Essay 350

a)

Hx

I will ask for last LMP looking for a period of amennorhea sugestive of pregnancy.Also determine nature of bleeding, if grape like materials were passed suggestive of molar pregnancy. I will take a detailed menstrual history,asking for  time of menarche and if the periods have been regular since menarche and at what time did it changed suggestive of hormonal imbalance and PCOS. I will also asked for inter menstrual bleeding suggestive of endometrial or cervical polyp.history of mass effect or lower abdominal heaviness with pain suggestive of uterine fibroids.Deep dyspauronia, dysmenorrhea and hx of infertility suggest adenomyosis.Sexual hx, to determine if she is a high risk for cervial pathology. post coital bleeding is indicative of cervical pathology. Hx of contraception espercialy use of depo provera, heavy irregular bleeding is a complication.Newly placed  IUCD can cause  irregular menstrual bleeding Ask for symptoms of aneamia like SOB, dizziness, weakness, tiredness etc.

clinical examination

check BMI, high BMI with central obesity is associated with PCOS,I will also check for signs of hirsuitsm like facial hair, male pattern of pubic hair distribution and acanthosis nigricans, these are suggestive of PCOS. 

check for BP, pulse and signs of anaemia

abdominal pelvic examination will help to identify uterine fibroids

pelvic examination to check for the size of the uterus in case of pregnancy, adenomyosis, and uterine fibroids

speculum examination will help to identify cervicitis, cervical ectropion and cervical  polyp. Also check for the presence of IUCD.

Investigation

pregnancy test to rule out pregnancy. Beta HCG if molar pregnacy is suspected.

hormone studies ie check for serum level of LH ,FSH ,PROLACTIN,TSH,E,PROGESTRONE to confirm PCOS, hormonal imbalance and anovulatory bleeding.

If she is a high risk then she should have cervical smear done if not this can done at the age of 25yrs.

pelvic utrasound will confirm uterine fibroidsand polyp, and MRI will give the diagnosis of adenomyosis and uterine polyp.

hysteroscopy will confirm cervical polyp, uterine polyp and submucous fibroids.

b)

pelvic utrasound will identify uterine fibroids and polyp. MRI is more sensitive in identifying uterine polyp

also adenomyosis will be identified by MRI.

hysteroscopy will confirm cervical polyp, uteriine polyp and submucous fibroids

 hysteroscopy can be used for treatment and the same time diagnosisi like cervical polypectomy and uterine polypectomy  

Edomentral biopsy via hysteroscopy and D&C will help rule out endometrial hyperplasia associated with PCOS

A)

The menstrual cycle should be enquired about in details including the amount of blood loss, the frequency of menses, passage of clots, usage of double protection or flooding which would suggest the heaviness of the bleeding.  Pregnancy should be excluded by enquiring about symptoms such as breast tenderness, nausea and vomiting. Associated symptoms of dysmenorrhea, dyspareunia and chronic pelvic pain will be see in endometriosis. History of recent change in sexual partner, multiple sexual partners or abnormal vaginal discharge is seen in sexually transmitted infection, especially chlamydia which can also cause post coital and inter-menstrual bleeding. Family history of fibroids and belonging to afro-carribean race can be seen in cases of fibroids. Personal history of easy bruising, petechial haemorrhages, bleeding gums suggest bleeding and clotting disorders. Contraception usage should be enquired into. Usage of progesterone only pills, injectable progesterone can give rise to heavy irregular bleeding.  Contraception int he form of intrauterine contraceptive device can also give rise to heavy and irregular bleeding.  Loss of appetite and weight loss may suggest cervical cancer. Thyroid dysfunction can cause heavy menstrual bleeding hence symptoms of weight gain/loss, increased/ decreased appetite, increased sweatingI or cold clammy extremities should be excluded. f there are no causes found, the most likely presumptive diagnosis would be dysfunction uterine bleeding associated with anovulatory cycles, also see in polycystic ovarian syndrome. Symptoms and signs of anaemia such as shortness of breathlessness, constant tiredness and weakness should be enquired into to assess the severity of menorrhagia. 

General clinical examination should be undertaken to examine any sites of haemorrhage or bruising. Signs of thyroid disorders such a tachycardia, exophthalmos, tremors and thyroid gland enlargement should be ruled out. A menstrual diary is advised to objectively assess the amount of bleeding as heavy bleeding in patient's perception may be a normal bleeding. presence of pallor, tachycardia and flow murmur suggests anaemia. Abdominal examination to rule out enlarged uterus which may be seen in  fibroid uterus, endometrial polyps or adenomyosis should be undertaken. Speculum examination should be undertaken to assess the vagina and cervix to rule any local causes of bleeding such as cervical cancer, cervical ectopy or fibroid/ endometrial/cervical polyp protruding out of the cervical os. Bimanual assessment of the uterus should be undertaken to assess the uterine size for fibroids, rule out adnexal masses, and assess the mobility and fixed retroversion of the uterus for endometriosis.

B)

if the patient is sexually active, microbiological endocervical swabs for culture and sensitivity should be done to rule out chlamydial infection though a negative result does not rule out pelvic inflammatory disease. If the uterus measures large on examination, a pelvic ultrasound, most likely transvaginal, should be undertaken, to exclude fibroids, endometrial polyps. If adenomyosis is suggested int he history by dysmenorrhoea, MRI is indicated. Thyroid function tests and clotting screen is indicated if the history is suggestive of thyroid dysfunction and bleeding disorder, respectively. I dysfunctional uterine bleeding is suspected, and endometrial pipelle biopsy will help confirm the diagnosis. Hysteroscopy is the gold standard but is ususally not warrranted to investigate the cause unless emperical treatment resistant or failure, endometrial polyp is suspected which can be removed by undertaking operative hysteroscopy and resection of the polyp. If suspicious lesion found on the cervix, the patient should be referred for colposcopy urgently.

Information is obtained from her history regarding duration and nature of the bleeding ( flooding, passing clots ) , previous episodes to assess the severity of her symptoms. History is taken regarding fatigue, shortness of breath and palpitations which suggests anaemia. Enquiry is made about the effect of her bleeding pattern on her quality of life.

Details of previous menstrual history are noted with respect to age of menarche, cycle length, flow, and last menstrual period. Incomplete miscarriage can present as amenorrhoea followed by heavy and irregular bleeding.

History of abdominal pain and dysmenorrhoea point towards fibroids while painless heavy intermittent bleeding suggests cervical polyp. History of post coital bleeding is taken as ulcerated polyp can present with this symptom.

Information about her parity is asked along with her wishes for conception which may influence the management.

Contraceptive history (previous and present) is taken regarding the method of contraception and issues compliance are noted. Irregular intake of hormonal contraception and smoking may precipitate breakthrough bleeding.

History is taken if she is taking tamoxifen for ovulation induction which is associated with endometrial hyperplasia.

Although a rare possibility, family history of bleeding disorders, history of epistaxis, post partum haemorrhage may indicate coagulation defects.

History of weight gain, constipation and lethargy suggest hypothyroidism which may result in anovulation. History of weight gain, hirsutism suggest PCOS

Anovulation in hypothyroidism, and PCOS, and anorexia can present as irregular and unpredictable bleeding

Examination is performed to pallor suggesting anaemia.

BP is recorded, BMI calculated.

Abdominal examination is conducted to detect palpable abdominal masses. Speculum examination is done to identify cervival polyp, submucous fibroid protruding through cervical os or products of conception in case of incomplete miscarriage.

Bimanual pelvic examination is done to assess uterine enlargement, assess adnexal masses.

