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MFSRH part 1 > Abnormal uterine bleeding > Flashcards

Abnormal uterine bleeding Flashcards

1
Q

up to what percentage of women worldwide struggle with abnormal uterine bleeding?

A - 10%
B- 15%
C-25%
D- 50%

A

c- 25%

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2
Q

In abnormal uterine bleeding the blood loss per cycle is:

> 50ml
80ml
100ml
150ml

A

> 80mls

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3
Q

what is the name of the classification used to categorise causes of AUB

A

Palm - Coein

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4
Q

The PALM-COEIN classification is used to define the causes of AUB. It can also be used to to define the causes of AUB in women who have more than one contributing pathology.

True
False

A

True

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5
Q

A 30-year-old woman with menorrhagia and dysmenorrhoea unresponsive to tranexamic acid was diagnosed with adenomyosis and a subserosal leiomyoma on MRI. Coagulation screen confirms presence of mild von Willebrand disease. Her PALM-COEIN description would be P0A1L1M0-C0O0E0I0N0 (the numbers should be subscript but I can’t make it do that!)

True
False

A

False

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6
Q

what is the most common type of degeneration that occurs in Fibroids

A

Hyaline

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7
Q

what is the most common type of degeneration that occurs in fibroids during pregnancy and why

A

Red degeneration - fibroid grows rapidly during pregnancy due to increased hormones and then outgrows its own blood supply

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8
Q

Can you name the structural causes of abnormal uterine bleeding

A

PALM -
1. polyps
2. Adenomyosis
3. Leiomyoma
4. Malignancy

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9
Q

what are the non structural causes of abnormal uterine bleeding

A

COEIN

  1. Coagulopathies
  2. Ovulatory
  3. Endometrial pathologies
    I. Iatrogenic
    N. Not otherwise classified
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10
Q

A 35 year old lady presents to the GP surgery with HMB. there is nothing to see on PV examination of the cervix. USS confirms the following - localised projection of endometrial glands and stroma projecting over the endometrial surface.

What is the most likely diagnosis:

  1. Adenomyosis
  2. Leiomyoma
  3. Endometrial polyp
  4. endometriosis
A

3 - endometrial polyp

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11
Q

what is the aetiology of endometrial polyps

A - non-neoplastic endometrial glands and stroma within the myometrium
B- endometrial tissue grows outside the uterine cavity
C- cells loose apoptic cell regulation and overexpress oestrogen and progesterone receptors leading to overgrowth of endometrial glands and stroma
d- benign growth of myometrium

A

C

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12
Q

what is the gold standard treatment for endometrial polyps

A

hysteroscopic removal (note that polyps <1cm can regress on their own)

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13
Q

why do we like to offer removal of polyps if they can spontaneously regress

A

0.8-4.8% of polyps are pre-malignant or contain malignancy

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14
Q

What risk factors increase the risk of a polyp being malignant

A

PMW
tamoxifen use
obesity

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15
Q

which of the following describes the pathophysiology of adenomyosis

what is the aetiology of endometrial polyps

A - non-neoplastic endometrial glands and stroma within the myometrium
B- endometrial tissue grows outside the uterine cavity
C- cells loose apoptic cell regulation and overexpress oestrogen and progesterone receptors leading to overgrowth of endometrial glands and stroma
d- benign growth of myometrium

A

a - non neoplastic endometrial glands and stroma within the myometrium

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16
Q

how does adenomyosis most commonly present

A - post coital bleeding
B - heavy menstrual bleeding
C- HMB + dysmenorrhoea
D - intra menstrual bleeding

A

C - HMB and dysmenorrhoea

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17
Q

Can you name four risk factors for developing adenomyosis

A

multi-parity
previous c- section
D&C
miscarriage

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18
Q

Sarah is mum two two boys aged 4 and 6. She had one NVD and one c-section due to breach presentation. She has been referred to your gynaecology clinic from her GP due to painful heavy periods that she feels started after having her second baby. GP has tried CHC and oral progestogens that doesn’t really help.

