Abnormal Vaginal Bleeding

Question 1

What are the physiological causes of amenorrhoea?

Answer 1

Pregnancy, lactation, menopause

Question 2

Which gynaecological malignancies may present with abnormal vaginal bleeding?

Answer 2

Endometrial, cervical, vaginal and vulval

Question 3

Primary amenorrhoea is defined as the absence of menstruation by what age?

Answer 3

16 years

Question 4

In secondary amenorrhoea, there is absence of menstruation for how long, that is not explained by a physiological cause?

Answer 4

6 months or more

Question 5

What are some medications that may cause amenorrhoea?

Answer 5

Hormonal contraceptives and dopamine antagonists (anti-emetics, anti-psychotics)

Question 6

What is Asherman’s syndrome?

Answer 6

Intra-uterine adhesions

Question 7

What is the most common cause for amenorrhoea associated with cyclic pain?

Answer 7

Imperforate hymen

Question 8

What is the most important investigation to perform on any woman presenting with amenorrhoea?

Answer 8

Pregnancy test

Question 9

What imaging investigation is used in women with amenorrhoea to confirm the presence or absence of normal pelvic anatomy, and to identify the site of any possible obstruction?

Answer 9

Transvaginal US

Question 10

With what investigation can intra-uterine adhesions be diagnosed and treated?

Answer 10

Hysteroscopy

Question 11

What imaging investigation is indicated if a hypothalamic-pituitary cause is suspected in a woman with amenorrhoea?

Answer 11

Pituitary MRI

Question 12

What investigation is used to identify underlying chromosomal abnormalities which may be a cause of amenorrhoea?

Answer 12

Karyotyping

Question 13

If a patient is amenorrhoeic, aged < 50 and does not wish to become pregnant, what treatment is indicated?

Answer 13

HRT

Question 14

What two options are available as prevention of osteoporosis in amenorrhoeic women aged < 50?

Answer 14

HRT or COCP

Question 15

Oligomenorrhoea is defined as menstruation with abnormally long intervals between periods. How long are these intervals?

Answer 15

> 35 days

Question 16

Who is oligomenorrhoea most likely to occur in, and what is it associated with in these cases?

Answer 16

Adolescent girls and peri-menopausal women, associated with failed ovulation

Question 17

In patients with anovulatory DUB, what treatment can be used to impose regular endometrial shedding or withdrawal bleeds?

Answer 17

COCP

Question 18

Inflammatory disorders causing menorrhagia (e.g. endometriosis, adenomyosis) are most likely to be associated with which other symptom?

Answer 18

Dysmenorrhoea

Question 19

What are some endocrine conditions which may cause menorrhagia?

Answer 19

PCOS, hypothyroidism

Question 20

What are some medications that may be responsible for causing menorrhagia?

Answer 20

Cu-IUD, progesterone-only contraceptives, warfarin

Question 21

20-60% of women with menorrhagia will have what complication as a result?

Answer 21

Iron deficiency anaemia

Question 22

What are some examples of heavy menstrual bleeding which are always abnormal?

Answer 22

Changing protection hourly, flooding and passing clots

Question 23

If a pelvic examination is abnormal in someone with heavy menstrual bleeding, what is the first line imaging investigation?

Answer 23

Trans-vaginal US

Question 24

What investigation is recommended in all women aged > 45 with abnormal vaginal bleeding to exclude endometrial hyperplasia/cancer as the underlying cause?

Answer 24

Endometrial biopsy

Question 25

What is the first line imaging investigation for diagnosing fibroids?

Answer 25

Trans-vaginal US

Question 26

What is the first line treatment for menorrhagia with no identifiable, treatable underlying cause?

Answer 26

Mirena-IUS

Question 27

What is the second line treatment for menorrhagia with no identifiable, treatable underlying cause where the woman also wants contraception?

Answer 27

COCP

Question 28

What medication can be used to treat menorrhagia in women who do not want contraception or hormonal methods of management?

Answer 28

Tranexamic acid

Question 29

What medication can be given alongside tranexamic acid in women who suffer from menorrhagia and dysmenorrhoea?

Answer 29

Mefenamic acid

Question 30

When should tranexamic and mefenamic acid be started in terms of the menstrual cycle?

Answer 30

The first day of the period

Question 31

What are some surgical options for menorrhagia if medical management has failed?

Answer 31

Endometrial ablation/resection or hysterectomy

Question 32

What is the disadvantage to surgical management options for menorrhagia?

Answer 32

They remove fertility

Question 33

In what age group is dysmenorrhoea most common?

Answer 33

Adolescents and young women

Question 34

Primary dysmenorrhoea is thought to be associated with excessive production of what by the uterus?

Answer 34

Prostaglandins

Question 35

What is the most common cause of secondary dysmenorrhoea?

Answer 35

Endometriosis

Question 36

Uterosacral nodularity and/or tenderness, and a fixed, retroverted uterus on examination is most suggestive of what diagnosis?

Answer 36

Endometriosis

Question 37

What is adenomyosis?

Answer 37

Endometrial cells are found in the myometrium

Question 38

Deep dyspareunia, dysmenorrhoea and menorrhagia are most suggestive of what diagnosis?

Answer 38

Endometriosis

Question 39

What cause of dysmenorrhoea is associated with a history of STIs and chronic pelvic pain?

Answer 39

PID

Question 40

If an anatomical abnormality is suspected as the cause of dysmenorrhoea, what is the first line investigation?

Answer 40

Trans-vaginal US

Question 41

What is the gold standard investigation for suspected endometriosis?

Answer 41

Laparoscopy

Question 42

What are some medical management options for primary dysmenorrhoea?

Answer 42

NSAIDs and hormonal contraceptives

Question 43

If a woman presents with inter-menstrual or post-coital bleeding, what three investigations should always be done?

Answer 43

Pregnancy test, cervical cytology (if due), high vaginal and endocervical swabs

Question 44

If a woman presents with inter-menstrual or post-coital bleeding, and findings on examination are suspicious, what imaging investigations are indicated?

Answer 44

Trans-vaginal US and colposcopy

Question 45

What is the definition of post-menopausal bleeding?

Answer 45

PV bleeding > 12 months after the last menstrual period

Question 46

What are the two most common, benign causes of post-menopausal bleeding?

Answer 46

Atrophic vaginitis, unscheduled bleeding on HRT

Question 47

On trans-vaginal US, an endometrial thickness of what would make you suspicious of endometrial cancer? What further investigation would then be indicated?

Answer 47

5mm or more - endometrial biopsy would be the next best investigation

Question 48

How should post-menopausal bleeding as a result of vaginal atrophy be treated?

Answer 48

Oestrogen pessary or cream

Question 49

What is the most common cause of post-coital bleeding?

Answer 49

Cervical ectropion