B) Transvaginal ultrasound scanning is a preliminary screening tool to identify uterine and adnexal masses. Transvaginal scanning combined with abdominal ultrasound is used to assess the location of individual fibroids if the uterine enlargement is more than 12 weeks size. TVS is used to assess endometrial thickness in case of endometrial hyperplasia.

TV scanning is not 100% sensitive as polyps and small lesions can be missed. Better sensitivity can be expected with sonohysteroscopy .

Hysteroscopy and sonohysterography ( saline infusion sonography ) are of value in the assessment of submucous fibroids and endometrial polyps.

The advantage of hysteroscopy is that the resection can be undertaken at the same sitting.

The complications of hysteroscopy include fluid overload, uterine perforation, haemorrhage and infection.

MRI is helpful in the assessment of adenomyosis or if she is virgin but of limited availability.

XXXX

In the history I will ask her regarding her menstrual bleeding , the number and size of pads she is using and if she is using extra protection. Will ask if bleeding contain clots and if associated with pain that could point to polyp. Will ask of the effect of these symptoms on the quality of her life.

Will ask of pressure symptoms ,as frequency of micturition, urgency urge incontinence , constipstion and difficulty in breathing due to a huge fibroid.

Will ask of her menarche, and was her period was always like that or this is a new symptom ,and what she had for treatment. Will ask of her last normal LMP and any chance of being pregnant. Will ask of her parity and last delivery. Will ask of contraception if used ,as intrauterine contraceptive device(IUCD) can cause meno rrhagia and irregular bleeding. Will ask if she is at risk of sexually transmitted infections(STI)as these can cause such problems. Will ask of deep dyspareunia in case she has adenomyosis.

Will ask of family history of bleeding disorders as she can have undiagnosed bleeding disorder (healthy woman) or hupothyroidism - As she is 23y ,she is unlikely to be having malignancy, however the possibility of a functioning ovarian tumour should be put in mind.

Will ask of symptoms of anemia as fatigue and palpitation.

Will do a general examination for pulse, BP and pallor. NICE guidelines states that in absence of pain,pressure symptoms,post coital bleeding or intermenstrual bleeding , examination is not warranted in patients with menorrhgia. However as the patient has irregular bleeding ,local speculum examination might show a uterine polyp appearing through the cervix and also allow swabs to be taken for STI.

　

　

　

The aim is to detect the cause of abnormal uterine bleeding according to the PALM COEIN classification system. Transvaginal sonography (TVS)has a poor sensitivity in detecting uterine polyps,but sonohystrography improve this. Offfice hysteroscopy can accurately detect it ,but its removal will need operative hysteroscopy in operating theatre.

Adenomyosis can be difficult to detect with ultrasound and can be confused with interstitial myoma, however it will detect a bulky uterus. MRI can detect adenomyosis.

Leiomyomata can be detected by ultrasound and their location as interstitial or sub mucous can be seen. Hystroscopy will detect bulging of sub mucous types into the cavity.

As stated uterine malignancy is unlikely at such age and hysteroscopy and biopsy is the gold standard investigation.

Lost IUCD can be located by TVS and hysteroscopy ,the later can help in its retrival specially if it is embedded in the uterine wall

A coagulation screen will help to detect if she has an undiagnosed bleeding disorder with the help of the hematologist

Endometrial causes as hyperplasia can be detected by endometrial biopsy and histopathological examination.Some all investigations are normal and the cause of bleeding is idiopathic.

1) A detailed history should be taken enquiring about age of menarche and onset of symptoms. This will help to differentiate primary or secondary cause for her symptoms. Enquiring about amount of blood loss, need for double protection, passage of clots and flooding and its affect on quality of life will help in determining the seriousness of condition. Ask about symptoms of hypothyroidism such as weight gain, loss of appetite, lethargy and intolerance to cold. Features of central obesity, hirsutism and sub-fertility will point towards polycystic ovarian disease as likely cause. Excessive hair growth and male type baldness can make cushing disease a likely diagnosis as well.  Enquire about sexual history. A history of dyspareunia and congestive dysmenorrhoea will point towards endometriosis as likely cause. Recent change in life style such as excessive smoking, heavy alcohol intake and stress can also alter the pattern of menstrual cycle. Ask about contraception taken and any over the counter medications taken.

Patient’s BP and BMI should be checked. Look for signs of hirsutism. Presence of excessive hair growth with obesity, male pattern of baldness and presence of stria on abdomen can point towards cushing disease as likely cause. Abdominal examination be done to check for any masses such as fibroids or ovarian cysts. Look for any tenderness and guarding. Pelvic examination be done to check uterine size. Tender, bulky uterus will make adenomyosis a likely cause. Tenderness in pouch of douglas and uterosacral induration will make make endometriosis a likely diagnosis.

2) Pelvic ultrasound is the first line investigation to look for endometrial pathology such as polyps and fibroids. It is easily accessible, is non invasive and readily available. It has a high positive predictive value in assessing pelvic pathologies.  Ovarian morphology should be checked to rule out polycystic appearance and cysts. A bulky uterus on scan with no evidence of definitive fibroid might suggest adenomyosis. If very high suspicion of extensive endometriosis, MRI can be arranged. This modality is not only useful in assessing the extensiveness of endometriosis but is also useful in assessing site, size of fibroids in case embolisation is planned in future. However, it is expensive and risk of radiation is there.  Laparoscopy is gold standard to diagnose pelvic endometriosis and can be combined with hysteroscopy to rule out endometrial pathology. However, it is invasive procedure with risks involved such as anaesthetic risk, uterine perforation, visceral injury and need to stay in hospital.

a)The woman should be asked regarding the impact of menorrhagia in her quality of life.Detailed menstrual history as duration, cyclicity, amount of bleeding,presence or absence of dysmenorrhea and how long the symptoms have been present should be asked for.severe dysmenorrhea can indicate towards possibility of endometriosis.Delayed irregular cycles can more point towards hormonal disturbance.Any previous treatment taken and its effectiveness should be enquired to ensure the severity of condition and treatment failure.Her past obstetric history, any dificulty in conceiving indicating possibility of endometriosis is elicited. her future desire of pregnancy which will impact the type of treatment is also enquired. any use of contraception like IUCD which is associated with heavy bleeding or progesterone only contraceptives which can cause irregular bleeding is asked.Sexual history regarding recent change of partners , dyspareunia is taken..Family history of fiborids, especially in afro-carribean ethnicity , any familial gynecological malignancy like ovarian cancer which has genetic predisposition is enquired.To asess the severity of blood loss,history of symptoms like shortness of breath, weakness, loss of apetite is taken.           

General examination including her general built and nutrition, BMI, pulse, BP , pallor, pedal edema( for severe anemia) is done.any signs of hirsutism which is associated with PCO is looked for.Midline neck swelling for thyroid disorder which can lead to abnormal vaginal bleedingis examined.Presence of petechie, bruises over limbs and trunk can indicate towards bleeding diathesis.Abdominal examination for any palpable mass, any tenderness is done. speculum examination for signs of cervical erosion, cervicitis, cervical polyp, abnormal vaginal discharge (chlamydia can cause abnormal bleeding) is done. vaginal examination for size and mobility of uterus, rule out pregnancy associated bleeding( soft enlarged uterus) is done.Enlarged firm irregular uterus will indicate fibroid uterus or adenomyosis. Any forniceal fullness for ovarian mass or cyst is examined. Cervical exitation positive will indicate PID. Any posterior fornix nodulatity will indicate endometriosis.

b)high vaginal swab and endocervical and urethral swab for chlamydia, gonococcus to be taken to rule out sexually transmitted infection as a cause of abnormal vaginal bleeding.BHCG for any pregnancy associated bleeding as molar pregnancy is done. Pelvic ultrasound ,preferably TVS for presence of uterine fibroids or adenomyosis or endometrial polyp is done. It will also rule out any ovarian pathology or polycystic ovaries.outpatient endometrial sampling can be done for endometrial pathology. cervical smear can be taken if cervical erosion or ectropion is seen.Further referral for colposcopy can be done in presence of abnormal smear. . hysterosalpingography and sonosalpingography can be done to detect filling defects in case of presence of submucous fibroids.hysteroscopy as outpatient basis or as day case can be done for direct visualisation of uterine cavity and resection of endometrial polys or submucous fibroids.

