Menstrual Disorder

Question 1

pituitary and ovarian events - what occurs during the follicular phase?

Answer 1

FSH stimulates ovarian follicle development and granulosa cells to produce oestrogens

raising oestrogen and inhibin by dominant follicles inhibit FSH production

declining FSH levels cause atresia of all but dominant follicle

Question 2

pituitary and ovarian events - what occurs during ovulation?

Answer 2

prior LH surge

dominant follicle ruptures and releases oocyte

Question 3

pituitary and ovarian events - what occurs during the luteal phase?

Answer 3

formation of corpus luteum

progesterone production

luteolysis 14 days post-ovulation

Question 4

endometrial events - what occurs during the proliferative phase?

Answer 4

oestrogen induced growth of endometrial glands and stroma

Question 5

endometrial events - what occurs during the luteal phase?

Answer 5

progesterone induced glandular secretory activity

decidualisation in late secretory phase

endometrial apoptosis and subsequent mensturation

Question 6

endometrial events - what occurs during menstruation?

Answer 6

arteriolar constriction and shedding of functional endometrial layer

fibrinolysis inhibits scar tissue formation

Question 7

what are the features of menstrual loss?

Answer 7

usually lasts 4-6 days
flow peaks day 1-2
<80ml per menstruation
no clots

Question 8

how long is the normal menstrual cycle?

Answer 8

21-35 days
average = 28 days

*no IMB or PCB

Question 9

what is menorrhagia?

Answer 9

prolonged and increased menstrual flow

Question 10

what is metrorrhagia?

Answer 10

regular intermenstrual bleeding

Question 11

what is polymenorrhoea?

Answer 11

menses occurring at <21 day interval

Question 12

what is polymenorrhagia?

Answer 12

increased bleeding and frequent cycle

Question 13

what is menometorrhagia?

Answer 13

prolonged menses and intermenstrual bleeding

Question 14

what is amenorrhoea?

Answer 14

absence of menstruation >6 months

Question 15

what is oligomenorrhoea?

Answer 15

menses at intervals of >35 days

Question 16

what is the difference between organic and non-organic menorrhagia?

Answer 16

organic - presence of pathology

non-organic - absence of pathology, 50% of cases, also known as dysfunctional uterine bleeding

Question 17

which local disorders can cause organic menorrhagia?

Answer 17

fibroids 
adenomyosis
endocervical or endometrial polyp
cervical eversion 
endometrial hyperplasia 
IUCD
pelvic inflammatory disease
endometriosis
malignancy of cervix or uterus 
hormone producing tumours
trauma 
other eg arteriovenous malformation

Question 18

what systemic disorders can cause organic menorrhagia?

Answer 18

endocrine = hyper/hypothyroidism, diabetes, adrenal disease, prolactin disorders

disorders of haemostasis = von willebrands disease, ITP, factor II, V, VII and XI defects

liver disorders or renal disease

drugs = anticoagulants

Question 19

what causes relating to pregnancy can causes organic menorrhagia?

Answer 19

miscarriage
ectopic pregnancy
gestational trophoblastic disease
postpartum haemorrhage

Question 20

how do you diagnose dysfunctional uterine bleeding?

Answer 20

diagnosis of exclusion

Question 21

what two categories is DUB divided into?

Answer 21

anovulatory = 85%, occurs at extremes of reproductive life, irregular cycle, common in obese women

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

Question 22

what investigations should take place in DUB?

Answer 22

FBC
cervical smear
TSH
coagulation screen
renal/liver function tests 
transvaginal US
endometrial sampling

Question 23

what can transvaginal US detect?

Answer 23

endometrial thickness

presence of fibroids and other pelvic massess

Question 24

what types of endometrial sampling can be done?

Answer 24

pipelle biopsies
hysteroscopic directed
dilatation and curettage (D&C)

Question 25

what are the non-surgical management options in DUB?

Answer 25

medical therapy

• progesterones
• combined OCP
• danazol
• GnRH analogues
• NSAIDs
• anti fibrinolytics
• capillary wall stabilisers

progestogen-releasing IUCD (mirena IUS)

Question 26

what are the surgical management options in DUB?

Answer 26

endometrial resection/ablation

• transcervical endometrial resection (TCRE)
• rollerball endometrial ablation (REA)
• bipolar mesh endometrial ablation (novasure)
• thermal balloon ablation (thermachoice)
• thermal hydroablation (hydroblate)

hysterectomy

• sub-total hysterectomy
• total abdominal hysterectomy
• vaginal hysterectomy
• LASH / LAVH / TLH

Question 27

what are the main comparisons between medical and surgical treatments of DUB?

Answer 27

medical = cheaper, no wait list, no anaesthetic risks, adverse effects non-permanent, may not be as effective, fertility can be retained

surgery = more expensive, waiting list, anaesthetic risk, complications possible, very effective (amennorrhoea with hysterectomy), fertility lost

Question 28

what are the main differences between endometrial ablation and hysterectomy?

Answer 28

endometrial ablation = daycase procedure, shorter operating time, shorter recovery, fewer complications, requires cervical smears, combined HRT required

hysterectomy = major operation, longer operating time, longer recovery, more complications, no smears required (for total hysterectomies), oestrogen only HRT (unless cervix retained)