You request an USS which demonstrates the following ‘enlarged uterus with anechoic vascular cysts, scattered within the myometrium’

what do you think is the cause of Sarah’s bleeding

  1. Adenomyosis
  2. Leiomyoma
  3. Endometrial polyp
  4. endometriosis
A

A. Adenomyosis

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19
Q

which of the following diagnostic methods offers the best sensitivity and specificity to diagnose adenomyosis

A- USS
B- CT Abdomen and pelvis
C- MRI
D- Hysteroscopy

A

C - MRI - sensitivity and specificity up to 85%

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20
Q

what is the sign of adenomyosis seen on MRI

A

thickening of the junctional zone (area between the endometrium and myometrium)

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21
Q

what are some of the signs that might be visible on hysteroscopy in someone with underlying adenomyosis

A

Pitting on the endometrial surface, irregular endometrial surface, altered endometrial vascularisation

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22
Q

what are Leiomyomas

A

fibroids - benign growths of myometrium

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23
Q

describe the pathogenies of leiomyoma

A

overgrowth of myometrium caused by myometrial injury leads to cellular proliferation and decrease in apoptosis and increased production of extracellular matrix.

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24
Q

what growth hormone is responsible for driving the growth of the uterine fibroid

A

transforming growth factor beta

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25
Q

how common are uterine fibroids

A

very common - 70%

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26
Q

what is the mechanism of bleeding due to uterine fibroids

A

mechanism depends on the location of the fibroid but thought due to increasing endometrial cavity surface area and inhibiting uterine contraction- more likely with submucosal fibroid that subserosal.

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27
Q

what is the name of the classification system used to classify the location of a fibroid

A

FIGO

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28
Q

A 44-year-old woman is investigated for heavy menstrual bleeding following failed medical management. An abdominal ultrasound scan shows a fibroid measuring four centimetres in diameter at the fundus. It is protruding into the uterine cavity and is distorting the endometrium although the majority of the fibroid is located within the wall of the uterus.
What terminology is used to describe this type of fibroid?

A. Endometrial
B. Intramural
C. Pendunculated
D. Submucosal
E. Subserosal

A

D - submucosal

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29
Q

A subserosal fibroid will project into the endometrial cavity.

True or false

A

False - subserosal will indent into the abdominal cavity

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30
Q

A submucosal fibroid projects into the uterine cavity

True or False

A

True

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31
Q

A pedunculated fibroid projecting into the endometrial cavity is an example of what type of fibroid

A - Intramural
B- Subserosal
C- Submucosal

A

B - Submucosal

32
Q

If a fibroid is <3cm in size and not distorting the uterine cavity what is the first line management

A

LNG- IUS

33
Q

If a fibroid is <3cm in size and not distorting the uterine cavity but the patient declines IUS what would be the second line non hormonal management options

A

NSAIDs or TXA

34
Q

what hormonal options are there for Rx fibroids <3cm in size not distorting uterine cavity but patient declined LNG IUS

A

CHC, oral progestogens

35
Q

If a fibroid is >3cm in size, causing obstetric or fertility issues or compressive symptoms what should the GP do?

A

refer to secondary care and can start TXA or NSAIDs (mefanamic acid 500mg TDS) whilst awaiting specialist review

36
Q

what are the surgical options that a specialist may consider for fibroids >3cm distorting uterine cavity

A

Uterine artery embolisation
Myomectomy
Hysterectomy (definite treatment)

37
Q

Laura is a 46 year old female who has completed her family. She has a large intra-mural fibroid measuring 9cm which is distorting the uterine cavity. She has failed medical management. What would be the definite treatment for Laura

  1. UAE
  2. Myomectomy
  3. GNRH angonist
  4. Hysterectomy
A
  1. Hysterectomy
38
Q

Laura is awaiting hysterectomy for treatment of a uterine fibroid measuring 9cm. She failed medical treatment. What two medications can be used to help shrink the fibroid prior to surgery

