AUB- QUESTIONS Flashcards
Regarding the menstrual cycle…
1 - The secretory (luteal) phase of the cycle is fixed at 14 days
2 - The variability of menstrual cycle lengths is higher in women under 25 years of age than in women aged 35 to 39 years
3 - As age increases, menstrual cycle tends to shorten
4 - Endometrial sampling is required for all women presenting with AUB
5 - The normal monthly menstrual blood loss (MBL) is 80 ml
1 - The answer is true. This is the life span of the corpus luteum.
2 - The answer is true.
3 - The answer is true.
4 - The answer is false.
5 - The answer is false. Normal loss is 25-50 ml. Anaemia from heavy menstrual bleeding is more likely to occur if MBL exceeds 80 ml and particularly likely if MBL exceeds 120 ml
Preliminary assessment 2 - FIGO (PALM-COEIN) causes of AUB A: P0 A0 L(ism) M0- C0 O0 E0 I0 NO B: P0 A1 L M0- C0 O0 E0 I0 NO C: P1 A0 L M0- C0 O0 E0 I0 NO D: P0 A0 L M0- C0 O0 E1 I0 NO E: P0 A0 L(ism) M1 - C0 O0 E0 I0 NO F: P1 A1 L0 M0- C0 O0 E0 I0 NO G: P1 A0 L1 (0) M0- C0 O0 E0 I0 NO H: P0 A1 L1(0) M0- C1 O0 E0 I0 NO
1 - Menorrhagia and dysmenorrhoea in a 48-year-old woman. Hysteroscopy identified 3 cm posterior submucosal leiomyoma. Endometrial biopsy has identified atypical endometrial hyperplasia.
2 - A 30-year-old woman with menorrhagia and dysmenorrhoea unresponsive to tranexamic acid. Adenomyosis and subserosal leiomyoma were diagnosed by MRI. Coagulation screen confirms presence of mild von Willebrand disease.
3 - Dysmenorrhoea and menorrhagia unresponsive to Mirena therapy in a 40-year-old woman. Ultrasound shows diffuse thickening of the posterior uterine wall that contained focal ill-defined myometrial lacunae and hypoechoic heterogeneity.
4 - Menorrhagia in a 40-year-old woman. No abnormality identified on haematological, ultrasound, hysteroscopy and endometrial biopsy testing.
The answer is Part E.
The answer is Part H.
The answer is Part B.
The answer is Part D.
In 2011, FIGO approved a new classification system for the causes of AUB and have called it PALM-COEIN.
Where PALM-COEIN criteria refers to structural causes (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia) and non-structural (coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified) causes for AUB. Using the full notation ‘PALM-COEIN’ it is possible to define women with AUB who have one or more contributing pathologies.
In all cases, the presence or absence of each criterion is noted using 0 if absent, 1 if present, and ? if not yet assessed. For each of the clinical cases listed below, indicate which is the most likely representative image and corresponding PALM-COEIN terminology description.
TRUE /FALSE
The presence of which of the following ‘red flag’ features indicate referral to secondary care (e.g. one-stop ambulatory gynaecology clinic or rapid access gynaecology clinic)?
1 - New onset postmenopausal bleeding in a 52-year-old woman.
2 - HMB in a 45-year-old woman that has not responded to 3 months of tranexamic acid therapy.
3 - IMB for 6 months in a 28-year-old woman.
4 - HMB in a 32-year-old woman with a uterine cavity that measures 10 cm by uterine sounding.
1 - The answer is true.
2 -The answer is true.
3 - The answer is true.
4 - The answer is false.
- Cervical cytology
- Endometrial biopsy
- Full blood count
- Intpatient hysteroscopy and endometrial biopsy.
- Laparoscopy
- MRI pelvis
- Outpatient hysteroscopy and endometrial biopsy.
- Saline infusion sonohysteroraphy
- Serum ferritin
- Testing for coagulation disorders (e.g. Von Willebrand’s factor)
- Thyroid function tests
- Transvaginal +/- transabdominal pelvic ultrasound
The following items are general scenarios or questions regarding women presenting with AUB. For each item choose the single best diagnostic procedure from the options listed below that enables optimal management. Each option can be used once, more than once or not at all.
1 - A 32-year-old woman presents with symptoms of menorrhagia, dysmenorrhoea and cyclical, localised pelvic pain. The pelvic ultrasound showed no abnormality.
2 - A 48-year-old woman with menorrhagia and a 24-week sized multifibroid uterus has opted for uterine fibroid embolisation. Ultrasound shows variable sized intramural fibroids. Apart from hysteroscopy, what investigation is a necessary pre-requisite to uterine artery embolisation.
