Gynaecology - Menstrual disorders: AUB, Amenorrhea and Menopause, Dysmenorrhoea

Question 1

FIGO definition of normal menstruation

Answer 1

Question 2

FIGO classification of AUB

Answer 2

Question 3

AUB

Ddx

Answer 3

Question 4

AUB

Approach and history taking questions

Answer 4

Question 5

Heavy menstrual bleeding

Ddx

Answer 5

Question 6

HMB

Approach and history taking questions

Answer 6

Question 7

HMB

Physical exam

Answer 7

Question 8

HMB

First line Ix

Answer 8

Blood test:
- CBC: Hb, platelets
- Pregnancy test: to exclude pregnancy → must be done (or document no unprotected sex) before EA
- ± clotting profile: if HMB since menarche, or FHx +ve
- ± Fe profile: for Fe def anemia
- ± TFT: only when clinically symptomatic (uncommon)

Further investigations:
- Endometrial aspirate/sampling (EA) (子宮內膜吸取術)
- Hysteroscopy (宮腔鏡檢查術) ± endometrial biopsy
- Pelvic US when suspect structural pathology
- Saline infusion sonography (sonohysterography, SIS)

Question 9

Hysteroscopy and endometrial biopsy

Indications
Process

Answer 9

Question 10

Compare TAUS and TVUS

Answer 10

Question 11

Saline Infusion sonography

Indication and use

Answer 11

Question 12

HMB

Medical management options

Answer 12

Hormonal treatment:
- Combined OC pills (COCP): 1st line unless C/I
- Levonorgestrel IUD (Mirena): also 1st line unless C/I
- High-dose oral progestin: if prefer to avoid or C/I to estrogen
- Danazol: a/w significant S/E, NOT used nowadays
- Gonadotrophin-releasing hormone agonist (GnRHa): a/w significant S/E, NOT used nowadays

Non-hormonal treatment:
- NSAIDs: e.g. mefenamic acid (Ponstan)
- Tranexamic acid (TXA, Transamin): antifibrinolytic agent (flow control only)
- Fe supplement: FeSO4 300mg BD ×12w

Question 13

HMB

Surgical management options

Answer 13

Endometrial ablation (子宮內膜去除術)

Hysterectomy (子宮切除術)
- Abdominal hysterectomy (AH)
- Vaginal hysterectomy (VH): approach through vaginal introitus
- Laparoscopic hysterectomy (LH)
- ± concurrent oophorectomy: preferred when near menopause: ovaries no use after menopause

Question 14

HMB

COCP
- Forms
- MoA
- Effect
- Advantage
- S/E
- C/I

Answer 14

Question 15

HMB

Mirena
- MoA
- Effect
- Advantage
- S/E
- C/I

Answer 15

Question 16

HMB

High-dose oral progestin
- Forms
- MoA
- Advantage
- S/E

Answer 16

Question 17

HMB

Mefenamic acid
- MoA
- Effect
- Use

Answer 17

Question 18

HMB
Transamin

• MoA
• Max dose
• C/I

Answer 18

Question 19

HMB

Endometrial ablation
- Indications
- C/I
- Preoperative preparation
- Procedure
- Complications

Answer 19

Question 20

HMB
Hysterectomy

• Indication
• Choice of route of hysterectomy

Answer 20

Question 21

Intermenstrual and Irregular Bleeding

Ddx

Answer 21

Question 22

IMB

History taking questions

Answer 22

Question 23

IMB

PE

Answer 23

Question 24

IMB

First line investigations

Answer 24

Question 25

IMB Management options

Answer 25

Question 26

Post coital bleed Ddx

Answer 26

Question 27

Post coital bleed Management flowchart

Answer 27

Question 28

Post menopausal bleed Definition Ddx

Answer 28

Question 29

Post menopausal bleed History taking questions PE

Answer 29

Question 30

PMB First-line investigations Treatment options

Answer 30

Question 31

Primary and secondary amenorrhea Definitions

Answer 31

Question 32

Primary amenorrhea Ddx

Answer 32

Question 33

Secondary amenorrhea Ddx

Answer 33

Question 34

Physiological causes of amenorrhea

Answer 34

Question 35

Functional hypothalamic amenorrhea Hormonal profile Common causes

Answer 35

Question 36

Primary ovarian insufficiency - Definition - Hormonal profile - Causes

Answer 36

Question 37

PCOS Diagnostic criteria

Answer 37

Question 38

Cryptomenorrhea Classical symptom Causes

Answer 38

Cryptomenorrhea (outflow tract obstruction) - present with cyclical abdominal pain due to accumulation of blood in vagina (hematocolpos) or uterus (hematometra)

