Chapter 21: Disorders Of The Menstrual Cycle Flashcards
You are a trainee intern in general practice seeing Tema, a 29 year old Fijian woman who presents with post coital and intermenstrual bleeding. Tema’s periods are regular every 28 days and last for 5 days. She is on the combined oral contraceptive pill for contraception and has been taking it reliably. She does not experience significant dysmenorrhoea or heavy menstrual bleeding. She is nulliparous. Her last smear was 4 years ago. Tema has no significant medical or gynaecological history. She is a non-smoker. Abdominal, speculum and vaginal examinations are unremarkable. From the following options, which are the 2 MOST IMPORTANT investigations that you will arrange?
A. Transvaginal ultrasound scan and cervical smear
B. Cervical smear and pipelle sample of endometrium
C. Cervical smear and swabs for infection
D. Transvaginal ultrasound scan and swabs for infection
E. Transvaginal ultrasound scan and pipelle sample of endometrium
C. Cervical smear and swabs for infection
You are a trainee intern doing your O&G rotation and are helping out in the pre-admission clinic. Te Aroha is a 47 year old wahine Māori, para 3, who is being preadmitted for a laparoscopic hysterectomy for heavy menstrual bleeding. Medical management options including a Mirena have been unsuccessful. Te Aroha is otherwise healthy apart from a mild iron deficiency anaemia. She has had a previous Lletz for CIN3 but follow up smears have all been normal and she has had a successful ‘test of cure’ (negative HrHPV tests). She asks you what will be removed during her surgery and why? Which of the following options will you say to her?
A. Her uterus, cervix and Fallopian tubes will be removed. This will stop the heavy menstrual bleeding. The Fallopian tubes are removed to reduce her risk of ovarian cancer. Her ovaries are left behind as if her ovaries are removed then she will undergo a surgical menopause.
B. Her uterus and cervix will be removed. This will stop the heavy menstrual bleeding. The Fallopian tubes will be removed (if she consents) to allow the registrar to practice their laparoscopic skills as the fallopian tubes are no longer required. Her ovaries are left behind as if her ovaries are removed then she will undergo a surgical menopause.
C. Her uterus, cervix, Fallopian tubes and ovaries will be removed. Removing the uterus will stop the heavy menstrual bleeding. The fallopian tubes and ovaries should be removed to stop her getting ovarian cancer.
D. Her uterus and cervix will be removed. The ovaries and Fallopian tubes will be left behind because if her ovaries are removed then she will undergo a surgical menopause.
E. Her uterus will be removed but the cervix will be left behind. The Fallopian tubes and ovaries will be left behind because if her ovaries are removed then she will undergo a surgical menopause.
B. Her uterus and cervix will be removed. This will stop the heavy menstrual bleeding. The Fallopian tubes will be removed (if she consents) to allow the registrar to practice their laparoscopic skills as the fallopian tubes are no longer required. Her ovaries are left behind as if her ovaries are removed then she will undergo a surgical menopause.
ou are a trainee intern in general practice with Bernadette, a 43 year old G3P3 Pākehā woman who presents with increasingly heavy periods. She passes clots and experiences flooding and is unable to leave the house on the first 2 days of her period. These symptoms have come on gradually over the last three years. Bernadette has no dysmenorrhoea, dyspareunia, or bowel symptoms. There is no intermenstrual or post-coital bleeding. She has noticed a ‘fullness’ in her lower abdomen. She has urinary urgency and frequency that is gradually worsening. Her past medical and obstetric history is unremarkable. Contraception is vasectomy. On examination, Bernadette’s BMI is 24. Inspection of the vagina and cervix is normal. You take a cervical smear as her last smear was nearly three years ago. From the following options, what is the most likely finding on your bimanual examination?
A. Uterus retroverted and fixed, no adnexal masses, tenderness over nodular uterosacral ligaments
B Uterus retroverted and fixed, left adnexal mass 6cm, tenderness over nodular uterosacral ligaments
C. Uterus anteverted 6 week size, mobile with a left adnexal mass 6cm
D. Uterus anteverted and bulky 14 week size, no adnexal masses.
E. Uterus anteverted 6week size, mobile with no adnexal masses or pelvic tenderness
D. Uterus anteverted and bulky 14 week size, no adnexal masses.
DISORDERS OF THE MENSTRUAL CYCLE You are a trainee intern in general practice seeing Charlotte, a 48 year old P3 New Zealand European woman who presents with four weeks of prolonged vaginal bleeding. Charlotte’s periods have become irregular and infrequent over the past year. She feels tired and drained. Charlotte’s past medical and obstetric history is unremarkable and she has had a tubal ligation. Her BMI is 30. She looks pale. Abdominal examination and inspection of the vagina and cervix are normal. You take a cervical smear as her last smear was three years ago. On bimanual examination the uterus is anteverted, a normal size and mobile. There are no adnexal masses and no pelvic tenderness. What investigations are important for you to arrange?
