AUB

Question 1

Workup of AUB

Answer 1

DDx
- cervical ca/polyps
- Fibroid/LMS
- adenomyosis
- uterine polyps
- EH/AH/EAC
- STI
- coagulopathy

Initial Ix
- FBE/Ferritin/TSH/LDH +/- bHCG
- Coag - prolonged APTT +/-vWF
+/- STI +/- CST
- Pelvic USS
- Pipelle vs HDC (exclude EH/AH/Ca)

Question 2

HMB Mx (fibroids)

Scenario 1 - 32yo, G1P0, requesting hysterectomy, failed medical mx

Scenario 2 - 42yo, nulliparous, large multi-fibroid uterus with x2 large SMF distorting cavity, HMB is c/b anemia, pt is also a JW

Scenario 3 - 44yo, requesting EA after failed medical mx

Scenario 4 - 30yo HMB c/b anaemia in setting of SMF

Answer 2

• risk - pain/anemia/pressure effect…
• d/w senior gyn
  +/- MDI if need pre-op optimization
• medical mx
  1. anaemia mx - Fe/PRBC
  2. sx (pain/bleed) mx - Txa/MA
  3. thin endo - P4 - PO/Depo/IUD
• F/U to rv for further mx option

+/- surgical
1. EA - irrevers, contra, cavity suitab
2. Resect - staged, H2o intox, Ash
3. Myo - focal, bleeding, hyster
4. Hyster - major op, fertility

+/- radiological
1. UAE/MRgFUS - min invasive, fertility, not suitable for large/multi-fibroid/SSF/SMF

UAE
- does not increase ov failure rate
- assoc ⬇️preg rate/⬆️MC/⬆️CS/PPH

Question 3

HMB Mx (Adenomyosis)

Answer 3

• risk - pain/anemia
• d/w senior gyn
  +/- MDI if need pre-op optimization
• medical mx
  1. anaemia mx - Fe/PRBC
  2. sx (pain/bleed) mx - Txa/MA
  3. thin endo - P4 - PO/Depo/IUD
• F/U to rv for further mx option

+/- surgical +/- radiological
- Adenomyomectomy - focal
- Hysterectomy
- MRgFUS - focal

EA not suitable - trap blood

Question 4

Emergency of Mx of HMB

Scenario 1 - 42yo, nulliparous, large multi-fibroid uterus with x2 large SMF distorting cavity, HMB is c/b anemia, pt is also a JW

Answer 4

• risk of anemia/cardiac issue
• senior gynae input
• MDI - gynae/haem
• Explore all alternatives
• document what product acceptable
• NBM/IVT/IVC x2/anti-fibrinolytic
• +/- surgical management

Question 5

Mx options for EH

Scenario 1 - 48yo lap band, HMB, EH on D&C

Scenario 2 - 53yo PMB, on tamoxifen, HDC identified EH

Answer 5

• risk of EAC 5% over 20yr
• risk reduced w hormonal rx
• d/w senior gynae
• options based on fertility plan
• LS mod - weight/HRT/Tmx
• EBs vs EBs+Rx vs Hyster +/-BSO

Follow-up
- EB in 6mo
- BMI <35 -> x2 6mo -‘ve EB = dc
- BMI >=35 -> x2 6mo-‘ve EB ->12mo
- Persist bleeding -> hyster +/- BSO
- Persist post 12mo rx -> hyster+/-BSO
- Relapse -> hyster+/-BSO

Question 6

Mx options for AH

Scenario 1 - 40yo, P0, multi-fibroid

Scenario 2 - 44yo, HMB, polyp found with AH

Answer 6

• risk of EAC 30% over 20yr
• risk of 40% concomitant EAC
• risk of progression/relapse w rx
• d/w senior gynae
• options based on fertility wishes
• LS mod - weight/HRT/Tmx
• EBs vs EBs + Rx vs Hyster+/-BSO

Follow-up plan
- EB in 3mo
- if progress/persist -> hyster +/- BSO
- 2 consecutive negative EB
- bx 6-12 monthly & rv
- if relapse -> hyster +/- BSO