AUB

Question 1

Classification of abnormal uterine

bleeding

Answer 1

Abnormal rhythm
Abnormal amt
Combination (rhythm and amount)

Question 2

Abnormal rhythm bleeding examples
1
2
3
4

Answer 2

Irregularity of cycle
Intermenstrual bleeding (metrorrhagia)
Postcoital bleeding
Postmenopausal bleeding

Question 3

Abnormal amount example

Increased amount = ______
Decreased amount =_______

Answer 3

menorrhagia

hypomenorrhoea

Question 4

Combination (rhythm and amount)

Irregular and heavy periods = _____
Irregular and light periods =_______

Answer 4

metromenorrhagia

oligomenorrhoea

Question 5

Up to _____ of women in the reproductive age

group complain of increased menstrual loss

Answer 5

20%

Question 6

The mean blood loss in a menstrual cycle is

________

Answer 6

30–40 mL

Question 7

Heavy menstrual bleeding (menorrhagia)—

HMB—is a menstrual loss of more than______

Answer 7

80 mL per

menstruation

Question 8

Two common organic causes of HMB are _____ and ______

Answer 8

fibroids
and adenomyosis (presence of endometrium in the
uterine myometrium

Question 9

Most girls reach menarche by the age of ________

Answer 9

13 (range 10–16 years).

Question 10

Dysfunctional bleeding
is common in the first ______ after menarche due
to many anovulatory cycles resulting in irregular
periods, heavy menses and probably dysmenorrhoea

Answer 10

2–3 years

Question 11

A normal endometrial thickness, as measured by

ultrasound, is between_______

Answer 11

6 and 12 mm

Question 12

The menstrual
cycle is confirmed as being________(biochemically)
if the serum progesterone (produced by the corpus
luteum) is >20 nmol/L during the mid-luteal phase
(5–10 days before menses).

Answer 12

ovulatory

Question 13

The incidence of malignant disease as a cause of bleeding increases with age, being greatest after the age of _________ while endometrial cancer
is predicted to be less than 1 in 100 000 in women
under the age of 3

Answer 13

45,

Question 14

Dysfunctional
uterine bleeding is more common in the extremes of the
reproductive era, while the incidence of cancer as a
cause of bleeding is greatest in the _____ and _____

Answer 14

perimenopausal and

postmenopausal phases.

Question 15

What is HMB

Answer 15

• blood loss >80 mL per menstrual cycle
• bleeding that persists >7 days
• bleeding that is unacceptable to the woman

Question 16

Menorrhagia 4 is essentially caused by excessive local
production of ______in the endometrium
and myometrium and/or excessive _______

Answer 16

prostaglandins

local fibrinolytic activity.

Question 17

By far the most common single ‘cause’ of

menorrhagia is ______

Answer 17

ovulatory dysfunctional uterine

bleeding (DUB).

Question 18

_______ occurs at the
extremes of the reproductive period—around
menarche and perimenopausall

Answer 18

Anovulatory DUB

Question 19

MCC of Anovulatory DUB

Answer 19

fibromyomatas (fibroids),endometriosis, adenomyosis (‘endometriosis’ of the
myometrium), endometrial polyps and PID

Question 20

__________reserved for women who fail
conservative treatment or who are at increased risk
of endometrial cancer

Answer 20

UTZ

Question 21

When to request biopsy in UTZ

Answer 21

If it is >12 mm for premenopausal women
or >5 mm for perimenopausal women, endometrial
biopsy (with or without hysteroscopy) is indicated

Question 22

____ and _______remain the

gold standard for abnormal uterine bleeding.

Answer 22

Hysteroscopy and D&C

Question 23

______excessive bleeding, whether heavy, prolonged or
frequent, of uterine origin, which is not associated
with recognisable pelvic disease, complications of
pregnancy or systemic disease

Answer 23

DUB

Question 24

DUB is MC in what cycle?