A. FBC, coagulation screen and transvaginal pelvic ultrasound
B. FBC, coagulation screen and transabdominal pelvic ultrasound
C. FBC, transabdominal pelvic ultrasound and Pipelle endometrial biopsy
D. FBC, transvaginal pelvic ultrasound and Pipelle endometrial biopsy
E. FBC, coagulation screen, transvaginal pelvic ultrasound scan and Pipelle endometrial biopsy
C. FBC, transabdominal pelvic ultrasound and Pipelle endometrial biopsy
Charlotte’s irregular uterine bleeding is likely ovulatory dysfunction. However, because of her age, BMI and irregular bleeding she has risk factors for endometrial hyperplasia. She therefore requires an ultrasound to evaluate endometrial thickness and endometrial sampling which can be done via a Pipelle. Transvaginal ultrasound is more accurate than transabdominal ultrasound, transabdominal ultrasound would only be used if transvaginal inappropriate (e.g. patient unable to or doesn’t consent or has never had sexual intercourse).
Charlotte is tired and pale with heavy bleeding so her Hb should be checked. A coagulation screen doesn’t need to be done as a routine investigation unless there is something in the history suggestive of a bleeding disorder e.g. post partum haemorrhage bleeding after tooth extraction, HMB since menarche.
You are a trainee intern in general practice reviewing Elsie, a 43 year old G3P3 woman, with the results of her trans-vaginal pelvic ultrasound scan. Elsie has a three year history of increasingly painful and heavy periods. Her periods are regular. Contraception is vasectomy. Elsie has no dyspareunia or bladder or bowel symptoms. Her past medical and obstetric history is unremarkable. Elsie’s BMI is 24. Abdominal examination and speculum examinations were unremarkable. On bimanual examination the uterus was anteverted and bulky and a 10/40 size. The ultrasound scan has showed the uterus was bulky with the myometrium having a heterogenous echotexture and cystic lacunae consistent with adenomyosis. There was no other abnormality. From the following options, what is the most appropriate initial management?
A. Insertion of a Mirena Levonorgestrel IUS
B. Refer for hysteroscopy and dilatation and curettage
C. Refer for hysterectomy
D. Medroxyprogesterone acetate 10mg/day from days 5-25 each cycle
E. Insertion of a Jadelle Levonorgestrel implant
F. Norethisterone 10mg/day from day 5-25 of each calendar month
A. Insertion of a Mirena Levonorgestrel IUS
Elsie has adenomyosis. Her management should be focussed on treating her presenting symptoms which are HMB and dysmenorrhoea. Cyclical progesterone can be used for HMB but is not as effective as other strategies such as the Mirena IUS, tranexamic acid or the combined oral contraceptive pill (Cochrane review, 2019). Continuous progesterone treatment may be effective and induce amenorrhoea but many women don’t tolerate the side effects including weight gain and bloating. A Jadelle does not provide effective management of HMB as the progesterone dose is too low to suppress ovulation. (the contraceptive effect is by thickening cervical mucus). Hysterectomy is a surgical option usually reserved for medical treatment failures. Hysteroscopy and D and C is a diagnostic procedure when there are concerns about the endometrium - not the case with Elsie. It is not a treatment. Insertion of a Mirena (IUS) is an effective management to reduce both her HMB and dysmenorrhoea. She should be warned that she may get irregular bleeding for the first few months. The combined oral contraceptive pill would also be an acceptable answer but is not an option. Other therapies to consider include Tranexamic acid which may reduce the HMB but would not help with the dysmenorrhoea and NSAIDS which may help with the dysmenorrhoea and lead to some reduction in the HMB.
