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MRCOG PART 2 SBAs and EMQs

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ESSAY 277 - Menorrhagia

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		Posted by S D. Mon Aug 18, 2008 07:59 am
a) I would enquire about LMP, any associated dysmenorrhea and the effect of symptoms on her quality of life. I would take obstetric history including mode of deliveries and current contraception. Any history of IMB, PCB and dysparuenia should be asked. It is also important to know any treatments taken for menorrhagia and their effects and also her future reproductive intentions. b)Ferrous sulphate can be used if ferritin levels are low and to relieve symptoms of anaemia such as fatique. Tranexamic acid is antifibrinolytic which reduces blood loss by about 50%. Side effects include nausea, vomiting and diarrhea. Mefenamic acid is a NSAID which reduces blood loss by 20%. Main side effect is peptic ulceration. It also relieves associated dysmenorrhea. oral progestogens such as norethisterone in high doses used from D5 to D25 are effective in controlling blood loss but not when used from D15 -D25. Depot provera can also be used but it is not licensed for menorrhagia. It decreases blood loss by 55% after the 4th dose but it causes irregular bleeding. Other side effects include weight gain, acne and bloating which might not be acceptable to some women. The other option is COCP. It decreases blood loss by 50% and is a very effective contraceptive. Side effects include breast tenderness, weight gain, acne, VTE, headaches should be explained to the woman. Mirena IUS is one more option. It decreases blood loss by 97% at 12 months and is a very effective contraceptive. It can stay in for 5 yrs or can be removed whenever the woman wishes. Complications such as uterine perforation and spontaneous expulsion should be explained. As the uterus is 14 wks size, it is highly likely that the coil might get expelled spontaneously and this should be explained to the woman. Endometrial ablation is destruction of the lining of the womb which can be done by various methods such as microwave, laser, thermal balloon. It is a day case procedure, can be done under LA / GA. It is associated with less morbidity and shorter hospital stay. It requires less analgesia and is cost effective. Approximately 80% of patients are satisfied with the procedure. However does not produce amenorrhea and the re-operation rate is 30-50%. Women also need to continue with contraception as there is a risk of pregnancy. c)I will enquire about family history of ovarian cancer and personal history of breast cancer. I will also enquire about her cervical smear history. I would also explain to the lady about the use of GNRH analogues to shrink the fibroids and decrease the vascularity so that the operation would be technically easier to perform.. The consent should be taken by a person who performs the procedure or can do it under supervision. I will explain the nature of the operation, that is removal of the womb and cervix with conservation of ovaries and explain that ovaries will not be removed unless looks suspicious / diseased. I would also explain about subtotal hysterectomy if it is technically difficult and safer to do so. I will explain the benefits of the operation which is removal of the womb and decreasing the symptoms. Seriously occuring risks include visceral injury, haemorrhage, VTE, death 1 in 4000. Frequent risks include wound infection, bruising, wound haematoma. Other procedures which may become necessary such as blood transfusion and repair of damage to viscera should be explained. I will explain about alternative treatments and take account of procedures which should not be undertaken without her consent. This information should be backed up by information leaflets and telephone contact no\'s of the consultants secretary should be provided if she wants to discuss any queries in the future. I will ask her if she has any questions and get her signature and this should be confirmed again on the day of operation with the pt.