The gynaecological history of LMP and regularity of cycle should be undertaken. It is important to know how long the periods have been irregular. Contraceptive history and sexual history to identify the risk factor for STD as Chlamidia can cause irregular bleeding, possibility of pregnancy. Missed contraceptive pills can cause the irregular breakthrough bleeding. IUD could be the cause for heavy periods.

Other menstrual abnormalities such dysmenorrhea, PMS, intermenstrual bleeding could point towards the possibility of endometriosis, family history of endometriosis as there is increasing evidence the endometriosis has a genetic basis.

The enquiry about the blood loss such the using pads, flooding, time off work could help subjectively assess the amount of blood loss and more likely anaemia to be present. Bleeding from gums or other bleeding problems, family history of clotting disorders may help to identify the possible clotting abnormalities.

The risk factors such as early menarche, infertility, obesity, hypertension, diabetes are generally inquired about in order to provide assistance with further investigations required. Asking about excessive hair growth helps, as it is difficult to assess sometimes as most of patients use  mechanical methods to remove unwanted hair. It may help to think about the possibility of PCOS, therefore anovulation and irregularity of menstrual cycle.

What medications the patient is on and what has been previously tried, helps to decide on further management. 

 As part of the examination, BMI is important, inspection on signs of hyperandrogenism: acne, seborrhoea, acanthosis nigricans  to help in diagnosis of PCOS. Pallor will indicate anaemia. Abdominal and pelvic examination looking for abdominal and pelvic masses, such as fibroid uterus , speculum examination of the cervix on presence of ectropion, cervical polyp or any other abnormality as a reason for postcoital bleeding, if present.

2) Investigations for coagulopathy and thyroid function are required only if history suggests dysfunction.

Pregnancy test is done as initial investigation.

LH, FSH, raised androgens - testosterone / androstendione may indicate ovarian hypersecretion and more than half women with PCOS have elevated levels of DHEA-S, also increased concentrations of free oestradiol / oestrone (peripheral conversion from androstendione) and decreased sex hormone binding globulin, mild hyper-prolactinaemia are features of PCOS.

USS to identify uterine polyps as cause of heavy and irregular bleeding, adenomyosis could be diagnosed only by MRI and considered when all other possible causes are excluded.  Pipelle sample could be taken if history and examination strongly suggest malignancy; however this may be difficult if there is nulliparity and unlikely presents at this age.

ESSAY—350

1.  First I will assess her according to  physical,psychological,social effect of heavy menstrualbleeding in her life.

I will take detailed menstrual history-age at menarche,periods science menarche to detect any hormonal disorder.Duration,frequency of menstruation ,amount of bleeding,passing of clots for diagnosing the severity of the condition.Fibroid may present with such history so we have to ask her associated urinary symptoms,pressure symptoms like frequency of micturition,abdominal distension,pain during menstruation.Ethnicity like afrocarribean also help to suspect fibroid.Dyspareunia,dysmenorrhoea,dyschaesia associated with irregular bleeding can give suspicion of adenomyosis or endometriosis.

LMP is an important history to ascertain because incomplete miscarriage can come with such complaints. IUDs,DMPA can give rise to irregular bleeding so contraception history should be taken in details.History of taking tamoxifen should beasked. We should ask her fertility wishes for treatment plan.

Marietal status,number of partner,sexual history,use of condoms-these history can help to detect cervical cancer presenting with irregular or postcoital bleeding.Sexually transmitted infections like Chlamydia which is more common at this age can give rise to irregular bleeding ,vaginal discharge.

Her family history of bleeding diathesis,history of epistaxis,bruising,previous  abnormal bleeding history can guide us towards doing further investigations.

Weight gain can guide us towards taking further history . If hirsuitism,infertilityis there it could be PCOS.History of lethargy or palpitation will help to think for thyroid disorder either hypo or hyperthyroidism.Symptoms like palpitation,fatgue,shortness of breath can be helpful to detect anaemia.

During general examination anaemia should be looked for as it can cause heavy and irregular bleeding.Pulse,BP check,BMI should be calculated.Thyroid gland palpation should be done.Any abdominal mass,tenderness,adnexal mass can help diagnosis.Pelvic examination to exclude cervical polyp,cervicitis has to be done.

Routine investigation-fbc for anaemia.Pregnancy test for incomplete miscarriage,beta hCG to exclude molar pregnancy.Thyroid function test;LH,FSH,testosterone for PCOS and oestrogen,progesterone for other anovulatory conditions.

Pelvic ultrasound for fibroid,endometrial polyp;MRI to detect adenomyosis will help in our diagnosis.

b)Pelvic ultrasound specially transvaginal will help to detect fibroid and endometrial polyp.We have to differtiate different type of fibroid.If with TVS it is not possible then hysteroscopy or sonohysterocopy can be done.If vaginal access difficult or in virgin MRI can be done.MRI is specially helpful for detecting adenomyosis.

Patient’s age is not guiding us towards endometrial hyperplasia.Because of family history or PCOS if suspecting endometrial hyperplasia  endometrial sampling can be done.Pipelle biopsy will help to confirm diagnosis.We can do endometrial sampling under hysteroscopic evaluation of uterine cavity.Hysteroscopicaly we can diagnose endometrial polyp can resect also.In case of suspicion of cervical cancer should be referred for colposcopy .Endocervical swab for detecting STI or pelvic inflammatory disease is helpful.

a. From the history, i would enquire on the last menstrual period to rule out pregnancy or complication such as GTD. Menstrual history such as if cycles have been irregular since menarche or of recent onset, ie ovulatory becoming anovulatory. Duration of flow previously, and any changes in amount. The increase in amount of pads used per cycle, passage of clots and overflow may indicate significant bleeding. History of intermenstrual bleeding, which can be due to local causes such as polyp or infection. Post coital bleeding also due to local cause such as cervical malignancy, which may be unlikely if she has been upto date with her smears and smear history has been normal. Associated symptoms such as dysmenorrhoea which can occur in endometriosis or adenomyosis. Her parity and fertility wishes which would influence management. Contraceptive methods and compliance as IUCD, IUS, implants and poor compliance of pills can cause break through bleeding. Previous treatments that has been tried at primary level for this problem and possible reasons for failure ie due to side effects. Symptoms of anemia such as tiredness, palpitations, shortness of breath which suggest significant menstrual loss. The effect of this on her quality of life and if she is required to take time off from work or studies. History of weight gain, acne, hirsutism suggest PCOS. History of lethargy, cold intolreance, weight gain despite poor appettite in hypothyroidism. Bleeding tendencies such as easy bruising, gum bleeding on brushing or delay in clotting after a cut would indicate a bleeding disorder such as von Willebrand s or ITP. Family history of breast or colon cancer in a first dergree relative younger than 50 years old has high risk for familial cancer syndromes ( endometrial cancer). Social history of changes in lifestyle such as excessive exercise, new job, examinations, family problems which can be stressors affecting the HPO axis causing menstrual irregularities.