You are a trainee intern in general practice with Shihong, a 48 year old G4P3 Chinese woman who presents with an episode of prolonged vaginal bleeding which started 4 weeks ago. Shihong is going on holiday to Fiji next week and wants her bleeding to stop. Shihong has had irregular and infrequent periods for the past 3 years. Contraception is tubal ligation. Shihong’s past medical and obstetric history is unremarkable. Her BMI is 24. She is not pale. Abdominal examination and speculum exam are unremarkable. You perform a cervical smear as it is due. On bimanual examination, the uterus is midline anteverted mobile and a normal size. There are no adnexal masses or tenderness. You arrange blood tests and book a transvaginal pelvic ultrasound scan of the pelvis for when Shihong returns from Fiji. From the following options, what is the best IMMEDIATE medical management?
A. Insertion of a Mirena Levonorgestrel IUS
B. The Progesterone only pill Noriday
C. Reassure Shihong that the bleeding will stop prior to her holiday in Fiji
D. Medroxyprogesterone acetate (Provera) 20mg daily for 4 weeks
E. Norethisterone 10mg/day from day 5-25 of each calendar month
F. Tranexamic acid 1500 mg po tds
D. Medroxyprogesterone acetate (Provera) 20mg daily for 4 weeks
If we were to classify Shihong’s abnormal uterine bleeding by the PALM-COEIN classification it is likely ovulatory dysfunction. However, given her age it will be important to get arrange the ultrasound scan to exclude endometrial hyperplasia or abnormality. Shihong’s immediate concern is stopping her bleeding prior to her Fiji holiday. A course of oral progesterone such as Provera is the best way to stop the bleeding. Anovulation is associated with unopposed oestrogen so progesterone works by opposing this. Tranexamic acid may reduce the volume of bleeding but will not change the frequency. However, the 1500mg to tds dose is too high – the usual dose of tranexamic acid is 1g tds increased to a maximum of 4g / day. The Progesterone only pill is not useful for HMB and the dose is too low to stop an episode of prolonged bleeding. Reassurance is inappropriate. A Mirena may well be an excellent longer term management option but is not so useful in the acute episode of bleeding. It can take several months before bleeding patterns settle so is unlikely to settle Shihong’s bleeding prior to her Fiji holiday. Cyclical progesterone can be used in the longer term, but is not as effective as a Mirena, tranexamic acid or the oral contraceptive pill for HMB.
You are a trainee intern in general practice with Natalie, a 44 year old G3P3 Irish woman who you are seeing for follow up. Natalie presented to you 6 months ago with 3 weeks of continuous bleeding. Prior to the episode of prolonged bleeding she had had irregular, heavy periods for 6 months. You prescribed her oral cyclical Provera which stopped her initial episode of bleeding and has regulated her periods. While the Provera has improved her periods, Natalie finds it difficult to remember to take tablets and has gained weight on the Provera. The previous examination findings were normal. A transvaginal pelvic ultrasound was normal. From the following options, what is the most likely management advice?
A. Stop the Provera and “wait and see” as her periods will likely now been normalise.
B. Switch to a progesterone only pill (the ‘mini-pill’) eg Noriday.
C. Add tranexamic acid when the bleeding is heavy.
E. Commence her on cyclical clomiphene
F. Refer Natalie for a hysterectomy.
G. Insert a Jadelle Levonorgestrel implant.
H. Insert a Mirena (Levonorgestrel IUS)
H. Insert a Mirena (Levonorgestrel IUS)
Emma is a 28 year old para 2 Pākehā woman who presents to you in General Practice with abnormal bleeding on her combined oral contraceptive pill. Emma is a non-smoker who keeps good health. She used the oral contraceptive pill for 5 years prior to stopping it for a planned pregnancy. Her son is 3 years old and her daughter is now 10 months old. She didn’t use hormonal contraception in between her two pregnancies. Emma reports that her bleeding never really stopped once after her daughter was born. It was initially attributed to her being on the progesterone only pill for contraception. When her daughter was 6 months old Emma stopped breast feeding and so was switched back to the same combined oral contraceptive pill she had taken previously. Emma gets a period every 28 days but also gets some light spotting and bleeding in between her period. Emma’s last smear was five years ago. She didn’t attend for her last smear as she was pregnant and she hasn’t been able to have one recently as she has been bleeding. What do you advise Emma in the FIRST instance?
