NICE Endometriosis, Heavy mental bleeding, menopause

Question 1

What first investigation should be performed for all HMB?

Answer 1

FBC

Question 2

For whom should a coagulation should be performed?

Answer 2

If HMB started since menus or Fhx coagulation disorder.

Question 3

Should you start treatment for HMB without imaging?

Answer 3

If from history and examination low risk fibroids/uterine cavity abnormality/histological abnormality/adenomyosis

Question 4

What are the 1st line investigations other than bloods?

Answer 4

USS or hysteroscopy

Question 5

Which women should have hysterscopy as 1st line Ix?

Answer 5

Recurrent IMB
Risk factors for endometrial pathology

Question 6

What is standard technique of OP hysteroscopy?

Answer 6

OP: Analgesia, miniature hysteroscope 3.5mm or smaller
Vaginoscopy

Question 7

Which women should have endometrial Bx at hysterscopy?

Answer 7

Endometrial Bx if high risk: IMB, persistent irregular bleeding, infrequent heavy bleeding, obese, PCOS, tamoxifen, unsuccessful medical Tx HMB

Question 8

For which women should have USS as first line?

Answer 8

USS – uterus palpable abdominally, hx or exam of pelvic mass, examination inconclusive/difficult (obese)

TVUS if Sx of ?adenomyosis -dysmenorrhoea, bulky/tender uterus – If decline TAUS or MRI

Question 9

Main Qs when deciding which Tx?

Answer 9

?Trying to conceive
?Wants to retain fertility/uterus

Question 10

1st line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis

Answer 10

LNG-IUS – irregular PVB 6 months

Question 11

2nd line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis

Answer 11

• Non hormonal: TXA, NSAIDS
• Hormonal: COCP, cyclical POP

Question 12

For submucosal fibroids, what treatment should be consider

Answer 12

TCRF

Question 13

Treatment options for fibroids >3cm

Answer 13

o Non hormonal TXA/NSAIDS
o Hormonal: LNG-IUS, COCP, POP, uliprostal acetate
o UAE
o Surgical: Myomectomy, hysterectomy – pretreatment GnRH analogue if fibroids enlarged/distort the uterus
 Discuss route and total/subtotal, keep ovaries V not

Question 14

What major complication needs to monitored for ulipristal acetate?

Answer 14

Serious liver injury

Question 15

When should LFTs be checked when using ulipristal acetate?

Answer 15

Before starting, monthly for first 2 courses, once new treatment started

Question 16

How should ulipristal acatete be given/prescribed?

Answer 16

5 mg OD for 3 months, start 1st week of menstruation.

Can give up to 4 courses.

Start no sooner than 1st week of 2nd menstruation.

Question 17

Which patients should be considered for ulipristal acatate?

Answer 17

• No underlying liver damage
• Surgery and UAE no suitable
• premenopausal
• fibroids >3cm
• Hb <102

Question 18

If considering hysterectomy, what 4 factors of the pre-surgery and surgical treatment should be considered and discussed with the patient?

Answer 18

Pretreatment GnRH analogue
Route
Total/subtotal
+/- oopherectomy/salpingectomy

Question 19

If >45 how to diagnose peri menopause/menopause

Answer 19

o Perimenopause: Vasomotor + irregular peroids
o Menopause: No peroids for 12 months, no contraception
o Based on symptoms if no uterus

Question 20

Consider FSH testing for the menopause for which patients?

Answer 20

• Consider FSH age 40-45, perform if <40
• Not taking COCP/progesterone

Question 21

5 main group of symptoms of the menopause (other than menstrual irregularity/termination)

Answer 21

• Vasomotor
• MSK – joint/muscle pain
• Effect on mood
• Urogenital – vaginal dryness
• Sexual difficulties

Question 22

Treatments for vasomotor symptoms

Answer 22

• Offer HRT
  o Oestrogen + progesterone with uterus
  o Oestrogen alone no utuerus
• 2nd line – SSRI/SNRI or clonidine
• Isoflavens or black cohosh
  o Multiple preperations, safety uncertain

Question 23

Treatment for psychological symptoms

Answer 23

• HRT
• CBT – no evidence SSRI/SNRI improve mood

Question 24

Treatment for altered sexual function?

Answer 24

• Consider testosterone supplement if HRT not effective

Question 25

Treatment for urogenital atrophy

Answer 25

- Offer vaginal oestrogen - If does not relieve consider increasing dose - Symptoms may come back when stop, adverse effects V rare, report PVB - Can use moisturisers & lubricants alone

Question 26

For women with a uterus commencing HRT, for how long is unscheduled bleeding considered normal?

Answer 26

3 months, after 3 months must be reported

Question 27

What medications should not be given to women with breast cancer who are taking tamoxifen

Answer 27

- Do not give SSRIs paroxetine/fluoxetine

Question 28

Which route of HRT has lower risk of VTE?

Answer 28

o Increased risk, higher if PO vs transdermal – transdermal same as baseline o If RF VTE e.g. BMI >30 consider transdermal – if very high risk (FHx VTE/hereditary thrombophilia) – refer to haemotologist

Question 29

Does HRT commenced <60 years increase risk of CVD?

Answer 29

No CVD risk not CI for HRT Small increase risk of stroke with PO HRT

Question 30

Does HRT increase risk of T2DM

Answer 30

No

Question 31

Does HRT increase risk of breast cancer?

Answer 31

- Oestrogen alone no increased risk BC - Progesterone + oestrogen small increased risk, realated to duration of Tx and reduces after stopping - E.g. 10 yrs combine continuous – increased cases 40/1000

Question 32

Does HRT affect the risk of osteoporosis?

Answer 32

- Risk of fragility frscture is lower when taking HRT, decreases on TX stopped

Question 33

How to diagnose premature ovarian failure?

Answer 33

- <40 yrs + - Menopausal Sx, no/infrequent peroids + - FSH x 2 4-6 weeks

Question 34

Management of POF

Answer 34

- Offer HRT or COCP – continue until age of natural menopause - HRT has beneficial effect on BP vs COCP - Both offer bone protection - HRT not contraceptive - Give advice on bone and CV health & symptoms Mgmt

Question 35

Suspect endometriosis if 1 or more of:

Answer 35

Chronic pelvic pain Dysmenorrhoea effecting daily activities/QoL Deep pain during/after intercourse Period related/cyclical GI symptoms, painful bowel movements Period related/cyclical urinary symptoms, Infertility with any 1 above

Question 36

Initial Ix

Answer 36

Pain/symptoms diary Offer pelvic examination abdo and BM Consider USS

Question 37

Initial Tx if fertility not priority

Answer 37

Analgesia Hormonwal - COCP/POP Neuromodulators If no improvement refer - Gynaecology/paediatric and adolescent gynaecology (<17) or specialist Endometriosis service (deep Endo, involving bladder/bowe/ureter)

Question 38

If USS +/- MRI can laparoscopy be offered?

Answer 38

Yes

Question 39

What needs to be explained to patient consider laparoscopy?

Answer 39

What involves + potential surgical Tx How could effect Endo Sx benefits and risk Possible need for further Sx Alternatives

Question 40

Surgical considerations for fertility is priority vs not priority?

Answer 40