Menstrual Disorder

Question 1

What are the phases of the ovarian cycle?

Answer 1

Follicular phase, ovulation, luteal phase

Question 2

What happens in the follicular phase of the ovarian cycle?

Answer 2

FSH stimulates follicle development and granulosa cells to produce oestrogen
Raising oestrogen and inhibin by dominant follicle inhibits FSH production
Declining FSH levels cause atresia of all but dominant follicle

Question 3

What happens during ovulation?

Answer 3

Prior LH surge

Dominant follicle ruptures and releases oocyte

Question 4

What happens during the luteal phase of the ovarian cycle?

Answer 4

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

Question 5

What are the phases of the endometrial cycle?

Answer 5

Proliferative phase, luteal phase, menstruation

Question 6

What occurs in the proliferative phase of the endometrial cycle?

Answer 6

Oestrogen-induced growth of endometrial glands and stroma

Question 7

What happens in the luteal phase of the endometrial cycle?

Answer 7

Progesterone-induced glandular secretory activity
Decidualisation in late secretory phase
Endometrial apoptosis and subsequent menstruation

Question 8

What happens during menstruation?

Answer 8

Arteriolar constriction and shedding of functional endometrial layer
Fibrinolysis inhibits scar tissue formation

Question 9

What is the normal duration of the menstruation?

Answer 9

Menstrual loss usually lasts for 4-6 days

Flow peaks at day 1-2

Question 10

What is the normal amount of blood shed during menstruation?

Answer 10

<80ml per menstruation = no clots

Question 11

What is the normal length of a menstrual cycle?

Answer 11

Between 21-35 days
Average is 28 day cycle
No IMB or PMB

Question 12

What can the causes of menorrhagia be split into?

Answer 12

Organic and non-organic = non-organic accounts for 50% of cases and is also known as DUB

Question 13

What are some local disorders that cause menorrhagia?

Answer 13

Fibroids, adenomyosis and endometriosis
Endocervical/endometrial polyps
Cervical eversion and endometrial hyperplasia
IUCD and pelvic inflammatory disease
Cervical/uterine cancer or hormone producing tumour
Trauma or AVM

Question 14

What are some systemic conditions that cause menorrhagia?

Answer 14

Hyper/hypothyroidism or adrenal disease
Prolactin disorder, ITP or diabetes
Von Willebrand's disease, liver or renal disease 
Deficiency of factor 2, 5, 7 or 11
Anticoagulants

Question 15

What conditions associated with pregnancy can cause menorrhagia?

Answer 15

Miscarriage, ectopic pregnancy, gestational trophoblastic disease, postpartum haemorrhage

Question 16

How common is dysfunctional uterine bleeding (DUB)?

Answer 16

Accounts for 50% of women with abnormal uterine bleeding = diagnosis of exclusion

Question 17

What is DUB subdivided into?

Answer 17

Anovulatory and ovulatory

Question 18

What are the features of anovulatory DUB?

Answer 18

Accounts for 85% of all DUB
Occurs at extremes of reproductive life
Irregular cycle
More common in obese women

Question 19

What are the features of ovulatory DUB?

Answer 19

More common in women aged 35-45
Regular heavy periods
Due to inadequate progesterone production by corpus luteum

Question 20

What investigations are done for DUB?

Answer 20

FBC, cervical smear, TSH, coagulation screen, liver/renal function test, TVUS, endometrial sampling

Question 21

What does TVUS assess?

Answer 21

Endometrial thickness

Presence of fibroids and other pelvic masses

Question 22

What are the different methods of endometrial sampling?

Answer 22

Pipelle biopsies, hysteroscopically directed, dilatation and curettage

Question 23

What are the non-surgical treatments of DUB?

Answer 23

Medical = progesterones, combined oral contraceptive pill, danazol, GnRH analogues, NSAIDs, anti-fibrinolytics, capillary wall stabilisers
Progestogen-releasing IUCD = Mirena IUS

Question 24

What are the surgical treatments of DUB?

Answer 24

Endometrial resection/ablation

Hysterectomy

Question 25

What are the types of endometrial resection/ablation?

Answer 25

Transcervical endometrial resection (TCER) Rollerball endometrial ablation (REA) Bipolar mesh endometrial ablation Thermal balloon ablation and thermal hydroablation

Question 26

What are the different types of hysterectomy?

Answer 26

Sub total hysterectomy Total abdominal hysterectomy Vaginal hysterectomy LASH, LAVH and TLH

Question 27

What are the pros and cons of medical management of DUB?

Answer 27

Cheaper, no waiting list, no anaesthetic risk, adverse effects non-permanent, may not be effective, fertility preserved

Question 28

What are the pros and cons of surgical treatment of DUB?

Answer 28

More expensive, waiting list, anaesthetic risk present, complications possible, very effective, amenorrhoea occurs with hysterectomy, fertility lost

Question 29

What are the pros and cons of endometrial ablation?

Answer 29

Daycase procedure, shorter operating time and recovery, fewer complications, requires cervical smears, needs combined HRT

Question 30

What are the pros and cons of hysterectomies?

Answer 30

Major operation, longer operating time and recovery, more complications, no cervical smears needed (for total hysterectomies), oestrogen-only HRT (unless cervix is retained)