In examination, high BMI suggest PCOS. Signs of anemia such as pallor, tachycardia, heart failure. Hirsutism, acanthosis nigricans in PCOS. Thyroid swelling in hypopthyroidism. Petechial rash in ITP. Abdominal examination for masses such as uterine fibroid. Speculum examination to look for local causes such as polyp, ectrophy, prolapsed submucosal fibroid or cervical malignancy. A vaginal examination and bimanual to assess uterine size which would be bulky in adenomyosis and irregularly enlarged with fibroid. A pictoral chart to assess blood loss.

b. A cervical smear can be done if has not been done within the year. It is reIatively simple and can be done during examination. If a suspicious lesion is seen on the cervix then a colonoscopy and directed biopsy is required. A high vaginal swab for chlamydia infection as it can cause irregular bleeding, as well as an opportunity to screen for STI in this age group. An ultrasound either trans abdominal or transvaginal to look for uterine fibroid, globular uterus in adenomyosis and the thickened endometrial lining, which would be significant if more than 15mm for this age group. A transvaginal scan would be superior in identifying the pathology due to close proximity with the organ. However it may not be suitable if the patient is vigo intacta. Associated adnexal masses can be ruled out. A hysterosonography can provide a clearer view in case of endometrial polyp or submucosal fibroid. With addition of contrast the pathology is delineated effectively and rule out other uterine anomalies. Gold standard for investigation of irregular bleeding especially of age more than 40 years  would be hysteroscopy and directed biopsy or dilatation and curretage. However in this age group it is rarely done unless there is high suspicion of malignancy or treatment failure. Another option to access the endometrial lining for histopathology would be a pipelle sampling of the endometrium. It is relatively easy, can be done as outpatient. If resources are available an MRI can be done in suspected cases of adenomyosis.

1. History will be taken to ask for  etnicity as fibroids are more common in afrocarrabean women, parity , lNMP, detailed menstrual history including days of bleeding, regularity , bleed free intervals, post coital bleeding, premenstrual bleeding, dysmenorrhea, passage of clots . need to miss work or college to assess severity. In addition symptoms of pregnancy , contraception method  if there is history of missed pills it will be noted in addition recent insertion of iucd may give rise to this problem. Pressure symptoms pointing towards fibroid, deep dysparunea may point towards ovarian cyst. Other symptoms like hirsutism , weight gain or weight loss may point towards a functional ovarian tumor.

Sexual activity , recent change of partner , history of offensive discharge , or change in discharge may suggest STD. possibility of pregnancy state like missed miscarriage or incomplete miscarriage by exploring symptoms of pregnancy like nausea , vomiting, morning sickness, unprotected intercourse , missed pill all need to be elucidated.

Pre-existing clotting disorder like vWD, hemophilia can be found by history easy bruising or bleeding tendency, and then specific tests as directed by the haematologist. A hypoactive thyroid and hyperthyroidism can give rise to such symptoms.

Examination to check for pallor, recent weight loss or weight gain , thyroid enlargement should be noted bruises to be noted pointing towards clotting dysfunction. Abdominal examination for fibroids , ovarian cyst , palpable mass may be done. Speculum examination to check for polyps, discharge , iucd thread ectopy , high vaginal swab . A vaginal examination for size and mobility of uterus, adnexal masses can be done, cervical motion tenderness.

b. A full blood count to check haemoglobin levels a fall points towards severity of symptoms, platetlet levels if reduced then may point towards thrombocytopenia, a hematologists opinionmay be sought if family history suggestive of clotting disorders like Glanzmanns thrombocytopenia, hemophilia. A high vaginal swab for culture and NAAT screen for chlymidia infection. Ultrasound for pelvic pathology for detecting fibroids, ovarian cyst , pregnancy.

If she doesnot respond to the ususual treatments like antofibrinolytics, antibiotic therapy or use of combined oral contraceptive pills then an outpatient hysteroscopy may be performed to detect polyps , submucous fibroids etc. (NICE) 

A.

Detailed menstrual history including age of menarche and menses since then will help in identifying puberty onset heavy menses.

Last menstrual period is noted to rule out pregnancy related causes like miscarriage as etiology.

Contraceptive use is noted including the method, current duration of use and compliance in terms of regularity of the pills taken. IUCD can cause heavy menstrual bleeding (HMB).

Dysmenorrhea along with back ache is noted considering PID/uterine anomalies as a cause for HMB

Intermenstrual bleeding if any may suggest uterine pathology like endometrial polyps and post coital bleed may point towards cervical lesions like cervicitis.

Sanitary protection needed in terms of tampons, pads and diapers is noted considering HMB and any flooding or passage of clots is asked as well. It may indicate the amount of bleeding as well passage of clots may indicate disturbance in prostaglandin balance in endometrium. Time taken off from work and hampering of her social functions may indicate alteration in quality of her life.

History suggestive of anemia like tired feeling, dizziness or loss of appetite is noted.

Sexual history including any recent change of partner in the last 6 months is noted. Any vaginal discharge, yellow/green color and offensive odour may indicate PID.

Bleeding during minor surgical procedures or tooth extraction or easy bruising may point towards coagulation disorders like Von- Willebrand’s disease.

On examination height weight and her BMI is noted which will be normal since she is healthy.

Pallor is noted in submucous conjunctiva to look for anemia.

Cardiovascular examination done for  murmurs considering anemia.

Abdominal examination to identify any palpable masses like ovarian cyst/fibroids/pregnancy.

Speculum examination to look for discharge & cervical lesions like cervicitis or cervical polyp or protruding uterine/endometrial submucous polyp.

Vaginal examination to look for the size of uterus, any fibroid or palpable ovarian cysts is noted.

B.

Trans-vaginal ultrasound may help identifying uterine pathology such as polyps or fibroid.

Abdominal uss including renal tract ultrasound may be considered if mullerian +/- renal anomalies suspected.

Hysteroscopy under anesthesia may be considered if uterine pathology such as polyps is suspected with intention to diagnose and cure.

Endometrial pathology can be ruled out by endometrial biopsy on pipelle sampling or hysteroscopy if malignancy suspected.

Hystero-sono-salpingography for delineation of any uterine pathology can be done as outpatient provided adequate technical expertise available.

Laparoscopy may be done to identify endometriosis or PID which may cause HMB.

1. I will get history to assess how heavy her bleeding is and also I will ask her if she is passing clots. This will help to plan for the investigations. Full blood count has to be done if she has been having heavy bleeding with clots for a long time

Checking the duration of bleeding will help us to differntiate between acute and chronic causes like infection, pregnancy or due to fibroids. Check her last menstrual period to rule out pregnancy. 

Ask her if she is on any contraception as irregular heavy bleeding could be due to progesterone only contraception like progesterone only pills, Depo-provera, implants or Mirena coil

Check her last cervical smear and if the results are normal to rule out cervical cause of bleeding

Ask her if she gets postcoital bleeding to rule out cervical cause of bleeding

If she has got abdominal pain or pelvic pain associated with heavy bleeding it could be due to endometriosis or pelvic infection 

Deep dysparuenia might also indicated endometriosis

If she has got vaginal discharge in association with heavy bleeding, it indicates it could be due to pelvic infection

Ask her if she has taken any medication so far to control the bleeding so that we can avoid the same treatment again. 

Ask her if she has got any other medical disorders as these can cause heavy irregular bleeding.

Getting drug history will help to rule out causes related to drugs like warfarin

Examination

General examination should be done to rule out anaemia

Abdominal examination to rule out tenderness and to palpate abdominal mass. This will help to identify fibroids, ovarian cysts and endometriosis

Pelvic examination to rule out cervical causes and bimanual examination to assess adnexal tenderness to rule out endometriosis

b. Investigation to identify uterine causes of her symptoms

Transvaginal ultrasound is the first line investigaton to rule out uterine causes.