		Posted by J P. Mon Aug 18, 2008 11:42 pm
a.I will enquire in detail about menstruation including the last menstrual period.Any history of intermenstrual bleeding and post coital bleeding which may suggest local lesion in cervix and cervical neoplasia will be asked.Her cervical smear history also will be enquired. Any additional symptoms like urinary retention and frequency to be enquire.History of any mass in abdomen together with heavy bleeding suggest fibroid uterus.History o f contraceptive use and her future contraceptive desire will also be enquired.Social history like abstinence from work due to heavy bleeding which suggest severity will be enquired.Symptoms suggestive of anaemia like fatiguability will be enquired to detect severity and preoperative haematinic treatment.Obstetric history like the mode of delivery by caesarean section may increase morbidity in abdominal surgeries.Any previous treatment for heavy menstrual bleeding done will be enquired to assess the need for further investigations.History like venous thrombo embolism,personal or family history of breast cancer ,liver disease which are contraindications to oral contraceptive pills which are used in treatment will be enquired b.Non surgical management first includes oral iron replacement.Non hormonal drugs include tranexemic acid and NSAIDs.Tranexemic acid is an anti-fibrinolytic will be given which reduces MBL by 50%.Side effects include nausea,rash,vision disturbances.NSAIDs like mefenamic acid can also be given which reduces menstrual bleeding by 25-30%.Side effects include diarrhea,epigastric pain.Hormonal options include oral combined contraceptive pills and progesterone only pills if contraception also desired.OCP if given will reduce menstrual blood loss by 50 % but the hormonal side effects like mood changes,fluid retention,nausea and leg cramps should be borne in mind.Cyclical progestogens to given for 15 days[norethisterone 5mg 3 times daily] from day 5 ,but its use in regular heavy periods are to be evaluated.Progesterone can also be given as intr uterine device –Mirena which reduces heavy bleeding by 90% in 1 year.But the main disadvantage is the irregular bleeding for the initial 3-4 months. Use of danazol is not routinely advocated because of side effects. Gnrh analogues can be given upto 6 months to improve anaemia and they produce amenorrhea.Disadvantages are the cost,relapse of bleeding as soon asit is stopped,and ostoporosis if used beyond 6 months. c.I will explain the operation procedure in simple terms like removal of womb and cervix by a cut in abdomen which may be open or by laparoscopic method. The risk will be increased if she is obese and in presence of previous surgeries due to adhesions. Laporoscopic hysterectomy has the benefit of short hospital stay,less post operative discomfort ..The serious inherent risks associated with surgery like anaesthesia hazards,immediate or late haemorhage,ureteric injury [1 in500-1000prcedures],bladder damage 1in 200 cases, damage to bowel in 0.4%,return to thestre for additional procedure 0.6%,VTE,pelvic abscess and infection will be explained along with the risk due to fibroids. ● The frequent risks like urinary retention,wound infection ,keloid formation will also be informed.The procedure may be a total hysterectomy involving removal of uterus ,tube and cervix. Or a sub total hysterectomy .Sub total hysterectomy has the advantage of less haemorrhage and the less risk of bladder injury. But the limitation is there may be bleeding from endometrial remnants and the need for initial cervical smear monitoring.Wishes regarding conservation or removal of ovaries during hysterectomy should be enquired.If there is no positive familial history of ovarian cancer conservation may be advised an if the patient refuses the need for HRT post operatively should be informed. The form of anaesthesia planned will also be informed.Other alternative treatments like medical treatment and minimally invasive procedure will also be explained Any objections to procedures [oopherectomy in suspected disease] without consent and objecton to blood transfusion should be carefully enquired. This information should be given as verbal or written documentation and backed up with information leaflets..
		Posted by Manoj M. Tue Aug 19, 2008 02:40 am
(a) History of amount of blood loss with clots/flooding may suggest underlying anaemia which can be treated. History of any treatment failure for the current problem/ history of current contraceptive use may suggest these medications may not be suitable for her treatment options. Her wishes for future fertility is important as this forms the main stay of treatment options with fetlility sparing options. Mode of delivery of her 2 children as previous 2 caesarean section may have implication on current surgical treatment options. (b) Tranexemic acid is effective in controlling blood loss upto 50% but does not help in shrinkage of the size of fibroids and should be preferred to non steroidal anti_inflammatory drugs(NSAID\'s) as NSAID\'s are not effective in the reduction of heavy menstrual bleeding(HMB) due to fibroids. Combined oral contraceptive pills (COCP\'s) can be used if she is