Answer 24

It is more common in ovulatory
(regular) rather than anovulatory (irregular)
cycles.

Question 25

Peak incidence of ovulatory DUB in late_____

Answer 25

30s and 40s (35–45 years).

Question 26

_______DUB has two peaks: 12–16 years and 45–55 years. The bleeding is typically irregular with spotting and variable menorrhagia

Answer 26

Anovulatory

Question 27

The serum progesterone and the pituitary hormones___ and ______ will confirm anovulation

Answer 27

(LH and FSH)

Question 28

DUB Tx _________ is usually employed if the uterus is of normal size and there is no evidence of anaemia

Answer 28

Conservative management

Question 29

Consider surgical management if____ and _____

Answer 29

fertility is no longer important and symptoms cannot be controlled by at least 3–4 months of hormone therapy

Question 30

Mx of acute heavy bleeding

Answer 30

• oral high-dose progestogens (e.g. norethisterone 5–10 mg 4 hourly until bleeding stops then 5 mg bd or tds for 14 days

Question 31

MX of chronic bleeding For anovulatory women:

Answer 31

* cyclical oral progestogens for 12 days | * tranexamic acid

Question 32

MX of chronic bleeding For ovulatory women:

Answer 32

• cyclical prostaglandin inhibitor (e.g. mefenamic acid) or (one of) • oral contraceptive • antifibrinolytic agent (e.g. tranexamic acid 1 g (o) qid, days 1–4) • progesterone-releasing IUDs (e.g. Mirena

Question 33

The agent of first choice in DUB is usually ________, which reduces blood loss by 20–25% as well as helping dysmenorrhoea

Answer 33

mefenamic acid

Question 34

Hormonal agents for DUB include 1 2 3

Answer 34

progestogens, combined oestrogen–progestogen oral contraceptives and danazol.

Question 35

The_______constitutes important first-line therapy in both ovulatory and anovulatory patients, but at least 20% of patients do not respond

Answer 35

COC

Question 36

In the adolescent with anovulatory DUB, __________ may be required for 6 months until spontaneous regular ovulation eventuates

Answer 36

cyclical | oral progestogens

Question 37

The most effective agent for both ovulatory and anovulatory DUB is tranexamic acid, which inhibits ___________

Answer 37

endometrial plasminogen activation

Question 38

Dose of Tranex for DUB

Answer 38

The dose is 1 g | (up to 1.5 g if necessary) orally qid for the first 4 days

Question 39

It is regarded as the most efficacious of the hormone treatments with a mean blood loss of 94% of women with menorrhagia.

Answer 39

The intra-uterine progesterone implant system | Mirena

Question 40

Sx Mx • endometrial ablation or electrodiathermy excision—to produce _________

Answer 40

amenorrhoea

Question 41

It is preferred to drug therapy for women with endometrial hyperplasia with atypia—endometrial ablation is not appropriate

Answer 41

hysterectomy

Question 42

``` Emergency menorrhagia (acute flooding) 4 First line ```

Answer 42

• tranexamic acid 10 mg/kg IV, every 8 hours until bleeding stops or • tranexamic acid 1–1.5 g (o) 6 to 8 hourly until bleeding stops

Question 43

If above unavailable or not tolerated, other options | are:

Answer 43

• norethisterone 5–10 mg 4 hourly (o) till bleeding stops, then 5 mg bd or tds (or 10 mg daily) for 14 days or • medroxyprogesterone acetate 10 mg (o) 4 hourly until bleeding stops for 7 days then 20 mg daily for 21 days or • COCP e.g. until bleeding stops then re-evaluate after 48 hours

Question 44

General guidelines for surgical intervention

Answer 44

* no longer wish to be able to conceive * are perimenopausal * have poorly controlled symptoms * have adverse effects from the drugs * have significant uterine pathology

Question 45

Patients under 35 years: Cause of cycle irreg

Answer 45

• the cause is usually hormonal, rarely organic, but | keep malignancy in mind

Question 46

management options for cycle irreg in under 35

Answer 46

— explanation and reassurance (if slight irregularity) — COC pill for better cycle control—any pill can be used — progestogen-only pill (especially anovulatory cycles) norethisterone (Primolut N) 5–15 mg/day from day 5–25 of cycle

Question 47

MCC of Intermenstrual bleeding | and postcoital bleeding

Answer 47

factors such as cervical ectropion (often termed cervical erosion), cervical polyps, the presence of an IUCD and the oral contraceptive pill.

Question 48

Cervical ectropion, which is commonly found in women on the pill and postpartum, can be left untreated unless _____ and ______

Answer 48