Saline infusion sonography may identify endometrial polyps

Hysteroscopy will help to rule out endometrial pathology and to take biopsy at the same time if needed

Pipelle endometrial biopsy should be considered if she fails to respond to medical treatment. This can be done as an outpatient procedure

MRI scan will help to identify adenomyosis and for classification of fibroids before planning surgery like myomectomy or uterine artery embolisation.

Clinical assessment of healthy 23 years old with heavy irregular cycle.

Detailed menstrual history including time of menarche pattern of menses since that time , with recent change in the pattern excluding thrombotic diseases.

Pattern of bleeding in the last few month including no of days she used to bleed, accompanied by clots or floods and its effect on her social life specially sexual l life and no of days off from her work.

Ask about menstrual diary and offer her pictorial menstrual diary for assessment of her blood loss which may be a subjective feeling. It can also measure blood loss and compare it to the average blood loss around 35 ml.

Recent use of intrauterine device which may prolong her bleeding days .or recent insertion of  a Norplant system.

Ask the patient about the irregular use of combined contraceptive piles.

Symptoms that accompany her bleeding, like pain, deep dysparunia or PMS that suggest PID or endometriosis.

Pregnancy should be excluded from the history of bleeding after time of missed period. Orr can be suspected after missed pile use.

Recent result of pap smear and any post coital bleeding.

Drugs that can cause bleeding like POP, the other drugs like aspirin , antihypertensive and warfare may not be suitable as she is healthy .

Recent change in weight and measure of BMI may suggest thyroid disease that can cause irregular bleeding.

History suggestive of blood disease in her family like Von willibrand disease.

Examination include general examination for signs of anemia, abdominal palpation for mass, suggestive fibroids. Pelvic examination for the uterine size fixation, adnexal tenderness, or pelvic mass. Rectovaginal septum and doglus pouches for pain suggestive endometriosis, or PID.

Speculum examination for fibroid polyp or cervical ectriopion.

Offer menstrual diary for 3 month for the assessment of amount of blood loss.

Ask of investigation that may lead to detection of the cause, like pelvic us, hysteroscopy, sonohystrosalingiography,office hysteroscopy ,or laparoscopy for cases of endometrioses.

B

Investigation that point to the uterine cause include mainly pelvic ultrasound , can be abdominal or vaginal , gives good clue about the size of the uterus , endometrial lining, presence of polyp or fibroid. Also fair idea about myometrum in cases of adenomyosis, it also show possible adnexal causes like masses of cyst that can be of value.

Sensitivity is high in detecting average size lesions and it is considered first line before other investigation .

Office hysteroscopy use should be supported for the diagnosis of uterine cavity causes of bleeding, easy , done in an outpatient setting need local analgesia, less coast in relation to the inpatient hysteroscopy that can be done under general anesthesia. Biopsy can be taken but big lesion cannot be removed.

Sonohystrosalingiogram can be used to detect endometrial lining pathology like polyp it is used by injection of fluid in the utrine cavity under ultrasound guide and watch for the free fluid .

Hysteroscopy with D&c  is the Gold slandered . can be used to look , and treat in the same time if polyp , or suspecting lesion  seen taken for biopsy.

Endometrial sampling  can be done in the outpatient setting , sensitivity ranges from 68-97 % in the diagnosis of cancer in the endometrum several types of pipettes are uses, VIbros and novac catheter are famous, easy to perform and cheap.

MRI is used to assess myometrial lesions like adenomyosis or cancer staging. Expensive, not available in all  hospital sittings.

Pelvic femoral angiography is used to detect rare causes of A_V connection in the pelvis that may lead to excessive bleeding. 

History taking would define the problem and determine the impact on womans life as well as detect abnormal bleeding patterns/symptoms which indicate significant pathology.while menstrual calenders are helpful in defining pattern and severity of the symptoms,objective asessment of blood loss is recomended in practice.Onset of symptoms to menarche,prence or absence of associated factors such as dysmenorrhea,intermenstrual/postcoital bleeding(if sexually active),dysmenorrhea,reproductive status,social disruption will help in the assessment as well as management .A careful history about easy fatiguibility ,significant change in weight,hirsutism,acne,intolerance to heat or cold or bleeding from other sites is essential in assessing the relevant medical disorder(throid disease,polycystic ovarian disease) and the impact of the problem.

Irregular heavy menstruation is common at the extremes of reproductive age but she is now well past from menarche and anovulatory in the early years of mearche is the less likely cause in this case.In young females ,coagulation disorders especilly von willibrands disease could be the cause but then there would be regular cycles ,symptoms dating back to menarche aswell as historyof bleeding from other sites.Fibroids are the most common structural cause of HMB,30 percent prevelant in females of reproductive age.Bleeding asociated is mostly regular and painless.Painful,heavy  periods could indicate adenomyosis which is more commmonly present in older,multiparous women.Intermenstrual/postcoital bleeding frequently coexist and present mostly in benign causes  as chlamydial infection,cervical ectopy ,s ubmucous fibroids or endometrial polyp.while serious pathology  as cervical carcinoma could be present.Majority of the women with menstrual disordershave no underlying histological,structural abormality yet fibroids are present in 30 percent ,polps in 10 percent their incidence is less in younger women but age alone is poorly. predictive.Incidence of endometrial hyperplasia is 1 in 10000  in women less than 40 years and 15 per 10000 in women more than 45 years.Reproductive status and psychosocial factors have an important inluence regarding management options.

A detailed general physical examination inluding weight ,height(bmi),presence of pallor ,goitre,palpable lymph nodes would be done.Abdominal examination will exclude  palpable mass(uterrine,ovarian)on pelvic examination ,inspection of cervix...suspicious findings will indicate need for colpscopy,swabs for infection if indicated.Bimanual examination of pelvis will detect any enlargement of uterus,its mobility.adnexal mass or tenderness ,nodularity in the pouch of douglus.

Full blood count would be done in all patients with heavy bleeding.Although additional blood tests such as serum ferritin,thyroid function tests ,hormone assays(FSH,LH.TESTOSTERONE,SERUM PROLACTIN.SHBG)only done if indicated by history and examination.Ultrasound  examination would be first line of investigations ....abdominal if uterus size is more than 12 weeks .Otherwise TVS is more help to visualize ovaries ,endometial thickness.In cases of prolonged or persistent intermenstrual bleeding,or failure of medical treatment..endometrial biopsy is necessary to exclude endometrial hyperplasia or carcinoma.Pipelle technique has high sensitivity and specificity in detecting endometrial pathology.however it cannot detect submucosal fibroids and polys.Hystoscopy is more accurate in deliniating fibroids and polyps but it is expensive and avaailibility may be limited...in that case saline infusion sonography would help.G uidelines suggest thattvs should be used with endometrial biopsy and hystroscopy as the backup.Dilatation and curettege has no advantage over pipelle technique.MRI has no advantage over ultra sound excet where there is suspicion about the nature of fibroid(suspicion of malignancy)

9

Essay 350 (Abnormal uterine bleeding)

A healthy 23 year old woman has been referred to the gynaecology clinic because of heavy and irregular menstrual bleeding. (a) Discuss and justify your clinical assessment [12 marks]. (b) Discuss the investigations that may be undertaken to identify the uterine causes of her symptoms [8 marks].