considering contraception together with control of HMB and COCP reduces blood loss upto 50% but does not help in shrinkage of the size of the fibroids. High dose oral progestogens should be considered purely for sympotamatic relief of HMB while awaiting other treatment options as this does not again shrink the size of the fibroids and used for 21 days of 28 day cycle. Levonorgesterol intrauterine system (LNG-IUS) can be used if the fibroids is not distorting the uterine cavity and patient wants contraception at the same time. Danazol and gestrinome can be used to reduce the size of fibroids and also to control HMB but both have androgenic side effects which should be explained to the patient prior to starting them and these are potentially used for short term management options. Anti progestestrone like mifeprestone are future treatment option which can cause regression of fibroids and amenorrhoea and no effect on bone but currently not available. Gonadotrophin releasing hormone (GnRH) agonist induces amenorrhoea and shrinkage of fibroids however caessation causes rapid regrowth of fibroids, GnRH agonist is used either prior to surgical treatment options to shrink the fibroids and make it less vascular as it is beneficial in reducing operative morbidity or for those not suitable for surgical option GnRH agoinst can be used with add back therapy(low dose oestrogen-progestrone, progestrone alone or tibolone)for long term use to reduce detrimental effect on bone density. (c) Explain to her abdominal hysterectomy involves removal of the womb through abdominal route. Intended benefit is to remove the fibroids with the womb to stop menstruation. Explain to her the serious risk involved with abdominal hysterectomy are damage to bladder/ or ureter or long term disturbance of bladder function, damage to bowel, haemorrhage, venous thrombosis, pelvic abscess/infection, return to theatre and 2 in 100 women undergoing abdominal hysterectomy will have one of the above serious complications. If these serious risks happen they may require addition procedures or repair to save life or prevent serious harm of future. Antibiotics will be used intraoperatively to prevent infections, thomboembolic deterrent stockings and heparin will be used to prevent thromboembolism Extra procedure required are blood transfusion in haemorrhage, repair of bowel/ bladder if their injuries happen to them. Other non surgical and surgical treatment options like myomectomy, hysteroscopic resection of fibroids, laparoscopic removal of fibroids dependening of patient suitability and available treatment options should be discussed with the patient. Other options like Uterine artery embolisation for fibroids should also be discussed with the patient. She should explained regarding her anaesthetic options and arrangements to see an anaesthetic to discuss all her options. If addional pathology is seen in the ovaies she should be told it is best to remove the same at the same operation and consented for the same. If she has wishes to remove ovaries at the same time this should be documented and consented at the same time. Information leaflet and tape of consultation may be provided for more information to the patient.
		Posted by Manoj M. Tue Aug 19, 2008 02:45 am
(a) History of amount of blood loss with clots/flooding may suggest underlying anaemia which can be treated. History of any treatment failure for the current problem/ history of current contraceptive use may suggest these medications may not be suitable for her treatment options. Her wishes for future fertility is important as this forms the main stay of treatment options with fetlility sparing options. Mode of delivery of her 2 children as previous 2 caesarean section may have implication on current surgical treatment options. (b) Tranexemic acid is effective in controlling blood loss upto 50% but does not help in shrinkage of the size of fibroids and should be preferred to non steroidal anti_inflammatory drugs(NSAID\'s) as NSAID\'s are not effective in the reduction of heavy menstrual bleeding(HMB) due to fibroids. Combined oral contraceptive pills (COCP\'s) can be used if she is considering contraception together with control of HMB and COCP reduces blood loss upto 50% but does not help in shrinkage of the size of the fibroids. High dose oral progestogens should be considered purely for sympotamatic relief of HMB while awaiting other treatment options as this does not again shrink the size of the fibroids and used for 21 days of 28 day cycle. Levonorgesterol intrauterine system (LNG-IUS) can be used if the fibroids is not distorting the uterine cavity and patient wants contraception at the same time. Danazol and gestrinome can be used to reduce the size of fibroids and also to control HMB but both have androgenic side effects which should be explained to the patient prior to starting them and these are potentially used for short term management options. Anti progestestrone like mifeprestone are future treatment option which can cause regression of fibroids and amenorrhoea and no effect on bone but currently not available. Gonadotrophin releasing hormone (GnRH) agonist induces amenorrhoea and shrinkage of fibroids