Abnormal Uterine Bleeding & Pelvic Pain/Masses

Question 1

What are the RFs for endometrial hyperplasia/malignancy?

Answer 1

Increased age (most common gynaecological cancer >45)
Obesity
Nulliparity/Infertility
PCOS
DM
Hereditary Non-Polyposis Colorectal Cancer
Tamoxifen
Early menarche
Late menopause (>55 yo)
Cowden syndrome

Question 2

A 13 year old female presents with irregular periods. Some are very heavy and some are very light. Explain the cause.

Answer 2

This is normal development hypothalamic pituitary axis.

Question 3

A 25 year old presents with irregular menses. She spots irregular with very heavy bleeding. She has acne and hirsutism. What is the treatment if this patient wants to become pregnant?

Answer 3

Clomiphene induces ovulation. It is an exogenous gonadotrophin. Risks include the possibility of a multiple pregnancy and ovarian hyper-stimulation syndrome (cysts, pain, ovarian enlargement, potentially severe medical complications). If the patient does not want to become pregnant OCP is a reasonable therapy. If overweight, weight loss can also be therapeutic.

Question 4

A 18 year old girl presents with heavy vaginal bleeding she is passing clots and floods. She has a past history of abnormal bleeding following dental work. What is the cause of her AUB?

Answer 4

Coagulopathy; vWD

Question 5

A 59 year old post menopausal woman presents with unexplained vaginal bleeding. What is the most important investigation?

Answer 5

Endometrial biopsy

Question 6

A 53 year old woman presents with vaginal bleeding. She started HRT 2 years ago. You order an U/S and the report states that the uterine thickness is 6.5mm. What investigation do you order next?

Answer 6

Endometrial biopsy is indicated if a woman is bleeding greater than 1 year ofter starting HRT and if the uterine thickness is found to be >5mm on U/S.

Question 7

A 54 year old woman presents with vaginal bleeding. She started HRT 3 years ago. You order an U/S and the report states that the uterine thickness is 6mm and a mass is present. What is the next investigation?

Answer 7

D&C

Question 8

A 15 year old girl presents with cramps suprapubic pain. She states that the pain radiates to her lower quads and things. She is currently menstruating and has had this pain before. What is the diagnosis?

Answer 8

Primary dysmenorrhea. Treatment includes pain modulation or inducing anovulation (TENS, NSAIDs/COX2i, OCP, Depo proverb, Micronor, Mirena IUD).

Question 9

A 45 year old woman presents with severe dysmenorrhea. On exam she has a bulky uterus and clots. She also complains of pain with deep dyspareunia. What is your diagnosis?

Answer 9

Adenomyosis

Question 10

A 38 year old G2P0 presents with menorrhagia. She complains of pelvic pressure and has a uterus measuring at 12 weeks. What are the treatment options for this disease?

Answer 10

This is a patient presenting with uterine fibroids/leiyomyomas. Treatment options include:

• GnRH agonist (Lupron) (shrinks fibroids)
• Selective Progesterone Receptor Modulator (Ulipristal Acetate/Fibristol) (shrinks fibroids)
• Uterine artery embolization
• Surgical: myomectomy, hysterectomy
• Nothing if asymptomatic!

Question 11

A 32 year old female presents with dysmenorrhea and dyschezia. She also complains of deep dyspareunia. Her and her partner have been trying to conceive for 2 years with no success. What is the diagnosis?

Answer 11

Endometriosis
Investigations: U/S
Treatment: OCP, GnRH agonist