Menstrual Disorders Flashcards by David Houghton

What point in the menstrual cycles determines the beginning of the next cycle and the end of the previous cycle?

1 - first day of bleeding
2 - ovulation
3 - peak progesterone level
4 - luteal phase

1 - first day of bleeding
- typically lasts 3-7 days
- around 30-40ml of blood

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What is the best time point to measure progesterone as a measure if ovulation has occurred. When is the best time to measure this?

1 - day 3
2 - day 14
3 - day 21
4 - day 28

3 - day 21

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How does hormone contraception work?

1 - increases hormones levels and increases negative feedback loop
2 - reduces gonadotropin releasing hormone, FSH and LH
3 - inhibit follicular development and ovulation
4 - increases mucus thickness at cervix
5 - thins endometrial layer
6 - all of the above

6 - all of the above

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When performing a history on a patient with menstrual problems, there re 4 big red flags. Which of these is NOT one of these red flags?

1 - post-coital bleeding
2 - vaginal discharge
3 - dyspareunia
4 - dysmenorrhea (painful periods)
5 - intermenstrual (bleeding between periods)

2 - vaginal discharge

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Pressure symptoms are those where patients feel a pressure within their pelvic cavity due to an abnormality. Which 2 of the following are examples of something that could cause pressure symptoms?

1 - fibroids
2 - polyps
3 - pelvic inflammatory disease
4 - gonorrhoea

1 - fibroids
2 - polyps

pressure symptoms are essentially anything causing a pelvic mass

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In a patient with menorrhagia what is the first line hormonal treatment that should be tried for patients?

1 - Depo-Provera (contraceptive injection) lasting 12 weeks
2 - Levonorgestrel intrauterine system (progesterone only)
3 -Intrauterine copper device
4 - Nexplanon implant (progesterone only)

2 - Levonorgestrel intrauterine system (progesterone only)

Combined oral contraception can also be useful in reducing menorrhagia if patient doesnt want implant

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In a patient with menorrhagia what is the first line medication that should be tried for patients?

1 - tranexamic acid
2 - alteplase
3 - mefanamic acid
4 - clopidogrel

3 - mefanamic acid
- this is an NSAID

2nd treatment option would be tranexamic acid if the 1st line fails

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If a patient continues to have menorrhagia and hormonal and drug treatment has failed, we can perform surgery. Which 2 of the following are the most common forms of surgery?

1 - blood vessel ligation
2 - endometrial ablation
3 - balloon inflation
4 - hysterectomy

2 - endometrial ablation
4 - hysterectomy

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In a patient with menorrhagia which of the following blood tests is not super important to measure straight away in comparison with the rest?

1 - FBC
2 - TFTs
3 - coagulation profile
4 - U&Es

4 - U&Es
- typically done, but least important of the 4

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In a patient >45 y/o with menorrhagia that is not responding to treatment, what investigation should they have?

1 - bimanual and speculum
2 - laparoscopy
3 - hysteroscopy and endometrial biopsy
4 - pelvic ultrasound

3 - hysteroscopy and endometrial biopsy

bimanual and speculum and pelvic ultrasound are done on all patients

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In a patient with abnormalities in her menstrual cycle, which is often the 1st line for taking a biopsy?

1 - hysteroscopy
2 - colposcopy
3 - large loop excision of the transformation zone (LLETZ)
4 - pipelle biopsy

4 - pipelle biopsy

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All of the following are benign gynaecological causes of menorrhagia, EXCEPT which one?

1 - Abnormal (Dysfunctional) uterine bleeding (no structural or pathology found)
2 - Fibroid uterus
3 - Adenomyosis
4 - Clear cell Tumour
5 - Endometrial polyp
6 - Cu intrauterine device
7 - Atrophic vagina

4 - Clear cell Tumour
- malignant cause

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All of the following are malignant gynaecological causes of menorrhagia, but which is most common?

1 - Endometrial cancer
2 - Cervical cancer
3 - Vaginal cancer
4 - Ovarian cancer

1 - Endometrial cancer

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Non gynaecological causes of menorrhagia can include endocrine disorders. Which 2 of the following can lead to menorrhagia?