Question 39

Genetic causes of amenorrhea

Answer 39

Question 40

Primary amenorrhea Common clinical presentation and features

Answer 40

Question 41

Secondary amenorrhea Common clinical presentation and features

Answer 41

Question 42

Primary amenorrhea Key history taking questions

Answer 42

Question 43

Secondary amenorrhea Key history taking questions

Answer 43

Question 44

Primary amenorrhea P/E features

Answer 44

Question 45

Secondary amenorrhea P/E features

Answer 45

Question 46

Primary amenorrhea Workup investigations

Answer 46

Question 47

Secondary amenorrhea Workup investigations

Answer 47

Question 48

Primary and secondary amenorrhea Routine hormonal investigations

Answer 48

Question 49

Primary and secondary amenorrhea Second-line investigations

Answer 49

Question 50

Hypogonadotropic hypogonadism (Class 1) Cause Ix results

Answer 50

Question 51

Hypogonadotropic hypogonadism (Class 1) Management of underlying cause Hormonal and fertility management

Answer 51

Question 52

Normogonadotropic anovulation (Class 2) - Cause - Ix results

Answer 52

Question 53

Normogonadotropic anovulation (Class 2) Management of underlying cause Hormonal and fertility management

Answer 53

Question 54

Hypergonadotropic hypogonadism (Class 3) Cause Ix findings

Answer 54

Question 55

Hypergonadotropic hypogonadism (Class 3) Management of underlying cause Hormonal and fertility management

Answer 55

Question 56

Hyperprolactinemia (Class 4) Ix findings Management

Answer 56

Question 57

Outflow tract abnormalities Ix findings Management

Answer 57

Question 58

Concealed male karyotype Ix findings Management

Answer 58

Question 59

Outline flowchart for amenorrhea assessment

Answer 59

Question 60

Define Climacteric, Menopause and Perimenopause

Answer 60

Question 61

Types of menopause

Answer 61

Question 62

Menopause Stages and endocrine stages

Answer 62

Question 63

Climacteric symptoms - Vasomotor symptoms

Answer 63

Question 64

Climacteric symptoms - Neuropsychiatric symptoms

Answer 64

Question 65

Climacteric symptoms - Sexual and urogenital changes

Answer 65

Question 66

Postmenopausal osteoporosis - Cause - Risk factors - Risk assessment

Answer 66

Question 67

Menopause Diagnosis

Answer 67

Question 68

Menopause Hormone replacement therapy - duration - options/ regimens

Answer 68

Question 69

HRT Benefits and risks

Answer 69

The combined regimen has a higher risk of CA breast and CAD compared to Estrogen only regimen despite conventional belief that estrogen only regimen induces CA breast

Question 70

HRT Contraindications

Answer 70

Fibrocystic disease is not a relative C/I

Question 71

HRT Indications

Answer 71

Initiating HRT: Indication: - premature menopause: <40y for bone and cardiac protection (no extra lifetime risk) - symptomatic menopausal pt: only for vasomotor symptoms ± mild mood disorder (not for cardio- and bone protection alone) - (menopausal women with established osteoporosis) - (hypopituitarism and other endocrine disease) Timing: need not await amenorrhea before starting HRT

Question 72

HRT When to stop therapy

Answer 72

Standard duration about 2-3 years Taper from standard to low dose after 1st year Stop regimen during winter Investigations for metabolic and cardiovascular profile every 2 years Rapid symptom control within a month usually Taper off and remain low dose regimen if possible after few months of symptom relief

Question 73

HRT Algorithm of HRT administration

Answer 73

Question 74

Menopause Management of menopausal symptoms

Answer 74

Question 75

Postmenopausal osteoporosis

Answer 75

Question 76

Primary ovarian insufficiency - Definition - Causes

Answer 76

Question 77

Primary ovarian insufficiency Workup Management

Answer 77

Question 78

Endometrial aspirate Indications Process

Answer 78