``` intolerable discharge or moderate postcoital bleeding (PCB) is present ```

Question 49

________ are benign tumours of smooth muscle of the | myometrium

Answer 49

Fibroids

Question 50

``` Pelvic ultrasound (investigation of choice) . Endometrial thickening >4 mm demands ________ If >7 mm, ________ ```

Answer 50

endometrial sampling. endometrial cancer should be excluded

Question 51

Med Mx of uterine fibroids • Consider COCP (30 mcg oestrogen can reduce bleeding _________—especially if >42 years can shrink fibroids (maximum 6 months)—use only immediately pre-operative

Answer 51

• GnRH analogues

Question 52

Sx Mx of fibroids

Answer 52

``` — myomectomy (remove fibroids only, esp. child-bearing years) — hysteroscopic resection/endometrial ablation — hysterectomy ```

Question 53

This should be the diagnosis until proved otherwise for postcoital, intermenstrual or postmenopausal bleeding

Answer 53

Cervical CA

Question 54

MC Sx of cervical CA

Answer 54

* Postcoital bleeding * Intermenstrual bleeding * Vaginal discharge—may be offensive

Question 55

PE of cervical CA

Answer 55

* Ulceration or mass on cervix | * Bleeds readily on contact—may be friable

Question 56

This is the diagnosis until proved otherwise in any | woman presenting with postmenopausal bleeding.

Answer 56

Endometrial cancer

Question 57

T or F Endometrial cancer is not excluded by a normal cervical smear

Answer 57

T

Question 58

Primary amenorrhoea is the failure of the menses | to start by _______

Answer 58

16 years of age

Question 59

Secondary amenorrhoea is | the absence of menses for over______

Answer 59

6 months in a woman | who has had established menstruation

Question 60

The main approach in the patient with primary amenorrhoea is to differentiate it from ________ in which there are no signs of sexual maturation by age

Answer 60

delayed | puberty,

Question 61

Amenorrhea It is important to keep in mind the possibility of an ____ and _______, which can suppress hypothalamic GnRH production.

Answer 61

imperforate hymen and also | excessive exercise

Question 62

``` Causes of primary amenorrhoea include 1 2 3 4 5 ```

Answer 62

genital malformations, ovarian disease, pituitary tumours, hypothalamic disorder and Turner syndrome

Question 63

Diagnostic tests for amenorrhea include

Answer 63

serum FSH, LH, prolactin, | oestradiol and also chromosome analysis.

Question 64

``` In secondary amenorrhoea, consider a physiological cause such as 1 2 3 ```

Answer 64

pregnancy or the menopause, failure of some part of the hypothalamic– pituitary–ovarian–uterine axis (e.g. PCOS) or a metabolic disturbance

Question 65

_________is the term for infrequent and usually irregular periods, where the cycles are between 6 weeks and 6 months

Answer 65

Oligomenorrhoea

Question 66

Premature ovarian failure Apart from iatrogenic causes this may be caused by idiopathic early menopause and _______

Answer 66

autoimmune ovarian | failur

Question 67

Remember that ____can obscure the | organic causes of menorrhagia

Answer 67

mental dysfunction

Question 68

_______is more effective than the traditional curettage. Studies have shown that usually less than 50% of the uterine cavity is sampled by curettage.

Answer 68

Hysteroscopy