1 - hyperthyroidism
2 - hypothyroidism
3 - cushing syndrome
4 - prolactinoma

1 - hyperthyroidism
2 - hypothyroidism
- others typically cause amenorrhea

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Non gynaecological causes of menorrhagia can include bleeding disorders, but which of the following is most common?

1 - hemophilia A (factor VIII deficiency)
2 - hemophilia B (factor IX deficiency)
3 - von Willebrand disease (VWD)
4 - all equally common

3 - von Willebrand disease (VWD)

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Fibroids are benign smooth muscle tumours of the uterus, also referred to as leiomyomas. Are caucasian or black-ethnic background more likely to have fibroids?

black-ethnic background
= 50% of women
caucasians women = 20-60%, but not as high as black-ethnic women

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Fibroids, also called leiomyomas, are benign smooth muscle tumours of the uterus that are responsive to a specific hormone. Which hormone is this?

1 - FSH
2 - oestrogen
3 - LH
4 - progesterone

2 - oestrogen
- fibroids increase/decrease with levels of estrogen

i.e. meopause = decrease in size
pregnancy = increase in size

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Although incredibly rare, what % of fibroids can become malignant and become leiomyosarcomas?

1 - 90%
2 - 60%
3 - 25%
4 - 1%

4 - 1%

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Fibroids are names based on thir positions in the pelvic cavity. Which of the following descriptions describes a Submucosal fibroid?

1 - the fibroid is situated in the myometrium, the uterine smooth muscle.
2 - these fibroid have a stalk attaching to the uterus
3 - the fibroid is situated below the serosal layer of the uterus, protruding into the abdominal cavity.
4 - the fibroid is situated below the endometrium, protruding into the endometrial cavity.

4 - the fibroid is situated below the endometrium, protruding into the endometrial cavity.

these fibroids are typically responsible for bleeding

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Fibroids are names based on thir positions in the pelvic cavity. Which of the following descriptions describes a intramural fibroid?

1 - the fibroid is situated in the myometrium, the uterine smooth muscle.

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Fibroids are names based on thir positions in the pelvic cavity. Which of the following descriptions describes a Subserosal fibroid?

3 - the fibroid is situated below the serosal layer of the uterus, protruding into the abdominal cavity.

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Fibroids are names based on thir positions in the pelvic cavity. Which of the following descriptions describes a Pedunculated fibroid?

2 - these fibroid have a stalk attaching to the uterus

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Do fibroids always cause symptoms?

no can be asymptomatic and incidental finding on a scan for something else

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Fibroids can be asymptomatic, but can cause symptoms as well. Which of the following is NOT a common symptom of a fibroid?

1 - menorrhagia
2 - abdominal pain/bloating
3 - pressure symptoms
4 - urinary and bowel changes
5 - ascites
6 - fertility issues
7 - dyspareunia
8 - complication during pregnancy

5 - ascites
- common in ovarian cancer

Both fibroids and endometriosis and adenomyoisis can cause menorrhagia. Which of these would be associated with heavy periods and/or pressure symptoms BUT not dysmenorrhea?

- fibroids

If we suspect a fibroid is present, which of the following examinations is NO typically performed? 1 - General examination 2 - Abdominal examination 3 - Digital rectal examination 4 - Speculum examination 5 - Bimanual examination: Firm enlarged uterus

3 - Digital rectal examination - can be performed if suspecting GIT cause

If we suspect a fibroid is present, there are 3 main blood tests that should be performed, which of these is NOT one of the 3? 1 - LFTs 2 - TFTs 3 - coagulation profile 4 - FBCs

1 - LFTs

What is typically the first line imaging for fibroids? 1 - abdominal/transvaginal ultrasound 2 - MRI 3 - CT 4 - hysteroscopy

1 - abdominal/transvaginal ultrasound - hysteroscopy if fibroid is submucosal - MRI used peri-operatively to plan surgery