a)      History in regards to menstrual symptoms should be taken such as regularity of the cycle . What is the normal duration of her normal cycle and the length and the duration of the abnormality . The amount or quantification of bleeding in terms of pads used or pictorial based assessment would be important. Symptoms of anemia such as palpitation,  lethargy, dyspnea should also be taken to the severity of menstrual loss. Other symptoms such as intermenstrual bleeding, post coital bleeding may indicate a local or cervical cause of bleeding. Presence of pelvic pain with secondary dysmenorrhea with a history of subfertilty may indicate endometriosis or pelvic inflammatory disease(PID). Other symptoms such as acne, hirsutism, weight increase may indicate polycystic ovarian syndrome. Presence of headache, visual disturbances, with galactorrhea may indicate hyperprolactinemia. Her history of last unprotected sexual intercourse and risk of pregnancy must be also assessed as this could also be pregnancy related bleeding such as miscarriage. Her sexual history, number of partners and history of STD should also be taken to assess risk of PID. The orevious use any contraception such as any emergency contraception or depo provera may also cause irregular cycle. Her past obstetric history should also be taken and including history of currently breastfeeding and her fertility wishes as to tailoring for her treatment later. Symptoms of tremors, palpitation and proximal muscle weakness may indicate underlying thyroid disease causing menstrual disturbances. History of easy bruising and bleeding and any excessive dental bleeding with a family history of bleeding disorders may indicate cogulation disorder. Family history of blood clots should also be taken before any prescription of any medication for her problem. Examination Should include her body mass index in which the obesity may indicate PCOS. Presence of hirsutism , acne should also be noted to indicate PCOS. Neck should be palpated for any neck mass for thyroid enlargement, breast examination for presence of galactorrhea. Abdominal examination should be done to assess for nay uterine or ovarian mass and presence of tenderness for Endometriosis or PID.  Pelvic examination should include to look for local cause such as polyp , the appearance of cervix or other mass. Uterus should be assessed for mobility, size and tenderness. The presence of fixed retroverted uterus with presence of nodules in the pouch of douglas could indicate endometriosis. This time would also be ideal to take triple swabs from the endocervix, rectum and high vaginal swab if she is high risk for STD. Cervical smear is also to be taken if she considered high risk.

b)      The usual investigation of uterine cause would be a transvaginal scan. This would be ideal in apatient who is sexually active. The scan could be used to diagnose any presence of fibroid, ovarian cyst, polycystic appearance of the ovaries in PCOS. It is relatively cheap and easily vailable modality to diagnose gynaecological condition. This also could be complemented with saline infusion hysteron sono graphy to diagnose small polyps or submucosal fibroids. Other methods include hysteroscopy to assess endometrial cavity for polyp, abnormal endometrial thickening and biopsy. Excision of the biopsy also could be done in the same sitting. Of course laparoscopy could also be done and this is invasive and requires the risk of general anesthesia to diagnose endometriosis, PID  and could do adhesiolysis or excision of endometriosis in the same sitting. Pipelle sampling could be done to exclude malignancy or hyperplasia of the endmetrium in PCOS. Magnetic resonance imaging could be reserved for patient with virgo intact who refuses invasive investigation. However this modality is costly and not available in all centres.

1. I will ask her in sympathetic manner her LMP , amount of bleeding,passage of clots although it will not suggest any cause of bleeding. Often the pictorial charts are helpful to assess the amount bleeding .

   I will assess impact on quality of her life. I will ask her if associated pain/dysmenorrhoea. As fibroid uterus especially submucous myomais associated with dysmenorrhoea & menorrhagea. I will ask her history of contraception as hormonal method initially during 3-6 months may give rise to irregular bleeding .I would also like to know her fertility wishes as it has implications for further treatment. I will ask her recent pregnancy event or miscarriage as initial few cycles after pregnancy event may be heavy. Irregular bleeding per vaginum is also a symptom suggestive of Pelvic inflammatory disease, so I will ask her sexual history including number of sexual partners& symptoms suggestive of PID like pain, fever, vaginal discharge. I will also ask her if she is a smoker or alcoholic . I will ask her if she has any medical illness or taking treatment for thyroid disorder as hypothyroidism is associated with menorrhagea. I will also ask her personal history or family H/O  coagulation disorders. I will take her BMI as high BMI may be associated with anovulatory , irregular bleeding . I will take her pulse , B.P measurement to see general conditions . I will do per abdominal examination to palpate for masses e.g fibroid . ovarian masses. I will do per speculum examination to see any local cause of bleeding e.g cervical polyp or peduncu lated fibroid.Bimanual examination to see uterine size , cervical movement tenderness & adenexal masses for for PID.

1.  Pelvic ultrasound will give important information in the form of uterine size, shape , any distortion of the cavity or presence of masses to see if she has fibroid uterus . At this age adenomyosis is rare . Pelvic ultrasound will also give information on adenexal masses if any. The uterine cavity e.g polyp may be diagnosed on pelvic ultrasound. If doubt it may be supplemented by Transvaginal scan Ultrasound. In few cases MRI may be helpful. Hysteroscopy – Office hysteroscopy can be taken to diagnose intrauterine masses like polyp , submucous fibroid. Hysteroscopy guided biopsy can be taken if suggestive of hyperplasia. At this young age hyperplasia is rare occurrence .

I would like to know how long she has been having this symptom.  I would like to establish the pattern of her cycle, how often her period occurs and how long she would bleed and whether she has flooding, passing clots.  Also would like to know, whether she needs to use double protection and when her last period was.  I would like to know, whether she is sexually active and how long she has been with her current partner and what type of contraception that she uses.  I would like to know whether any history of Pelvic inflammatory disease or risk of the same, which may be the reason for bleed.  I would like to know,  any history of intermenstrual bleed and post coital bleed.  More about her cycle whether it is associated with pain and any other symptoms and would take time off from regular work due to heavy bleed.

If she takes contraceptive pill, would she take it regularly or is she taking any other medication which may be interfering with its function and causing the break through bleed.   I would like to know, whether she suffers from any bleeding disorder or on any anticoagulant medication for any reason which could be the cause.  I want to know whether she has hypothyroid or polycystic ovarian disease.  I want to know, the treatments that she had tried so far.

I would like assess her weight, height and BMI.  I would like to check, whether she is pale, breathless and unusually tired.  I would examine her abdomen for any big pelvic mass, pelvic examination to check the cervix for any reason for bleed and vaginal examination to check uterus size, mobility and masses – fibroid uterus could be the cause.  I would like to arrange FBC and coagulation screen to check for anaemia and rule out any bleeding disorders.  I would like to do scan to check fibroid, or polyp could be the cause for bleeding.  Check ovaries to rule out polycystic ovaries that could be the cause for heavy bleed.  I also would like to do pregnancy test to rule out miscarriage which could be the reason.  I would her to try either Tranxemic acid and NSAIDs or OCP for 3months and review in the clinic.  I would like her to keep a menstrual calendar for assessment purpose.  I would like to discuss more option during the review.

For investigation to find the uterine cause, I want to do endocervical swab to rule out chlamyidal infection.  I also would like arrange for her to have transvaginal scan of pelvis to check the uterus for endometrial polyp, submucosal fibroid and retained products of conception.  I also would like her to have hysteroscopy to check inside the uterus for polyp, fibroid and assess the endometrial thickness.

Detail menstrual history should be enquired .This includes age of menarche, cycle length, and duration of symptoms, amount of bleeding.Irregular and heavy bleeding of long duration might suggest polycystic ovaries. History of dysmenorrhea and passage of clots, dyspareunia with or without bowel symptoms will suggest endometriosis.Her last menstrual period is important to rule out pregnancy related causes like miscarriage, molar pregnancy,and chronic ectopic. Contraception history as oral pills or recent insertion of IUCD should be enquired. History of any mass/lump in abdomen will point to the presence of fibroids. Personal or family history of bleeding  disorders should be asked. History of bleeding from other sites will suggest this. History of other related symptoms like tiredness, fatigue, bowel habits may suggest degree of anemia and thyroid disorder. Finally drug history is important  eg. Aspirin or anticoagulant can cause irregular bleeding.

