)
Endometrial disorders (inflammatory - endometritis)
Iatrogenic (COCP, IUS, warfarin)
Not yet classified

Question 8

Questions to ask to determine whether coagulation problems are present?

Answer 8

Heavy from menarche?
FH?
PPH?

Question 9

Definition of heavy menstrual bleeding?

Answer 9

Excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material QoL.

Question 10

History in menorrhagia?

Answer 10

•	How heavy is the bleeding?
o	Clots (including size), flooding.
o	Frequency of pad change, type of pad
o	Waking at night to change protection
o	How is it affecting her daily life?

• Associated symptoms? – pain/pressure
• Anaemia symptoms?
• Smear history
• Gynae history  contraception use
• Past obstetric history
• Medical (bleeding disorders), drug (warfarin), social, family histories.

Question 11

Examination in menorrhagia?

Answer 11

• Anaemia common.

• Pelvic signs often absent
o Irregular enlargement of uterus suggests fibroids
o Tenderness with or without enlargement suggests adenomyosis
o Ovarian mass may be felt

• Tenderness and immoblile pelvic organs are common with infection/ endometriosis (not a cause but may co-exist)

Question 12

Main investigation in menorrhagia? Bloods if history suggests?

Answer 12

FBC (Hb)

Coagulation (VW disease screen) and TFTs

Question 13

Further investigations in menorrhagia if indicated?

Answer 13

TV USS Pelvis - indicated if enlarged uterus, mass, treatment failure - assess endometrial thickness, exclude fibroid/ovarian mass/polyps

Hysteroscopy - Allows inspection of uterine cavity – detection of polyps and submucous fibroids that could be resected.

Endomtrial biopsy - done at hysteroscopy with a Pipelle – to exclude endometrial malignancy or premalignancy.

Question 14

Indications for endometrial biopsy in menorrhagia

Answer 14

o If endometrial thickness >10mm or polyp suspected
o If woman >40 years old with recent onset menorrhagia
o IMB
o Not responding to treatment

Question 15

1st line medical treatment for menorrhagia?

Answer 15

Mirena coil – reduces menstrual flow by >90% with considerably fewer side effects.

Question 16

2nd line medical treatments for menorrhagia?

Answer 16

• Antifibrinolytics (tranexamic acid) - Taken during menstruation only. Reduce blood loss by 50% - few side effects.
• NSAIDs (Mefanamic acid) - Inhibit prostaglandin synthesis –> reduce blood loss by 30%. Also useful for dysmenorrhoea. Similar side effects to aspirin.
• Combined Pill - Induces lighter menstruation – less effective if pelvic pathology present. Use limited - complications more common in older patients.

Question 17

3rd line medical treatments for menorrhagia?

Answer 17

• Progestogens - Taken in high doses orally/IM –> amenorrhoea. Bleeding follows withdrawal. NOT CONTRACEPTIVE.

GnRH agonists - Produce amenorrhoea. Unless add-back HRT used, duration limited to 6 months. Bleeding follows withdrawal.

Question 18

Surgical options for menorrhagia?

Answer 18

Endometrial ablation - destruction of endometrium –> amenorrhoea or lighter periods (not contraceptive)

Uterine artery embolisation - collateral circulation keeps uterus alive.

Hysterectomy - last resort - uterus normal in 50%

Question 19

When is irregular menstruation/IMB more common?

Answer 19

At extremes of reproductive age

Question 20

Two main causes of irregular bleeding/IMB?

Answer 20

Anovulatory cycles

Pelvic pathology

Question 21

What are anovulatory cycles and why do they cause IMB?

Answer 21

No ovulation –> no progesterone - oestrogen cannot support growing endometrium –> bleeding = oestrogen breakthrough bleed

Question 22

What pelvic pathology can cause irregular bleeding/IMB?

Answer 22

Fibroids, uterine/cervical polyps, adenomyosis, ovarian cysts, chronic pelvic infection

MALIGNANCY

Question 23

Investigations in IMB/irregular bleeding?

Answer 23

FBC - assess effect of blood loss
Exclude malignancy
- smear if needed
- USS - >35 or not responding to treatment
- Biopsy - if thickened, polyp suspected, >40

Question 24

1st line management of IMB/irregular bleeding?

Answer 24

IUS or COCP

Question 25

2nd line managment of IMB/irregular bleeding?