If we suspect fibroids, we must also consider other diagnoses. Which of the following is NOT a realistic differential? 1 - Fibroid uterus 2 - Adenomyosis 3 - Endometriosis 4 - Abdominal hernia 5 - Endometrial polyp 6 - Endometrial cancer

4 - Abdominal hernia

What size fibroids are treated medically rather than surgically? 1 - <1cm 2 - <3cm 3 - <5cm 4 - <10cm

2 - <3cm - non-hormonal = mefanamic acid and tranexamic acid - hormonal = mirena coil insertion provided uterine cavity is not distorted Combined oral contraceptive Cyclical oral progesterone

What surgical treatments are available for fibroids that are small but >3cm? 1 - Endometrial ablation 2 - Transcervical resection of the submucous fibroid 3 - Hysterectomy if other measures fail 4 - all of the above

4 - all of the above - but all depend on if woman wants to maintain fertility

What treatments are available for large fibroids? 1 - Myomectomy 2 - Hysterectomy 3 - Uterine artery embolisation 4 - all of the above

4 - all of the above - GnRH agonist can be used to shrink the fibroid prior to surgery

All of the following are complications of fibroids, EXCEPT which one? 1 - Iron deficiency anaemia due to menorrhagia 2 - Subfertility 3 - Urine Retention 4 - Peritonitis 5 - Pregnancy complication 6 - Leiomyosarcoma

4 - Peritonitis - Red degeneration is a hemorrhagic infarction of the uterine leiomyoma,

Adenomyosis is when endometrial tissue is found in the myometrium of the uterus. Is this more common in multiparous or nulliparous women?

- multiparous typically towards the end of their reproductive years.

Adenomyosis is when endometrial tissue is found in the myometrium of the uterus. What % of women are affected by adenomyosis? 1 - 1% 2 - 10% 3 - 30% 4 - 70%

2 - 10%

Patients with suspected adenomyosis can present with all of the following, EXCEPT which one of the following? 1 - Asymptomatic 2 - Pressure symptoms 3 - Menorrhagia 4 - Dysmenorrhoea 5 - Dyspareunia 6 - Fertility issues

2 - Pressure symptoms - common when masses are present

Patients with suspected adenomyosis will need a pelvic examination. The uterus will typically be which of the following? 1 - enlarged, boggy uterus 2 - enlarged, bulky, mass present

1 - enlarged, boggy uterus - pelvic may be tender as well

Can adenomyosis exist with endometriosis and fibroids?

- yes

What is the firs line imaging for a patient with suspected adenomyosis? 1 - MRI 2 - CT 3 - pelvic X-ray 4 - transvaginal ultrasound

4 - transvaginal ultrasound - MRI may be appropriate if surgery is discussed

What is the gold standard for diagnosing adenomyosis? 1 - histology from biopsy 2 - hysterectomy 3 - MRI 4 - transvaginal ultrasound

1 - histology from biopsy

Which of the following is NOT a medical management approach to adenomyosis? 1 - non-hormonal = mefanamic acid and tranexamic acid 2 - hormonal = mirena coil insertion provided uterine cavity is not distorted 3 - Combined oral contraceptive or Cyclical oral progesterone 4 - endometrial ablation

4 - endometrial ablation - this with hysterectomy would be a surgical option

All of the following are complications of adenomyosis, EXCEPT which one? 1 - Subfertility 2 - Miscarriage 3 - Preterm labour 4 - Ovarian cysts 5 - Postpartum haemorrhage

4 - Ovarian cysts - postpartum haemorrhage is because uterus doesnt contract effectively causing uterine atony

If we suspect adenomyosis, we must also consider other diagnoses. Which of the following is NOT a realistic differential? 1 -Endometriosis 2 - Fibroid uterus 3 - Endometrial polyp 4 - Endometrial cancer 5 - Abdominal hernia

5 - Abdominal hernia

Intramenstrual bleeding is bleeding in between periods, and is a red flag and what must be ruled out? 1 - endometriosis 2 - adenomyosis 3 - gynaecological cancer 4 - polyps

3 - gynaecological cancer

In the image match A-D with the following: - Intramenstrual bleeding - menorrhagia - amennorhea - normal