 Detailed examination need to be done.  Pallor to note the degree of anemia, skin for evidence of petechiae, and icterus in case of bleeding disorder, any thyroid swelling can point towards thyroid disorder or can co-exist with polycystic ovaries. Respiratory and cardiovascular examination can reveal the pathology eg. Heart disease for which she may be on anticoagulants. Per abdomen examination for any mass suggestive of fibroid or endometrioma or uterine enlargement pointing towards pregnancy. Per speculum to know the source eg. Cervical polyp,cervicitis, fibroid polyp  or any products of conception . Vaginal examination for the size of uterus, mobility, fixity, cervical motion tenderness due to endometriosis,or any adnexal mass.

Answer b) Urine pregnancy test or b- hcg to rule out pregnancy-related cause. Pelvic scan for evidence of polycystic ovaries, fibroids, endometriotic cyst, pregnancy or retained products. Endometrial thickness can be measured simultaneously.Endometrial polyp is difficult to diagnose on ultrasound.

Saline infusion sonohysterography is more sensitive for detection of endometrial polyp as well as type of fibroid and any focal pathology. Hysteroscopy can be done to look for intrauterine pathology like endometrial polyp or fibroid, MRI Pelvis is sensitive for diagnosing endometriosis or adenomyosis.  

a)Heavy menstrual bleeding(HMB) is the excessive menstrual blood loss which affects the womans physical ,emotoinal, social and material quality of life , mainly the only presenting symptom or associated with other symptoms.Any investigations or interventions to diagnose and interfere the cause should be aimed to improve her quality of life.

In history it should be elicited her nature of bleeding and her state of latest smear test, whether she was treated previously, any drug use and failure of treatment.HMB relation with intermenstrual bleeding, post coital bleeding, duration of HMB  associated with pain and pressure symptoms elicited.The womans perspectives of cause,ideas, concern, need , what type of treatment she needs to be given priority.Her views of future fertility, contraception should be known.Prevalence of HMB is 8-27%(WHO).Risk factors are fibroids, increasing age, vWD (presents with HMB from menarche 13-15% ), among life styles amoking and alcoholism  and noncaucasians.Other factors are endometriosis, uterine malignancy( rare in this age group) excluded with histology.

Among lab investigations full blood count, clotting disorders elicited from her personal or family history.HMB leads to anaemia mostly iron deficiency anaemia ( serum ferritin identify it but not routinely estimated).

Physical examination by observation, abdominal palpation, visualisation of cervix, bimanual exmination to know the size of the uterus and adnexal pathology.If history excludes structural and histological pathology direct pharmaceutical agents prescribed as first line of treatment.If she refuses examination , it must be documented and informed to senior obstetrician.

b)In investigations for structural causes of her symptoms USG,MRI,saline infusion sonography,hysteroscopy,pipelle biopsy,D&C are available options.

USG first line of choice it diagnoses the fibroids sensitivity 48-100% specificity 12-100%, completeness of 88% , unacceptability 11%.If it clubbed with pipelle biopsy it is more accurate.But it may not give the information of polyps and endometrial disease.Saline infusion sonography,MRI, Hysteroscopy were cost effective and not first line choice.Saline infusion sonography sensitivity 85-100% specificity 50-100% diagnose polyps and endometrial disease.Hysteroscopy completeness 77% unacceptability 26%.MRI done when USG is inconclusive.

a)Heavy menstrual bleeding(HMB) is the excessive menstrual blood loss which affects the womans physical ,emotoinal, social and material quality of life , mainly the only presenting symptom or associated with other symptoms.Any investigations or interventions to diagnose and interfere the cause should be aimed to improve her quality of life.

In history it should be elicited her nature of bleeding and her state of latest smear test, whether she was treated previously, any drug use and failure of treatment.HMB relation with intermenstrual bleeding, post coital bleeding, duration of HMB  associated with pain and pressure symptoms elicited.The womans perspectives of cause,ideas, concern, need , what type of treatment she needs to be given priority.Her views of future fertility, contraception should be known.Prevalence of HMB is 8-27%(WHO).Risk factors are fibroids, increasing age, vWD (presents with HMB from menarche 13-15% ), among life styles amoking and alcoholism  and noncaucasians.Other factors are endometriosis, uterine malignancy( rare in this age group) excluded with histology.

Among lab investigations full blood count, clotting disorders elicited from her personal or family history.HMB leads to anaemia mostly iron deficiency anaemia ( serum ferritin identify it but not routinely estimated).

Physical examination by observation, abdominal palpation, visualisation of cervix, bimanual exmination to know the size of the uterus and adnexal pathology.If history excludes structural and histological pathology direct pharmaceutical agents prescribed as first line of treatment.If she refuses examination , it must be documented and informed to senior obstetrician.

b)In investigations for structural causes of her symptoms USG,MRI,saline infusion sonography,hysteroscopy,pipelle biopsy,D&C are available options.

USG first line of choice it diagnoses the fibroids sensitivity 48-100% specificity 12-100%, completeness of 88% , unacceptability 11%.If it clubbed with pipelle biopsy it is more accurate.But it may not give the information of polyps and endometrial disease.Saline infusion sonography,MRI, Hysteroscopy were cost effective and not first line choice.Saline infusion sonography sensitivity 85-100% specificity 50-100% diagnose polyps and endometrial disease.Hysteroscopy completeness 77% unacceptability 26%.MRI done when USG is inconclusive.

a

History of duration of symptoms as persistent symptoms of more than 3 months is significant.history of clotting,flooding and impact on her social life can demonstrate subjective assessment of her condition.Pictorial blood loss chart if available is helpful in semiquantitative objective assessment of condition.History of dysmenorrhea,dysparenia,dyschesia and pelvic pain can point towards adenomyosis,endometriosis,leiomyoma or pelvic inflammatory disease.Pressure symptoms like frquency of micturation can point pressure effects of leiomyoma.Abnormal vaginal discharges and history of smear and post coital bleeding can demontrate cervical copathology.History of infertility,polycystic ovarian syndrome ,hypothyroidism and hyperprolactinemia is associated with dysfuntional uterine bleeding.Desire of her fertility should be sought as treatment modality will depend on it.History of any treatment taken for her condition should be asked and inquired about any treatment failure or in effective treatment as it might necessetate to take endometrial biopsy.Examination of abdomen might reveal masses or tenderness predicting leimyoma or pelvic infection.Speculum examination might reveal abnormal vaginal discharges or cervicitis.Bimanual exam should be done for uterine size,shape,consistency,position and tenderness and mobility as it might predict adenomyosis,endometriosis ,leiomyoma or pelvic infection.

b

According to history and examination if she is suspected to have structural abnormality than 1st line investigation will be transvaginal scan.If no structural abnormality suspected on history and examination and she has persistent abnormal menstrual bleeding with ineffective or failed tratment then endometrial sampling should be considered according to NICE guideline.If history and examination is suggestive of infection then chlamydial screening should be performed.If ultrasound features indicative of endometrial polyps or leiomyoma encroaching on endometrial cavity or if scan result is suboptimal then image with either outpatient hysteroscopy with endometrial biopsy or perform sonohysterography which has advantage of showing endometrial polyps but has disadvantage of no endometrial biopsy can be done.hysterosalpingography can be done if fertility is desired and it has advantage of showing patency of tubes together with endometrial cavity.If patient has difficult vaginal access or we need to differentiate between adenomyosis and leimyoma then MRI can br requested.If other tests shows polyps or endometrial leiomyoma or if she has difficult vaginal access then hysteroscopy under anaesthesia can be done as it is diagnostic and as a tratment at the sane time. 