3 - What is the first-line diagnostic tool for the identification of structural pathology in women with HMB?
4 - A 56-year-old woman presents with postmenopausal bleeding. Ultrasound identified an endometrial thickness of 15mm and an intrauterine fundal echogenic mass of 2 cm. She is taking warfarin as prophylaxis due to a prosthetic metal heart value. She has congestive cardiac failure.
5 - Which specific test, additional to routine screening, is undertaken on women with HMB in their teenage years or who have had HMB since menarche.
1 -The answer is laparoscopy. This procedure provides the opportunity to simultaneously diagnose and treat endometriosis, which may be responsible for the menstrual abnormalities and pelvic pain.
2 - The answer is MRI pelvis.
3 - The answer is transvaginal +/- transabdominal pelvic ultrasound. Neither saline infusion sonography, nor MRI, should be used as first-line diagnostic tools for HMB.
4 - The answer is outpatient hysteroscopy and endometrial biopsy.
5 - The answer is testing for coagulation disorders (e.g. Von Willebrand’s factor)
- Abdominal hysterectomy
- COCP
- Endometrial ablation
- Etonoestrel implant (implanon)
- GNRH - agonist
- Hysteroscopic myomectomy
- Hysteroscopic polypectomy
- Depo- provera
- Laparoscopic vaginal assisted hysterectomy
- Mirena
- Mefenamic acid
- Norethisteron daily from DAY 5-26 O
- Total laparoscopic hysterectomy
- Tranexemix acid
- UAE
- Vaginal hysterectomy
The following items are clinical scenarios of women presenting with AUB. For each item choose the best treatment from the options listed that enables optimal management. Each option can be used once, more than once or not at all.
1 - A 34-year-old woman (parity 3) presents with menorrhagia. Considering she has no uterine pathology and is seeking an effective long-term reversible form of contraception, what would you suggest?
2 - A 41-year-old woman with three children presents with menorrhagia, without significant dysmenorrhoea, that has not responded to 6 months of Mirena therapy. Hysteroscopy showed a normal-shaped uterine cavity with cavity length of 10 cm. No intracavity fibroids or polyps were identified. She does not seek future fertility. What is the best treatment option, with the lowest risk?
3 - A 42-year-old woman is seeking a hysterectomy for persistent menorrhagia that has been unresponsive to endometrial ablation. She is parity 3, has a normal sized uterus and second degree cervical descent. She wishes to conserve her ovaries. What is the preferred type of hysterectomy?
4 - A 24-year-old woman presents with menorrhagia but without significant dysmenorrhoea. Given that she wishes to conceive, what would be the best form of treatment?
5 - What treatment would you suggest for a 44-year-old woman with a completed family and 28-week size fibroid uterus who is complaining of menorrhagia, chronic abdominal pain, bowel and bladder obstructive symptoms? Note: she is seeking a definitive cure.
1 - The answer is levonorgestrel-releasing intrauterine device (Mirena). Women should be fully counselled regarding possible changes to their menstrual cycles particularly in the first few months following the insertion of an LNG-IUS. Perseverance for at least 6 months is recommended for the benefits of this procedure to be appreciated.
2 - The answer is endometrial ablation. Compared with hysterectomy, endometrial ablation is quicker to perform and results in shorter hospital stays and a faster return to work. Hysterectomy on the other hand, results in more adverse effects and is more expensive. It should be noted that the need for retreatment in endometrial ablation (approximately 20% over 5 years) leads its differential benefits to decrease over time.
3 - The answer is vaginal hysterectomy. A meta-analysis of studies comparing types of hysterectomy has shown the lowest complication rate with vaginal hysterectomy.
4 - The answer is tranexamic acid. This treatment is able to achieve a 60–75% reduction in menstrual blood loss. When HMB coexists with dysmenorrhoea then NSAIDs should be preferred to tranexamic acid because NSAIDs may impair the ovulatory process and thus may impair fertility (although the evidence for this association is mainly of theoretical origination). Use of NSAIDs or tranexamic acid should be stopped if they do not improve symptoms within 3 months.
5 - The answer is abdominal hysterectomy. Such a large fibroid uterus is unlikely to be effectively treated by either myomectomy or uterine artery embolisation.