  1. GnRH Agonist
  2. IUS
  3. Mefanamic acid
  4. Esmya
A
  1. GnRH agonist
  2. Esmya
39
Q

Goserelin, Leuporelin and Triptorelin are examples of what class of medications

A

GnRH agonist

40
Q

Describe the MOA of GnRH agonist

A

GnRH agonist work by mimicing the action of GnRH. They are synthetic decapeptides. GnRH agonist continuously provide GnRH causing the anterior pituitary to release FSH and LH continuously. Normally GnRH is released in a pulsatile manner. When a patient initially starts on GnRH agonist it causes a surge in LH and FSH however after a period of time the anterior pituitary becomes de-sensitised to the GnRH agonist and leads to down regulation and reduced FSH/LH and reduced gonadotrophin. induces menopause state.

41
Q

how long can GnRH agonists be used for

A

6 months, or up to 1 year with add back HRT

42
Q

what class of medication is Esmya

A

Esmya is a selective progesterone receptor modulator (UPA) works to block the action of progesterone . Can only be used intermittently currently due to concerns over causing liver failure.

43
Q

Ullipristal acetate exerts its effect

A - on the anterior pituitary
B- directly on the hypothalamus
C- on the progesterone receptors lining the endometrial cavity

A

c- on progesterone receptors lining the endometrial cavity

44
Q

how does UPA decrease fibroid size

A

Inhibits cell proliferation and induces apoptosis

45
Q

a daily dose of UPA will inhibit ovulation

True or false

A

True

46
Q

A patient undergoes uterine artery embolisation for treatment of fibroids. one week later presents to A&E with history of fever, rigours and pelvic pain.

Bloods demonstrate raised WBC and CRP. TV USS shows the known uterine fibroid but nil else.
What do you think is the most likely cause?

A- appendicitis
B- Pelvic infection secondary to UAE
C- Ovarian torsion
D- post-embolisation syndrome

A

D- post embolisation syndrome

47
Q

what is the risk of malignant transformation of fibroids

A - 0.1%
B - 0.2%
C - 0.5%
D - 1%

A

B - 0.2%

48
Q

Why can fibroids cause sub fertility

A

failure of implantation - structurally as fibroid might be in the way and secondly fibroid secretes transforming growth factor Beta that interferes with implantation

49
Q

Increasing in the number of cells describe the process of

A - hyperplasia
B- Dysplasia
C- Metaplasia

A

A - hyperplasia

50
Q

Histology that demonstrates cells with an abnormal appearance is describing

A - hyperplasia
B- Dysplasia
C- Metaplasia

A

B - dysplasia

51
Q

Conversion of one type of cell to another so that the cell has changed form is describing

A - hyperplasia
B- Dysplasia
C- Metaplasia

A

C- Metaplasia

52
Q

what causes endometrial hyperplasia

A

unopposed oestrogen binds to the oestrogen receptors in the endometrial cells and stimulates endometrial cell growth

53
Q

what are some risk factors for causing endometrial hyperplasia

A
  • obesity
    -unopposed oestrogen
    -early menarche and late menopause
    -nulliparity
  • oestrogen secreting tumours (granulose cell)
    an ovulation a/s menopause and PCOS
54
Q

A 47 year old female with BMI of 35 is investigated due to IMB. TV USS demonstrates a thickened endometrium but nil else. Histological biopsy shows ‘‘crowded cells, irregular size and shape and an increase in the number of cells but the cells do not appear atypical’’

What would the first line management be

A

lose weight and continuous oral or local progestogen ideally - LNG -IUS, follow up in 6 months with second biopsy

(this is endometrial hyperplasia without atypia)

55
Q

in endometrial hyperplasia without atypia if a patient declines LNG- IUS would you use

A) cyclical progestogens
B) Continuous progestogens

A

Continuous oral progestogens

56
Q

which oral continuous progestogen is the best option for pre-menopausal women with endometrial hyperplasia without atypia

A

Norethisterone

57
Q

which oral continuous progestogen is the best option for peri- or post menopausal women with endometrial hyperplasia without atypia

A

medoxyprogesterone acetate

58
Q

In patients with endometrial hyperplasia without atypia at what point can you discharge them from secondary care

A

two consecutive negative endometrial biopsies

59
Q

sue has been treated for 12 months with LNG-IUS for endometrial hyperplasia without atypia. Biopsy today after 12 months of treatment shows no regression or improvement.
What would be the definite treatment now?