Sorry forget to type

In history risk factors for endometrial carcinoma should be asked like age at menarche,infertility,PCO or family history of nonpolyposis colorectal cancer syndrome as it increases lifetime risk of endometrial carcinoma by 60% in carriers.9

(A)   I will take a detailed history of her presenting complaint, including the duration of symptoms and associated symptoms of discharge and abdominal and pelvic pain. I’ll obtain her complete menstrual history including her menarche, LMP, details of her cycle and period before the currant complaint, dysmenorrhea and post coital bleeding  and dysparunea. I’ll  ask her about any complaints of sexually transmitted diseases in the past and number of sexual partners in last six months and the age at which she became sexually active, to assess her risks of PID and cervical cancer. Ask her about the number of pregnancies she had in past and their outcome. I’ll inquire her about the method of contraception as irregular use of oral contraception or Depo-Provera are associated with heavy and irregular bleeding, use of IUCD may also present with such symptoms. I’ll ask her about anorexia and rapid weight loss to assess the risk of malignancy. I’ll ask her about symptoms of mass in lower abdomen that is frequency of micturation, constipation alternating with diarrhea and feeling of pressure or pain in lower abdomen.I’ll perform a detailed examination, to note her BMI, pulse and blood pressure, pallor, jaundice and check for lymphadenopathy in cervical, supraclavicular, axillary and inguinofemoral areas. I’ll palpate her abdomen for any mass or tenderness .Perform speculum examination to note any lesion in vulva, vagina or cervix and also perform bimanual examination to assess the size and mobility of uterus ,cervical excitation and any mass in adenexa.If cervix looks abnormal I’ll take smear for cytology and if any abnormal discharge I’ll take swabs for microscopy and culture.

(B)   I can ask for smear if the cervix looks abnormal. I’ll take cervical swabs for Chlamydia and ask for NAAT for detection of Chlamydia and take cervical and urethral swabs for the microscopy and culture of gonorrhea. I’ll ask for transabdominal and transvaginal ultrasound for uterus and adenexa. Transabdominal scan can assess masses which are out of the range of transvaginal ultrasound as it has better depth than TVS whereas TVS has better resolution than TAS, so it is more sensitive in detection of cervical and endometrial lesions and ovarian masses. If there is suspicion of endometrial polyp I’ll ask for sonohysterogram. If there is suspicion of adenomyosis or malignancy I’ll request for MRI because MRI has better sensitivity for adenomyosis and useful in assessing the extent of spread of disease in case of malignancy. Endometrial biopsy using pipelle can be taken to exclude endometrial hyperplasia or outpatient diagnostic hysteroscopy may be requested if there is a need to visualize the uterine cavity along with biopsy.

　

　

a) this patient is most likely has dysfunctional uterine bleeding ( DUB). however pathologic cuases shold be roled out before having this diagnosis, the etiology is included in PALM COEIN FIGO Classification system.

A detailed history is a paramount to reach the diagnosis, I will ask her when she start to have heavy and irregular bleeding, is it mild, moderate or severe, how many days bleeding, LMP, the anture of bleeding, fresh blood or associated wih clots, is it associated with intercorse as this may caused by cervical etiology,such as cervical polyp. Is it associated with dysmenorrhoea as this may due to adenomyosis, does she has any history of coagulopathy, drug history esspecialy hormonal as this may affect endometrim and cause irregular or heavy periods.

Pap smear if any although she is less than 25 years.

Any previous investigations and treatment and what was its efficacy.

Physsical exam started with BMI, vital sings aand general inspection as may looks pale

due to associated anaemia.

abdominal exm to look for abdomino-pelvic mass, ascites.

vaginal exam with speculum to exclude polyps, abnormal cervix or vaginal discharge and at the same time vaginal swabs or pap smear may be consisered.

Bimanual exam to assess the uterus and adnexia and any pelvic mass.

A diary of her symptoms may be considered.

investigations include FBC, to chick for anaemia , ultrasound if clinicaly indicated it will show any uterine pathologies such as fibroids or endometrial polyps or increased thickness, ovarian cysts or mass .

b) Investigations may include pelvic ultrasonography to chick for fibroids endometrial polyps or abnormal endometrial thickness in such case endometrial sample may be indicated to diagnose or hyperplasia or endometrial cancer.

hydro ultra sonography may be beneficial in diaagnosis endometrial polyps and to defferntiate it from endometrial thickness and it is cheap,done as out patient procedure and no need for anaesthesia. However, it require experince which not available in all centres.

diagnostic hysteroscopy may be used as it is out patient procedure and no need for GA , out patient procedures and it is cost effective combared to operative hysteroscopy. However, polypectomy can not be done and only taking biopsy is possible.

In cases of suspected adenomyosis either clinicaly or by US Scan, MRI may be helpful, especialy in cases where US Scan is not conclusive.

If bleeding disorders --such as ITP, haemophelia, protien C defeciency--are suspected by history or positive family history,investigations should be considered, and may include, platelets count,PT, APTT

　

　

a) this patient is most likely has dysfunctional uterine bleeding ( DUB). however pathologic cuases shold be roled out before having this diagnosis, the etiology is included in PALM COEIN FIGO Classification system.

A detailed history is a paramount to reach the diagnosis, I will ask her when she start to have heavy and irregular bleeding, is it mild, moderate or severe, how many days bleeding, LMP, the anture of bleeding, fresh blood or associated wih clots, is it associated with intercorse as this may caused by cervical etiology,such as cervical polyp. Is it associated with dysmenorrhoea as this may due to adenomyosis, does she has any history of coagulopathy, drug history esspecialy hormonal as this may affect endometrim and cause irregular or heavy periods.

Pap smear if any although she is less than 25 years.

Any previous investigations and treatment and what was its efficacy.

Physsical exam started with BMI, vital sings aand general inspection as may looks pale

due to associated anaemia.

abdominal exm to look for abdomino-pelvic mass, ascites.

vaginal exam with speculum to exclude polyps, abnormal cervix or vaginal discharge and at the same time vaginal swabs or pap smear may be consisered.

Bimanual exam to assess the uterus and adnexia and any pelvic mass.

A diary of her symptoms may be considered.

investigations include FBC, to chick for anaemia , ultrasound if clinicaly indicated it will show any uterine pathologies such as fibroids or endometrial polyps or increased thickness, ovarian cysts or mass .

b) Investigations may include pelvic ultrasonography to chick for fibroids endometrial polyps or abnormal endometrial thickness in such case endometrial sample may be indicated to diagnose or hyperplasia or endometrial cancer.

hydro ultra sonography may be beneficial in diaagnosis endometrial polyps and to defferntiate it from endometrial thickness and it is cheap,done as out patient procedure and no need for anaesthesia. However, it require experince which not available in all centres.

diagnostic hysteroscopy may be used as it is out patient procedure and no need for GA , out patient procedures and it is cost effective combared to operative hysteroscopy. However, polypectomy can not be done and only taking biopsy is possible.

In cases of suspected adenomyosis either clinicaly or by US Scan, MRI may be helpful, especialy in cases where US Scan is not conclusive.

If bleeding disorders --such as ITP, haemophelia, protien C defeciency--are suspected by history or positive family history,investigations should be considered, and may include, platelets count,PT, APTT