Preliminary assessment 6 - Endometrial ablation
Regarding endometrial ablation…
1 - UK MHRA guidance recommends uterine assessment (ultrasound and/or hysteroscopy and endometrial biopsy) is conducted prior to scheduling for endometrial ablation
2 - Endometrial ablation may be undertaken on women not wishing to become pregnant in the future
3 - Endometrial ablation should be considered preferable to hysterectomy in women with HMB whose uterine cavity length does not exceed 12 cm
4 - Ablative techniques are contraindicated in women with a single previous caesarean section and a lower uterine myometrial thickness of 12 mm
5 - Immediately after dilatation of the cervix and prior to positioning the device for treatment, the uterine cavity should be reassessed by hysteroscopy (or ultrasound) to confirm there is no uterine perforation, false passage or uterine wall trauma
6 - Endometrial thinning and/or scheduling of ablation surgery for the postmenstrual phase are necessary pre-requisites for thermal balloon and bipolar radio-frequency endometrial ablation techniques
1 - The answer is true.
2 - The answer is false. Women must be counselled on the need to use effective contraception after endometrial ablation.
3 - The answer is true, based on cost-effectiveness studies reported in NICE HMB guideline.
4 - The answer is false.
5 - The answer is true.
6 - The answer is false. Endometrial thinning may be advantageous for microwave endometrial ablation. However, there is no such requirement for thermal balloon endometrial ablation. Most ablative techniques nowadays do not require such preoperative endometrial preparatory strategies.
KEY POINTS MENSTRUATION
Key points
Menstruation is controlled by the cyclical hormonal change in the menstrual cycle.
Normal frequency is between 24–38 days.
Normal duration is 4.5–8 days.
Normal volume is between 5–80 ml.
Regular cycle-to-cycle variation is between 2–20 days.
Recommendations prior to endometrial ablation
An endometrial biopsy is obtained and histologically analysed to exclude the possibility of endometrial hyperplasia or endometrial cancer.
Hysteroscopy is performed immediately prior to the insertion of the ablation device to ensure that:
any sounding or dilation of the cervix has not caused a perforation or false passage, resulting in subsequent introduction of the ablation device into the wrong space
there is no significant intrauterine pathology that would preclude ablation, e.g. uterine cavity distorted by intrauterine fibroids
the operator can accurately determine uterine cavity length (and cervical canal length if using NovaSure®).
Regarding endometrial ablation…
1 - Second-generation ablation techniques are less costly than hysterectomy but hysterectomy provides greater gain in quality of life over the long term
2 - Hysteroscopy should be undertaken post-dilation of the cervix and prior to insertion of the ablation device in the uterus to confirm uterine integrity
3 - Endometrial thinning pre-ablation is required for most ablative techniques
4 - Endometrial ablation provides effective contraception
5 - Hysteroscopic sterilisation may be conducted at the same time as endometrial ablation
6 - Endometrial ablative techniques should be undertaken under local anaesthetic where appropriate
1 - The answer is true.
2 - The answer is true.
3 - The answer is false.
4 - The answer is false.
5 - The answer is true.
6 - The answer is true.
TRUE /FALSE
1 - The number of hysterectomies performed for benign gynaecological disorders decreased by over 50% between 1993–2002
2 - There is no significant difference in urinary tract injury (includes bladder and ureter) between laparoscopic hysterectomy and abdominal hysterectomy
3 - There is no statistically significant differences in urinary tract injury for LH versus VH or for LH(a) versus LAVH
4 - Approximately 85% of women are willing to accept a 50:50 chance of treatment failure for HMB in order to avoid hysterectomy
5 - There are fewer abdominal wall infections and other postoperative infective episodes for LH versus AH
6 - In women undergoing VH compared with AH, hospital stay was shorter and there was a quicker return to normal activities
7 - The presence of fibroids at a hysterectomy increases the risk of operative complications
8 - The route of hysterectomy to be used should be considered in the following order: first line, vaginal; second line, abdominal; and third line, laparoscopic
9 - There is no medical advantage to perform medical pre-treatment before hysterectomy and myomectomy with GnRH-a for 3–4 months for women with enlarged uterine fibroids
10 - Over the short- and long-term, there is higher patient satisfaction with hysterectomy than endometrial ablation
1 - The answer is true. According to UK hospital episode statistics there were 24 355 hysterectomies in 1993 and 10 559 in 2002.
2 - The answer is false. A systematic review showed that there was a significant two-fold increase for LH versus AH (OR 2.61, 95% CI 1.22 to 5.60).
3 - The answer is true.
4 - The answer is true. This was identified in a UK patient preference study.
5 - The answer is true.
6 - The answer is true.
