Abnormal Vaginal Bleeding

Question 1

5 things required for normal menstruation to occur

Answer 1

1. hypothalamic function
2. pit. function
3. ovarian function
4. endometrial function
5. patent cervix and vagina

Question 2

What is mehorrhagia?

Answer 2

heavy menstrual bleeding in cyclical patterns which interferes with physical and social and emotional QoL

Question 3

Best way of diagnosing menorrhagia

Answer 3

pictorial blood loss assessment charts are the best way but many doctors will diagnose based on subjective assessment

Question 4

Systemic causes of HMB

Answer 4

thyroid disease

clotting disorders

Question 5

Local causes of HMB

Answer 5

fibroids
endometrial polyps/carcinoma
endometriosis
PID
dysfunctional uterine bleeding

Question 6

Iatrogenic causes of HMB

Answer 6

IUDs

Oral anticoagulants

Question 7

Why do fibroids and polyps cause vaginal bleeding?

Answer 7

1. they englarge the uterine cavity and so increase the SA of the endometrium
2. they may secrete prostaglandins

Question 8

Which local cause of HMB is diagnosed by exclusion?

Answer 8

Dysfunctional uterine bleeding

Question 9

Which questions can help diagnose a proper HMB?

Answer 9

Flooding
Sanitary replacement
Clots
Nocturnal bleeding

Question 10

What might be found on examination of a patient presenting with HMB?

Answer 10

Signs of anaemia
Signs of thyroid disease
Abdominal mass may be present
Vaginal discharge
Polyps/fibroids
cervical motion tenderness
enlarged uterus

Question 11

Which blood tests are relevant for a pt presenting with HMB?

Answer 11

FBC
Thyroid
Clotting

Question 12

Which imagining techniques will assist the Dx of HMB?

Answer 12

TVUSS / abdominal ultrasound

Question 13

When should an endometrial biopsy be routinely taken?

Answer 13

Women aged over 45 with HMB and under 45 if there are risk factors for endometrial cancer

Question 14

Apart from a gynaecology and obstetric history, which other history is key in a woman presenting with HMB?

Answer 14

Sexual history

Question 15

Which antifibrinoltyic drug can be prescribed to help in HMB?

Answer 15

transexamic acid

Question 16

Which other drug can be prescribed to help in HMB?

Answer 16

NSAIDs mefenamic acid, indomethacin or aspirin

Question 17

What needs to be taken into account before providing a hormonal treatment for women?

Answer 17

fertility desires

Question 18

Which IUS system is commonly prescribed in women who do not wish to conceive?

Answer 18

Mirena coil (levonorgestrel)

Question 19

What is the risk of using GnRH agonists over a long period of time?

Answer 19

Bone density loss

Question 20

What else should be prescribed with a GnRH agonist if it is planned to be used over a long period?

Answer 20

Add back hormone therapy

Question 21

Which surgical procedures can be used to treat HMB?

Answer 21

Endometrial ablation

Hysterectomy

Question 22

Which three systems can the causes of IMB and PCB be split into?

Answer 22

Cervical
Intrauterine
Hormonal

Question 23

What are seam cervical causes of IMB/PCB?

Answer 23

Ectopy
Polyps
Malignancy
Cervicitis

Question 24

What are some intra-uterine causes of IMB/PCB?

Answer 24

Polyps
Submucosal fibroids
Endometrial hyperplasia
Endometrial malignancy 
Endometritis

Question 25

Breakthrough bleeding is usually due to what cause?

Answer 25

Hormonal changes

Question 26

Which investigations should be considered in a woman with unexplained symptoms of IMB/PCB?

Answer 26

``` HVS + ECS: rule out STI Cervical smear: exclude CIN or cervical cancer Pelvic USS: identify polyps or fibroids Hysteroscopy: for biopsy Laparoscopy: identify pelvic pathology ```

Question 27

What are some possible treatment options for IMB/PCB?

Answer 27

Abx for any infections Cautery to cervical surface Removal of polyps/fibs

Question 28

Why does PMB require prompt investigation?

Answer 28

Malignancy needs to be excluded

Question 29

What percentage of women presenting with PMB will have a malignancy?

Answer 29

9%

Question 30

Using anatomical regions of the female genital tract as a guide, what are some causes of PMB?

Answer 30

Ovaries: ovarian cancer, oes. sec. tumour Uterus: Fibroid,polyp, hyperplasia, carcinoma Cervix: atrophic changes, malignancy Vagina: haematuria Vulva: vulvitis, dystrophies, malignancies

Question 31

What is the most common cause of PMB?

Answer 31

Atrophic changes to the lower genital tract due to oestrogen deficiency

Question 32

Which physical change to the body can bring on PMB?

Answer 32

Gaining weight

Question 33

Which other symptoms may accompany atrophic changes to the genital tract?

Answer 33

Vaginal dryness, soreness, superficial dyspareunia

Question 34

What might you see O/E of a pt presenting with oestrogen deficiency as a cause of PMB?

Answer 34

Signs of anemia Abdominal tenderness or masses Vulval lesions

Question 35

Which investigations should be performed on all women with PMB?

Answer 35

Pelvic USS Hysteroscopic examination of the uterus Endometrial biopsy

Question 36

What is the most common medical treatment for PMB?

Answer 36

Oestrogen replacement either with progesterone as HRT or as a local cream/ring/pessary