Menstrual disorders and abnormal uterine bleeding

with the normal menstrual cycle, menstrual bleeding occurs when

the first day of menstrual bleeding is day 1 of the cycle (average 28 days)

explain the mechanism of the follicular phase

FSH stimulates follicular development → produce estrogen → estrogen has negative feedback of FSH production → estradiol levels peak → this has positive feedback on pituitary gland → LH surge → ovulation

when is the follicular phase?

first 14 days of the ovarian cycle and day 1-14 of the menstrual cycle

variations in cycle length reflects differences in the length of what phase?

the follicular phase of the ovarian cycle (the luteal phase is always the last 14 days)

what is the mechanism of the luteal phase?

ovulation is the in-between state of the follicular and luteal phase

graafian (dominant) follicle ruptures releasing an oocyte → LH receptors produced → LH causes graafian follicle to become corpus luteum → corpus luteum produces progesterone → inhibits LH release → no pregnant means the corpus luteum regresses

what indicates that ovulation has occurred?

progesterone increase

once ovulation occurs, the ___ phase is ___

the luteal phase starts and is always 14 days

what are the two phases of the ovarian cycle?

follicular phase then luteal phase

what phase?

characterized by transformation of granulosa and theca cells under the influence of progesterone

luteal phase

what are the phases of the uterine cycle?

proliferative phase and secretory phase

what phase?

characterized by growth of the endometrium under the influence of estrogens

proliferative phase of the uterine cycle

what phase?

functional layer of the endometrium is prepared for implantation under the influence of progesterone

secretory phase

explain progesterone levels and the fate of the endometrium

increased levels: baby

decreased levels: slough off lining (period)

what is this?

prominent mood symptoms and clear functional impairment with work, school, or personal relationships

this is PMDD (severe form of PMS)

what neurotransmitter plays a central role in the development of PMS and PMDD?

serotonin

What are the steps/criteria to diagnose PMS and PMDD? (4)

symptom diary spanning 3 cycles

calendar of premenstrual experiences

exclude other diagnosis (like thyroid of psychiatric d/o)

analysis of daily urinary steroid metabolites

How do we treat PMS and PMDD?

lifestyles changes

first line pharm: NSAIDs, SSRIs (severe), and OCPs (oral contraception pills)

supplements: calcium and vitamins E and D

what is this?

recurrent lower abdominal pain shortly before or during menstruation not due to an underlying condition

primary dysmenorrhea

what is this?

increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction and inschemia and stronger sustained uterine contractions

primary dysmenorrhea

What is this?

clinical features: crampy pain in the lower abdominal and/or pelvic midline, headaches, diarrhea, nausea, and flushing BUT normal pelvic exam

primary dysmenorrhea

How do we treat primary dysmenorrhea?

NSAIDs, heat, hormonal contraceptive

what is this?

recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition

secondary dysmenorrhea

what is this?

causes: pelvic inflammatory disease (PID), IUD, adenomyosis, fibroids, cervical polyps

secondary dysmenorrhea

describe these characteristics of menstrual migraines: treatment, aura, duration, functional impairment/disability, and when they occur

occur exclusively in association with menses, typically more resistant to treatment, no aura, longer duration, and increased functional impairment/disability

what are catamenial conditions? examples?

conditions that are associated with menstrual cycle (monthly); ex: catamenial epilepsy, catamenial pneumothorax, etc.

describe the layers of the endometrium

basalis layer: reservoir for regeneration of the functionalis layer following menses

functionalis layer: sloughs during menstruation

what is the source of most bleeding in the reproductive tract

endometrium

what is breakthrough bleeding and unscheduled bleeding?

associated with hormone administration

what is withdrawal bleeding?

predictable bleeding that results from an abrupt decline in progesterone levels

what is precocious menstruation?

menses in childhood

what is postmenopausal bleeding?

bleeding 12 months or more after menses has ceased

what is a more frequent finding of abnormal uterine bleeding during perimenopause?

anovulatory uterine bleeding from HPO axis dysfunction

what are the AUB etiologies we need to consider?

PALM (structural) COEIN (non-structural)

P: polyps

A: adenomyosis

L: leiomyoma

M: malignancy/hyperplasia

C: coagulopathy

O: ovulatory disorder

E: endometrial causes

I: iatrogenic

N: not otherwise classified

What are the 6 essentials of diagnosing AUB?

1. confirm uterine source of bleeding

2. exclude pregnancy

3. ovulatory or anovulatory bleeding pattern

4. structural abnormalities (PALM)

5. medical conditions that may impact bleeding

6. assessing current meds

What is one of the first imagings we get for AUB?

pelvic or transvaginal ultrasound

what evaluation technique can provide tissue for diagnosis and sometimes treatment?

dilation and curettage

What is useful to distinguish adenomyosis from fibroids?

MRI

what imaging can we get if we suspect intrauterine pathology when looking at the ultrasound?

saline-infused sonohysterogram

When should we do an endometrial biopsy? (4)

1. increased risk of hyperplasia or neoplasm

2. all pts 45+

3. postmenopausal pts with endometrial thickness 5+

4. less than 45 if: bleeding despite treatment, unopposed estrogen (PCOS, obesity, etc.), or other risk factors like DM2, lynch syndrome, or tamoxifen therapy

How do we treat acute AUB?

estrogen, combined oral contraceptive, oral progestin

nonhormone: oral or IV tranexamic acid

what can we use for fibroids or uterine arteriovenous malformations? How does it affect fertility?

transcatheter uterine artery embolization; fertility data limited

what can we use to treat endometrial polyps or uterine fibroids? How does it affect fertility?

hysteroscopic polypectomy or myomectomy; preserves fertility

how does endometrial ablation affect fertility?

does not preserve fertility; contraindicated if pt pregnant or plans to be, or endometrial hyperplasia or cancer

How does transcatheter uterine artery embolization affect fertility?

limited data/unsure

how does hysteroscopic polypectomy or myomectomy affect fertility?

preserves fertility

how does hysterectomy affect fertility?

does not preserve fertility