Abnormal uterine bleeding

Question 1

What are the causes of heavy menstrual bleeding

Answer 1

Structural:
Polyps
Adenomyosis
Leiomyomas
Malignancy and hyperplasia

Non-structural
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet specified

Question 2

What time frame defines chronic AUB

Answer 2

> 6 months

Question 3

What investigation should be done in all women with AUB and why

Answer 3

FBC to check for anaemia

Question 4

What further investigations should be arranged for women with heavy menstrual bleeding

Answer 4

Bloods: FBC, TFTs, coagulation studies
Imaging: TVUSS, hysteroscopy ± endometrial biopsy

Question 5

What is the management for heavy menstrual bleeding

Answer 5

1. IUS (not trying to conceive), tranexamic acid or mefenamic acid (NSAID) (trying to conceive)
2. COCP
3. Progesterone
4. surgery

Question 6

What are uterine polyps and its clinical features

Answer 6

Focal proliferations of the uterine tissue
RF: older age
Asymptomatic, may cause intermenstrual bleeding
Smooth, lobular, friable lump on bimanual

Question 7

What is adenomyosis and what are its features

Answer 7

Growth of the endometrium in the myometrium

Prolonged, heavy, painful menstrual bleeding
Pelvic pain
Dyspareunia
Subfertility

Question 8

What features of a gynae history may suggest a coagulopathy

Answer 8

Heavy menstrual bleeding since menarche
Postnatal haemorrhage
Surgery-related bleeding
Bleeding associated with dental work
Frequent and large bruising
Frequent epistaxis or gum bleeding
FHx bleeding symptoms

Question 9

What are some iatrogenic causes of heavy menstrual bleeding

Answer 9

gonadal hormone use → unscheduled breakthrough bleeding
Anticoagulants
Tamoxifen
IUS/IUD
TCAs, phenothiazines

Question 10

What are some causes of intermenstrual bleeding

Answer 10

Polyps
Cervical cancer
Endometrial hyperplasia

Question 11

What are some cause of post-coital bleeding

Answer 11

Cervical ectropion
Polyps
Cervicitis e.g. secondary to chlamydia
Cervical cancer
Vaginal cancer
Trauma
Condylomata accuminata
Vaginitis

Question 12

What is cervical ectropion and how does it present

Answer 12

Endocervical glandular epithelium expands beyond the os and becomes visible on the ectocervix (squamous) → may be friable
Usually asymptomatic, otherwise post-coital bleeding
Erosions where there is a darker red colour around the external os

Question 13

What are the risk factors for cervical ectropion

Answer 13

Hormonal contraception use
Pregnancy
Adolescents

Question 14

What is condylomata accuminata caused by and what is their appearance

Answer 14

HPV infection → genital warts
Verrucous flesy papules that may coalesce into plaques

Question 15

What are the surgical options for heavy menstrual bleeding

Answer 15

Hysteroscopic polyp removal
Endometrial ablation
Transcervical resection of the endometrium (TCRE)
Second generation techniques involving balloons, microwaves, cryotherapy or radiotherapy.
Transcervical resection of fibroid: for fibroids up to 2cm in diameter
Hysterectomy

Question 16

What are the causes of irregular menstrual bleeding

Answer 16

Anovulatory cycles (common in early and late reproductive years)
Fibroids
Polyps (uterine and cervical)
Adenomyosis
Ovarian cysts

Question 17

What investigations should be done for irregular menstrual bleeding

Answer 17

Bedside: cervical smear
Bloods: FBC, coagulation studies, TFTs
Other: TVUSS, Hysteroscopy ± endometrial biopsy

Question 18

What is the management for irregular menstrual bleeding

Answer 18

1. IUS or COCP
2. Progestogens
3. Surgery: avulsion of cervical polyps + histological examination

Question 19

What is the definition of post menopausal bleeding

Answer 19

Vaginal bleeding occurring after 12 months of amenorrhoea

Question 20

What are the causes of post-menopausal bleeding

Answer 20

Vaginal atrophy (most common)
HRT use (common in the first 4-6 months)
Endometrial hyperplasia
Endometrial cancer
Ovarian cancer
Cervical cancer
Vaginal cancer
Trauma
Vulval cancer

Question 21

What investigations should be done in women with post menopausal bleeding

Answer 21

women >55 should have an TVUSS for endometrial cancer on 2WW
Women on HRT still need investigation

Question 22

What is vaginal atrophy caused by and what are its clinical signs

Answer 22

Due to thinning, drying and inflammation of the vaginal walls from hypo-oestrogenism in menopause

Speculum: vaginal mucosa appears thin and friable, erythematous or pale and shiny

Question 23

What is the management for vaginal atrophy

Answer 23

Topical oestrogens
Lubrication
HRT