A. She should be referred to Family Planning for a Mirena Levonorgestrel IUS
B. She should have an ultrasound scan of her pelvis to look for an abnormality of the endometrium
C. She should be switched to an oral contraceptive pill with a higher dose of oestrogen
D. She should do self-swabs for an STI screen
E. She needs to have a speculum examination and cervical smear
E. She needs to have a speculum examination and cervical smear
You are a trainee intern in gynaecology clinic seeing Sapna for follow up. Sapna is a 44 year old G3P3 woman of Indian ethnicity who was seen three months ago with heavy menstrual bleeding. Sapna has a 10 year history of increasing abnormal uterine bleeding. She has previously tried the combined oral contraceptive, tranexamic acid and mefenamic acid without success. When you saw Sapna three months ago she was started on Provera (medroxyprogesterone acetate) 10mg daily. An ultrasound scan and blood tests were requested. Sapna otherwise keeps good health. All three of her children were born all by caesarean section for abnormal presentation – her first baby was breech and her second and third babies were a transverse lie. She has a tubal ligation for contraception. Smears are up to date and normal. Sapna has a BMI of 28. When you see Sapna, she reports that her bleeding has stopped on the Provera but she is finding the side effects of bloating, nausea and weight gain intolerable. The ultrasound scan showed a bicornuate uterus with an endometrial thickness of 10mm and normal ovaries. Her blood tests showed an iron deficiency anaemia and Sapna is feeling less tired now that she is on iron tablets. Sapna reports that she is fed up with her periods and ‘wants something done’. What management would you advise?
A. An endometrial ablation (but not a Mirena)
B. A vaginal hysterectomy
C. A Mirena or an endometrial ablation
D. A laparoscopic hysterectomy
E. . A Mirena (but not an endometrial ablation)
F. Now that the bleeding has stopped the ‘cycle’ of abnormal bleeding has been broken, Sapna can stop all of her medications.
G. A hysteroscopy and dilatation and curettage (D&C)
D. A laparoscopic hysterectomy
You are a trainee intern in general practice reviewing Eloise, after blood tests and a transvaginal ultrasound scan. Eloise is a 42 year old para 3 wahine Māori who presented last week with a history of increasing heavy menstrual bleeding over the past 2 years. Her periods occur monthly and last for 7 days. She bleeds heavily with clots, flooding and is soaking through onto the bedsheets at night. She has to take 1-2 days per month off work because of her bleeding. Eloise is in a same sex relationship so doesn’t require contraception. Eloise has no dyspareunia or bowel symptoms. She has urinary frequency and urgency, but no dysuria. Her past medical, obstetric and family history is unremarkable. Her BMI is 24. Abdominal examination revealed a suprapubic mass. On bimanual examination, the uterus is an 18 week size with an irregular outline. The blood tests showed a Hb of 110 and a ferritin of 4 (low). The scan confirmed multiple subserosal and submucosal fibroids, up to 50mm in diameter. The smear was normal. You commence Eloise on iron tablets and discuss management of her heavy menstrual bleeding From the following options, what is the most likely management?
A. Referral for a total abdominal hysterectomy and bilateral salpingo-oophorectomy
B. Referral for a total abdominal hysterectomy
C. GnRH analogue injections only
D. Referral for hysteroscopy and dilatation and curettage
E. Referral for endometrial ablation
F. Referral for myomectomy
B. Referral for a total abdominal hysterectomy
You are a trainee intern in gynaecology clinic seeing Sister Adele, a 62 year old para 0 Pākehā nun who has been referred in with post-menopausal bleeding. She has had 3 episodes of light red bleeding over the past 4 months. Menopause was at age 53. She has never had a cervical smear as she has never been sexually active. She takes enalapril for hypertension and a statin for hypercholesterolemia. Her BMI is 28. Her abdomen is soft and non-tender with no masses palpable. A transabdominal ultrasound scan of the pelvis showed a small uterus with poor views of the endometrium and neither ovary was able to be visualised. Which of the following options will be your management?
Book Sister Adele for an MRI scan of her pelvis
Book Sister Adele for an examination under anaesthetic, hysteroscopy and dilatation and curettage (D&C)
Advise Sister Adele she needs a trans-vaginal ultrasound scan of the pelvis
Advise Sister Adele that she needs a cervical smear as she probably has a cervical cancer
Prescribe Sister Adele Ovestin oestrogen cream as this will help with her atrophic vaginitis
Book Sister Adele for an examination under anaesthetic, hysteroscopy and dilatation and curettage (D&C)
?Cancer. Won’t tolerate speculum or transvaginal
You are a trainee intern in a gynaecology clinic with Irene, a 63 year old Para 4 Pākehā woman who has been referred because of two episodes of post-menopausal bleeding in the past 3 months. Each episode was painless, unprovoked, and lasted 5 days. Her menopause was 10 years ago. At 45 years of age Irene had a LLETZ procedure for CIN3. Follow up smears have all been normal. Irene smokes 15 cigarettes per day. Prior to menopause, Irene had heavy, irregular periods. These were effectively managed with a Mirena IUCD. Irene was diagnosed with PCOS when she was 30 years old. Her BMI is 45. You are worried that Irene has endometrial cancer. Which of the following aspects of Irene’s history INCREASE her risk for endometrial cancer?