7 - The answer is true. Hysterectomy for fibroids was associated with significantly more complications than women with DUB (adjusted OR 1.34 [95% CI 1.14 to 1.56]).
8 - The answer is true.
9 - The answer is false.
10 - The answer is true. The systematic review of hysterectomy against endometrial ablation found that patient satisfaction favoured hysterectomy (at 12 months OR = 0.46 [0.24 to 0.88], and at 24 months OR = 0.31 [0.16 to 0.59]).
Utilise the NICE 2007 Heavy menstrual bleeding (link is external) guideline with its three-step approach.
1 - Step one is medical treatment with both hormonal and non-hormonal treatment.
2 - Step two is minimally invasive uterus conserving surgery e.g. hysteroscopic fibroid resection, endometrial ablation, transcervical resection of endometrium and laparoscopic myomectomy.
3 - Additional treatments have been added to step 2 involving newly developed intervention in keeping with the above. It includes MRI guided focused USS therapy, radiofrequency ablation of fibroids, uterine fibroid embolisation and laparoscopic uterine artery occlusion.
4 - Step three involves major surgical procedures e.g. abdominal myomectomy and hysterectomy.
Treatment of HMB
Choose the treatment technique associated with the adverse effects listed in the items below. Each option can be used once, more than once or not at all.
A - Day-case procedure. COMMON: 1 - persistent vaginal discharge, 2 - post-embolisation syndrome [pain, nausea, vomiting and fever (not involving hospitalisation)]. LESS COMMON: 1 - need for additional surgery, 2 - premature ovarian failure particularly in women over the age of 45 years, 3 - haematoma. RARE: 1 - haemorrhage, 2 - non-target embolisation causing tissue necrosis, 3 - infection causing septicaemia.
B- Inpatient surgical procedure.
COMMON:
1 - menopausal-like symptoms. Although beneficial outcome is substantial reduction in the risk of developing ovarian cancer.
C- Inpatient surgical procedure.
COMMON:
infection.
LESS COMMON:
1 - intraoperative haemorrhage,
2 - damage to other abdominal organs, such as the urinary tract or bowel,
3 - urinary dysfunction (frequent passing of urine and incontinence).
RARE:
1 - thrombosis (DVT and clot on the lung).
VERY RARE:
1 - death. (Complications are more likely if performed in the presence of fibroids).
D - Surgical procedure. LESS COMMON: 1 - adhesions (which may lead to pain and/or impaired fertility), 2 - need for additional surgery, 3 - recurrence of uterine fibroids, 4 - perforation (if performed by hysteroscopic route), infection. RARE: haemorrhage.
E - Day-case surgical procedure, able to be performed under local anaesthetic in outpatient setting.
COMMON:
1 - vaginal discharge;
2 - increased period pain or cramping (even if no further bleeding);
3 - need for additional surgery.
LESS COMMON:
1 - infection.
RARE:
1 - uterine perforation (but very rare with second generation techniques).
F - Preparations are licensed for 4 weeks or 3 months. COMMON:
menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness) which may require add-back therapy.
LESS COMMON:
osteoporosis, particularly trabecular bone with longer than 6 months’ use.
G - Preparations are licensed for 3 months or 3 years. COMMON:
weight gain,
irregular bleeding,
amenorrhoea,
premenstrual-like syndrome (including bloating, fluid retention, breast tenderness).
LESS COMMON:
small loss of bone mineral density,
largely recovered when treatment discontinued.
H - Taken daily from days 5–26. COMMON: hormonal side effects, weight gain, bloating, breast tenderness, headaches, acne (but all are usually minor and transient) RARE: depression.
I - Taken daily from days 1–21. Numerous contraceptive and non-contraceptive beneficial effects (e.g. reduced risk of ovarian cancer and treatment for estrogen-sensitive disorders, such as endometriosis and fibroids). COMMON: hormonal side effects, mood changes, headaches, nausea, fluid retention, breast tenderness. VERY RARE: deep vein thrombosis, stroke, heart attacks.
J - Only taken at the time of menses, no hormonal side effects, non-contraceptive. COMMON: indigestion; diarrhoea. RARE: worsening of asthma in sensitive individuals, peptic ulcers with possible bleeding and peritonitis.
K - Only taken at the time of menses, no hormonal side effects, non-contraceptive. LESS COMMON: indigestion, diarrhoea, headaches.
L - Licensed for 5-year therapeutic usage.
COMMON:
irregular bleeding that may last for over 6 months, hormone-related problems such as breast tenderness, acne or headaches (generally minor and transient).