Answer 25

Progestogens - give on a cyclical basis to mimic normal cyle HRT - can regulate bleeding in perimenopause Other treatments for menorrhagia can be used.

Question 26

Causes of primary amenorrhoea?

Answer 26

``` Anorexia nervosa Physiological athleticism Hyperprolactinaemia Hypo/hyperthyroidism Adrenal tumours/hyperplasia PCOS Premature ovarian failure Imperforate hymen Transverse vagainal septum Turner's syndrome ```

Question 27

Non-pathological causes of secondary amenorrhoea?

Answer 27

Pregnancy Lactation Menopause Drugs

Question 28

Pathological causes of secondary amenorrhoea?

Answer 28

``` Anorexia nervosa Physiological athleticism Hyperprolactinaemia Hypo/hyperthyroidism Adrenal tumours PCOS Premature ovarian failure Asherman's syndrome Cervical stenosis ```

Question 29

What is post-coital bleeding?

Answer 29

ALWAYS ABNORMAL must exclude carcinoma

Question 30

Causes of post-coital bleeding?

Answer 30

``` Situations where cervix not covered in healthy squamous epithelium --> more likely to bleed after mild trauma • Cervical carcinoma • Cervical ectropion • Cervical polyps • Cervicitis, vaginitis ```

Question 31

Management of post-coital bleeding?

Answer 31

* Cervical examination – smear taken. * If polyp evident --> avulsed and sent for histology * If smear -ve --> ctropion can be frozen with cryotherapy * Otherwise --> colposcopy to exclude malignant cause

Question 32

What causes pre-menstrual syndrome?

Answer 32

Progesterone - occurs in luteal phase

Question 33

Features of pre-menstrual syndrome?

Answer 33

Behavioural changes – ‘tension’, irritability, aggression, depression, loss of control. Physical symptoms – bloatedness, minor GI upset, breast pain.

Question 34

Medical management of premenstrual syndrome?

Answer 34

• SSRIs – continuous or intermittently in second half of cycle. • Ablation of cycle o Continuous oral contraception; oestrogen HRT patches. o Trial of GnRH agonist and add-back oestrogen therapy --> perimenopause. o Bilateral oophorectomy

Question 35

Supplements to help premenstrual syndrome?

Answer 35

* Oil of evening primrose oil – good for breast tenderness * Pyridoxine (vitamin B6) – good in mild doses, can cause neuropathy in excess. * Vitex agnus-castus extract

Question 36

Diagnostic criteria for PCOS?

Answer 36

(2/3 needed) o PCO on USS o Irregular periods (>35 days apart) o Hirsutism (Clinical – acne or excess body hair, Biochemical – raised serum testosterone)

Question 37

Aetiology of PCOS

Answer 37

Disordered LH production and peripheral insulin resistance --> increased insulin --> raised ovarian androgen production Environmental factors (weight) can modify phenotype

Question 38

Clinical features of PCOS?

Answer 38

``` • Obesity • Acne • Hirsutism • Oligomenorrhoea/ amenorrhoea • Subfertility/miscarriage Changes in weight over time will alter insulin levels and severity of syndrome. ```

Question 39

Bloods in PCOS?

Answer 39

Anovulation - FSH (↑ in ovarian failure, ↓in hypothalamic disease, normal in PCOS) Prolactin (to exclude prolactinoma) TSH Hirsutism - Serum testosterone levels (androgen-secreting tumour or congenital adrenal hyperplasia if very raised) LH - Often raised in PCOS but not diagnostic

Question 40

Complications of PCOS?

Answer 40

• Diabetes - 50% develop TIIDM; 30% develop gestational diabetes  risk reduced by weight reduction • Endometrial cancer - More common after many years of amenorrhoea due to unopposed oestrogen action. • Normal oestrogen levels so not at risk of osteoporosis.

Question 41

Treatment for PCOS?

Answer 41

Weight Reduction - Will reduce insulin levels  improvement in PCOS symptoms COP - If fertility not required --> regulates menstruation and treats hirsutism. 3-4 bleeds per year necessary to protect endometrium Antiandrogens - Cyproterone acetate/spironolactone – effective for hirsutism, but conception must be avoided. Metformin - Insulin sensitizer --> reduces insulin levels --> reduces androgens and hirsutism and promotes ovulation. Eflonithine - Topical antiandrogen for facial hirsutism.