Smoking, multiparity and Mirena use
Smoking and Mirena use
Obesity, PCOS and a previous Lletz
Obesity and PCOS
Obesity, smoking and multiparity
Obesity, PCOS and smoking
Obesity and PCOS
LLETZ is protective, Smoking is also protective technically
You are a trainee intern in a gynaecology clinic seeing Isobel, a 66 year old G1P1 Pākehā woman who has been referred because of two episodes of bright vaginal spotting in the past 3 months. Each episode was painless, unprovoked, and lasted 5 days. Her menopause was 10 years ago. Isobel has not taken any hormone replacement therapy. Isobel had a Lletz at age 45 for CIN3. Follow up smears have all been normal. Isobel has no bowel or bladder symptoms. Isobel has a BMI of 45. On speculum exam the cervix appears stenosed. You take a cervical smear but are unable to pass a Pipelle through the stenosed cervix. Bimanual examination is non-contributory because of Isobel’s BMI. Isobel’s GP had requested a pelvic ultrasound scan. This showed an enlarged uterus with an endometrial thickness of 12mm (normal <5mm). Of the following options, which ONE is the most appropriate next step in Isobel’s management?
Advise total hysterectomy & bilateral salpingo-oophorectomy
Reassure and review with a repeat transvaginal ultrasound in 6 weeks
Advise an endometrial ablation
Start a trial of progesterone therapy
Advise a vaginal hysterectomy
Commence hormone replacement therapy
Insert a Mirena
Advise a hysteroscopy and D and C under anaesthetic
Advise a hysteroscopy and D and C under anaesthetic
You are a trainee intern in general practice with Rena, a 30 year old G1P1 woman of Indian ethnicity who has suffered heavy menstrual bleeding and migraine headaches since the birth of her child two years ago. The situation is “getting her down”. Her periods have been regular every month. Examination and investigations do not show any obvious cause for her symptoms. Tranexamic acid and mefenamic acid at the time of her period have also not helped. Rena is not sure whether she wishes to have more children. She is using condoms for contraception. When she tried the combined oral contraceptive pill a year ago, it aggravated her headaches. Which of the following options would be the most appropriate management?
Endometrial ablation
A Mirena IUS
Cyclical oral progesterone
Laparoscopic hysterectomy & bilateral salpingectomy
Uterine artery embolisation
Levonorgestrel implant (Jadelle)
A Mirena IUS
Sophie is a 33 year old G3P3 Pākehā woman who presents to her GP because she has developed intermenstrual bleeding in the last six months. She experiences spotting in between her periods. Last month the intermenstrual bleeding was bright red and lasted for three days. Her periods are regular, every 28 days and are slightly heavier than they used to be. Sophie does not experience dysmenorrhoea or post-coital bleeding. Contraception is vasectomy. Sophie had a normal smear 6 months ago. Her BMI is 24. Speculum examination is normal, with slight bleeding visible through an otherwise normal cervix on Day 22 of her cycle. On bimanual examination, the uterus is normal sized, with no adnexal pathology. Which of the following options is the most likely cause of her intermenstrual bleeding?
Endometrial carcinoma
Subserous and intramural uterine fibroids
Ovulatory dysfunction
An endocervical polyp
A uterine sarcoma
An endometrial polyp
An endometrial polyp
You are trainee intern reviewing Pippa, a 40 year old G3P3 Pākehā woman who presented two months ago with a 12 month history of breast tenderness, bloating and irritability in the week before her period. She also feels clumsy and has difficulty concentrating during this time. Her symptoms are relieved within two days of her period starting. Her periods are regular and occur every 28 days. She does not experience dysmenorrhoea. She was asked to keep a diary of her symptoms and the diary confirmed the diagnosis of Premenstrual Syndrome. From the following options what management of her PMS would you be LEAST likely to advise?
Reduced caffeine intake
Blood tests for progesterone and prolactin in the mid luteal phase level
Explanation and reassurance
Aerobic exercise
Relaxation techniques
Drug treatment
Cognitive behavioural therapy
Blood tests for progesterone and prolactin in the mid luteal phase level
