gynaecology

Question 1

Abnormal Pre, perimenopausal bleeding - ddx

Answer 1

PALMCOEIN
P - polyps (10%)
A - adenomyosis
L - leiomyoma
M - malignancy, hyperplasia
C - coagulopathy
O - ovulatory dysfunction
E - endometrial
I - iatrogenic, infections like chlamydia
N - not yet classified (50%)

Question 2

abnormal pre, perimenopausal bleeding

• base investigations (5 +/- 2)
• postcoital bleeding (1)

Answer 2

serum b-hcg
CST
chlamydia screening
FBC
ferritin
consider TFT, coag profile

PCB - colposcopy

Question 3

pre, perimenopausal bleeding

• indications for ultrasound (3)
• what kind of USS
• optimal timing for ultrasound (pre, perimenopausal)

Answer 3

chronic anovulation or PCOS
anaemia
persistent erratic bleeding

transvaginal ultrasound

premenopause - 1st half of cycle, ie day 5-10
perimenopause - day 4-7, once bleeding stopped

Question 4

pre, perimenopausal bleeding

- significant endometrial thickness

Answer 4

> =12 mm in premenopause

>= 5mm in perimenopause

Question 5

pre, perimenopausal bleeding

- indications for gynae referral (5)

Answer 5

• endometrial thickness >12mm premenopause, or >5mm perimenopause
• ultrasound identified significant lesion
• medical management fails at 6 months
• intermenstrual bleeding
• postcoital bleeding

Question 6

pre, perimenopausal bleeding management

• initial
• hormonal

Answer 6

initial
- tranexamic acid 1g TDS for first 3 days
- NSAID (ibuprofen tds, mefenamic acid)
—
hormones
COCP - thin the endometrium
cyclical progestins - medroxyprogesterone 10mg od-tds up to 21 days of cycle
6 month trial norethisterone 5mg bd-tds up to 21 days,

mirena
medroxyprogesterone acetate 2.5-10mg daily, 5-10 days. repeat for 3 cycles

Question 7

risk factors for endometrial cancer

hormone related x5, other x2

Answer 7

excess oestrogen

• chronic anovulation +/- PCOS
• unopposed oestrogen therapy
• tamoxifen exposure
• nulliparity
• obesity

other
significant fhx of endometrial cancer or colon cancer
endometrial thickness > 8mm

Question 8

post-menopausal bleeding - ddx (6)

Answer 8

atrophic vaginitis - 60-80% 
exogenous oestrogen - 10-20% 
polyps - endo / cervical 2-12%
endometrial hyplerplasia 10%
uterine cancer 10% 
cervical cancer < 1% (1)

Question 9

postmenopausal bleeding - who requires investigation

Answer 9

any bleeding if not on hormone therapy
continuous hormone therapy - any bleeding after 6 months
cyclical hormone therapy - bleeding outside of expected times

Question 10

postmenopausal bleeding - investigations

Answer 10

cervical pathology - CST Co-test, chlamydia test
FBC
transvaginal ultrasound - measure endometrial thickness to stratify risk

Question 11

postmenopausal bleeding - indications for gynae referral (3)

Answer 11

persistent bleeding
TVUSS shows endo thickness > 4mm or focal lesions
risk factors for endometrial cancer present

Question 12

postmenopausal bleeding - management of atrophic vaginitis

Answer 12

vagifem 10 microg tabs nightly for 2 weeks then twice a week

lubricant