A

Hysterectomy (as hyperplasia has failed to improve after 12 months of treatment)

60
Q

A 48-year-old woman Para 2+0 undergoes a hysteroscopy and biopsy for persistent intermenstrual bleeding over the past 6 months. She has a BMI of 35 kg/m2 and takes
metformin for type 2 Diabetes Mellitus. She is currently not in a relationship and has completed her family. The histology report is suggestive of endometrial hyperplasia with atypia.

Which of the following is most likely to represent the best management option?

A. Continuousoralprogestogens for 6months
B. Cyclical oral progestogens for 12 months
C. Endometrial ablation
D. Insertion of LNG-IUS
E. Total hysterectomy

A

E - total abdominal hysterectomy as she has atypia

61
Q

a patient had hyperplasia with atypia and so has been recommended TAH + BSO. They are reluctant as want to avoid surgery and ask about endometrial ablation. Why do we avoid endometrial ablation in the management of endometrial hyperplasia with atypia

A

risk that not all is removed and also causes intrauterine adhesions making further histological surveillance very difficult

62
Q

what medication used in treatment of breast cancer can increase risk of endometrial hyperplasia

A - Tamoxifen
B - aromatase inhibitors

A

A - tamoxifen

63
Q

what percentage of women with endometrial hyperplasia with atypica will have underlying malignancy

A - 25%
B - 46%
C - 35%
D- 70%

A

B - 46%

64
Q

in a women diagnosed with endometrial hyperplasia with atypia but wanting persevere fertility how would you manage

A

oral high dose continuous progestogens e.g 100mg MPA or LNG -IUS and review in 3/12 with histological biopsy

65
Q

how does endometrial cancer most commonly present

A

post menopausal bleeding

66
Q

what is the most common type of endometrial cancer

A

Adenocarcinoma

67
Q

what are the main two types of endometrial cancer

A

Type 1 and type 2

Type 1 - oestrogen dependent, good prognosis and more common

Type 2 - often poor prognosis, seen in older women with rapid progression and not related to oestrogen

68
Q

Lynchh syndrome is inherited

  1. AD
  2. AR
  3. X-linked recessive
A
  1. Autosomal dominant
69
Q

what is another name for lynchh syndrome

A

HNPCC (hereditary non polyposis colorectal cancer

70
Q

what are people with lynchh syndrome at increased risk of developing

A

increased risk of developing certain cancers most commonly colorectal cancer.
40-60% lifetime risk of developing endometrial cancer

71
Q

which histogical type of endometrial cancer offers the best prognosis

A- Endometroid carcinoma
B -Mucinous Adenocarcinoma
C- Serous adenocarcinoma
D- Clear cell adenocarcinoma
E - undifferentiated carcinoma

A

A - endometriosis carcinoma

72
Q

which histological type of endometrial cancer is very aggressive and associated with poor prognosis

A- Endometroid carcinoma
B- Serous adenocarcinoma
C- Clear cell adenocarcinoma
D- undifferentiated carcinoma

A

B - serous adenocarcinoma

73
Q

which is the least common

A- Endometroid carcinoma
B -Mucinous Adenocarcinoma
C- Serous adenocarcinoma
D- Clear cell adenocarcinoma
E - undifferentiated carcinoma

A

B - mucinous adenocarcinoma

74
Q

describe the FIGO staging system for endometrial carcinoma

A

Stage 1-4

Stage 1 - cancer contained to the uterus
stage 2 - cancer that spreads into the cervical stroma
stage 3 - localised spread below the diaphragm
stage 4 - distant spread and mets above the diaphragm

75
Q

when does endometrial cancer most commonly present

A - 5th decade
B - 6th decade
C - 7th decade
D - 8th decade

A

C - 7th decade

MFSRH part 1 (20 decks)

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