LESS COMMON:
amenorrhoea.
RARE:
uterine perforation at the time of device insertion.
A - UAE
B - The answer is oophorectomy at time of hysterectomy.
C - The answer is hysterectomy.
D - The answer is myomectomy.
E - The answer is endometrial ablation.
F - The answer is GnRHa (gonadotrophin-releasing hormone analogue).
G - The answer is injected long-acting progestogens.
H - The answer is oral progestogen: norethisterone (15 mg) daily.
I - The answer is combined oral contraceptives.
J - The answer is non-steroidal anti-inflammatory drugs.
K - The answer is tranexamic acid.
L - The answer is Mirena (levonorgestrel-releasing intrauterine system).
- No suspicious pathology. Physical examination not required. Commence first-line treatment.
- Suspicious pathology. Physical examination required. Obtain cervical smear. Prompt referral to secondary care for urgent transvaginal pelvic ultrasound.
- Suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy.
- Suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy and laparoscopy.
AUB investigation and management
The following items are clinical scenarios of women presenting with abnormal uterine bleeding. For each item choose the best diagnostic procedure from the options listed above that enables optimal management. Each option can be used once, more than once or not at all.
1 - A 47-year-old woman presents with a 6 month history of intermenstrual bleeding. Despite this, she still exhibits regular menstrual cycles without associated pelvic pain and without any postcoital bleeding. She currently uses condoms for contraception, is not clinically anaemic and all previous cervical smears appeared normal. Her last smear was 1 year prior to symptoms.
2 - After a 2 month episode of postmenopausal bleeding, a woman presents with a cervical smear reporting ‘atypical glandular cells of undetermined significance, possibly endometrial cell origin’.
3 - A 41-year-old woman has a 2 year history of heavy menstrual bleeding. She exhibits regular menstrual cycles without any associated pelvic pain and does not suffer from intermenstrual or postcoital bleeding. She is currently using condoms for contraception and is not clinically anaemic. All previous cervical smears normal and her last smear was 1 year prior.
4 - A 61-year-old woman is concerned because over the last week she has been experiencing vaginal blood loss described as a period-like. Her final menstrual period was when she was around 50 and she has never taken HRT.
1 - The answer is suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy.
Persistent intermenstrual bleeding requires investigation. Given the risk associated with her age group, malignancy needs to be excluded definitively and after the initial investigation of a pelvic ultrasound more tests may be advised.
2 - The answer is suspicious pathology. Physical examination and pelvic ultrasound required. Recommend diagnostic hysteroscopy and endometrial biopsy. Underlying uterine cancer. Endometrial hyperplasia or cervical adenocarcinoma is present in 30–40% of such cases thus warranting urgent hysteroscopy and endometrial biopsy.
3 - The answer is no suspicious pathology. Physical examination not required. Commence first-line treatment as recommended in the NICE HMB guideline.
4 - The answer is suspicious pathology. Physical examination required. Obtain cervical smear. Prompt referral to secondary care for urgent transvaginal pelvic ultrasound.
PMB requires urgent investigation to exclude malignancy. If endometrial thickness is less than 4 mm and if pelvic ultrasound reveals no abnormalities then no further investigation is required.
Key points
Endometrial polyps
Key points
Endometrial polyps are localised hyperplastic overgrowths of endometrial glands and stroma.
They can cause HMB, PMB, abnormal vaginal discharge and breakthrough bleeding. When large or multiple they are implicated in subfertility.
Polyps of >1 cm, AUB and PBM are all risk factors for malignant polyps.
Diagnosis is achieved with USS, SIS and hysteroscopy.
They can be observed or removed hysteroscopically (symptomatic, asymptomatic in postmenopausal patient, >1cm in size in an asymptomatic premenopausal patient).
Key points
adenomyoma
Key points
A benign condition causing heavy painful periods, contributing to 10% of HMB and 30% of HMB with dysmenorrhoea.
Histologically it is defined as the presence of non-neoplastic endometrial glands and stroma in the myometrium.
On USS it is represented by an enlarged globular regular uterus with no fibroids, myometrial cystic areas and decreased myometrial echogenicity.
MRI diagnostic rates are higher than USS.
There are no serum markers available.
Management options include:
medical – mefanamic, tranexamic acid, low dose COC, high dose continuous progesterones, GnRHa agonists and the Mirena LNG-IUS
uterus conserving – balloon ablation and uterine artery embolisation
adenomyoma excision at abdominal myomectomy
laparoscopic myometrial electrocoagulation
hysterectomy.