A = normal B = amennorhea C = menorrhagia D = Intramenstrual bleeding (>7 days in duration)

Which of the following is NOT a benign cause of Intramenstrual bleeding? 1 - Endometrial / cervical polyps 2 - Clear cell tumour 3 - Cervical ectropion 4 - Atrophic vagina 5 - Hormonal contraceptives 6 - Ovulatory disorder 7 - Sexually transmitted disease 8 - Pregnancy

2 - Clear cell tumour

Which of the following is NOT a malignant cause of Intramenstrual bleeding? 1 - Endometrial cancer 2 - Endometrial hyperplasia 3 - Cervical cancer 4 - Vaginal cancer 5 - Ovarian cancer

5 - Ovarian cancer - is malignant but typically does not cause intramenstrual bleeding

what aged women should have a hysteroscopic guided endometrial biopsy if intramenstrual bleeding is present? 1 - >25 2 - >35 3 - >45 4 - >55

3 - >45 to rule out malignancy - BUT if bleeding is persistent hysteroscopic guided endometrial biopsy should be performed regardless of age

In intramenstrual bleeding is an abdominal or transvaginal ultrasound more accurate?

- transvaginal ultrasound

If a patient has intramenstrual bleeding and has a history of cervical hyperplasia, which test is best? 1 - Transvaginal ultrasound 2 - Hysteroscopy 3 - Endometrial biopsy 4 - Colposcopy

4 - Colposcopy - can be diagnostic and curative - management of all intramenstrual bleeding is dependent on the cause

Postcoital bleeding refers to vaginal bleeding after sexual intercourse in the absence of menstrual period. is this dangerous?

- yes - this is a red flag and must be investigated as soon as possible

Which of the following is NOT a typical benign causes of post-coital bleeding? 1 - Adenomyosis 2 - Cervical/ Endometrial polyps 3 - Cervical Ectropion 4 - Infection (Chlamydia) 5 - Atrophic vagina 6 - Cervical dysplasia

1 - Adenomyosis - causes bleeding, but not typically post-coital bleeding

Which of the following is NOT a typical malignant causes of post-coital bleeding? 1 - Cervical intraepithelial neoplasia 2 - Cervical cancer 3 - Vaginal cancer 4 - Ovarian cancer 5 - Endometrial cancer

4 - Ovarian cancer

In a patient with post-coital bleeding, which of the following would NOT be a first line investigation? 1 - Bimanual and speculum 2 - MRI 3 - Cervical swabs: Endocervical and high vaginal swab 4 - STI screening 5 - Colposcopy +/- biopsy 6 - Transvaginal ultrasound 7 - Hysteroscopy 8 - CT Scan

2 - MRI - management of patients with post-coital bleeding is dependent on the diagnosis

In a patient with post-coital bleeding, which of the following would NOT be a sensible differential? 1 - Cervical/ Endometrial polyps 2 - Cervical Ectropion 3 - Uterine prolapse 4 - Infection (Chlamydia) 5 - Cervical cancer / Cervical intraepithelial neoplasia 6 - Endometrial cancer 7 - Vaginal cancer primary / secondary

3 - Uterine prolapse

Atrophic vagina is a common cause of post-coital sex and inter-menstrual bleeding if the patient is not menopausal. Low levels of which hormone cause this? 1 - FSH 2 - oestrogen 3 - LH 4 - progesterone

2 - oestrogen

Atrophic vagina is a common cause of post-coital sex and inter-menstrual bleeding if the patient is not menopausal. Which of the following is NOT a common presentation of atrophic vagina? 1 - Itching 2 - Purulent discharge 3 - Dryness 4 - Dyspareunia 5 - Vaginal bleeding

2 - Purulent discharge

Topical oestrogen can be very helpful for patients with atrophic vaginas, such as: - Topical oestrogen cream - Oestrogen pessary - Vaginal lubricant can help with dryness But these are all contraindicated in which of the following? 1 - breast cancer 2 - angina 3 - thromboembolism 4 - all of the above

4 - all of the above