however caessation causes rapid regrowth of fibroids, GnRH agonist is used either prior to surgical treatment options to shrink the fibroids and make it less vascular as it is beneficial in reducing operative morbidity or for those not suitable for surgical option GnRH agoinst can be used with add back therapy(low dose oestrogen-progestrone, progestrone alone or tibolone)for long term use to reduce detrimental effect on bone density. (c) Explain to her abdominal hysterectomy involves removal of the womb through abdominal route. Intended benefit is to remove the fibroids with the womb to stop menstruation. Explain to her the serious risk involved with abdominal hysterectomy are damage to bladder/ or ureter or long term disturbance of bladder function, damage to bowel, haemorrhage, venous thrombosis, pelvic abscess/infection, return to theatre and 2 in 100 women undergoing abdominal hysterectomy will have one of the above serious complications. If these serious risks happen they may require addition procedures or repair to save life or prevent serious harm of future. Antibiotics will be used intraoperatively to prevent infections, thomboembolic deterrent stockings and heparin will be used to prevent thromboembolism Extra procedure required are blood transfusion in haemorrhage, repair of bowel/ bladder if their injuries happen to them. Other non surgical and surgical treatment options like myomectomy, hysteroscopic resection of fibroids, laparoscopic removal of fibroids dependening of patient suitability and available treatment options should be discussed with the patient. Other options like Uterine artery embolisation for fibroids should also be discussed with the patient. She should explained regarding her anaesthetic options and arrangements to see an anaesthetic to discuss all her options. If addional pathology is seen in the ovaies she should be told it is best to remove the same at the same operation and consented for the same. If she has wishes to remove ovaries at the same time this should be documented and consented at the same time. Information leaflet and tape of consultation may be provided for more information to the patient.
		Posted by hoping .. Tue Aug 19, 2008 06:15 am
If she could recall any change that corelates with onset of menorrhagia 2 years ago as she may have come off combined pill which had made her periods lighter or she had coppercoil insterted as it may cause menorrhagia in some women. If she has symptoms of polyuria or pressure symptoms in pelvis, these may suggest fibroid uterus. Any symptoms suggestive of fatigue, palpitations suggest anaemia associated with menorrhagia. Options include Tranexamic acid 1g TDS during menstruation. This is safe and not associated with hormonal side effects. However has limited efficacy in presence of fibroids. Combined pill is effective in reducing menstrual loss. It may not be suitable if she is trying to conceive. Cyclical progestogens are not effective in menorrhagia associated fibroids. Levonorgrstrol containing intrauterine system is effective when fibroids are not larger that 3cm.It has low systemic side effects and avoids hysterectomy in atleast 50% of patients. It serves as contraceptive also. However counselling is vital as irregular bleeding is common for first 6months and leads to request for removal of device in improperly counselled women. Gonadotrophin releasing hormone agonists are effective as lead to ovarian suppresion. These are suitable for short term measure while awaiting definitive treatment as longterm use is asociated with loss of bone mineral density. these lead to shrinkage of fibroid size but reverses on discontinuation of treatment. tHESE ALSO LEAD TO CONSIDERABLE MORBIDITY BECAUSE OF MENOPAUSAL SIDE EFFECTS. She should be informed procedure involves removal of uterus inorder to stop periods. She should be informed of other treatment options like medical as above or endometrial abaltion with their risks and benefits. Advantages and disadvantages of no treatment should also be discussed.Serious and frequent risks of hysterectomy should be discussed. These include injury to bowel. Bladder and ureteric injury is known complication. Major blood vessels injury requiring blood transfusion may occur. Nerve injury is rare but could be irreversible. Risk of any of these happening is about 2 in 100. Possibility of midline incision and subtotal hysterectomy should be discussed. In event of finding suspicious ovarian pathology , advantage of oopherectomy and omental biopsy should also be discussed. She should be informed that surgeon will have adequate expertise in performing surgery or optimal supervision. Her views regarding blood transfusion if required should be obtained. Postoperative risks involve pain, bruising, wound infection and thromboembolic disease. Long term complications include numbness at wound site and/ or incision site hernia .Keloid formation may occur in scar tissue. Vault prolapse is a recognised compliation of hysterectomy. Postoperatively she would have urinary catheter which stays for 24 hours and intravenous fluids until she is tolerating oral fluids. Thromboemblolic deterant stockings and subcutaneous heparin help reduce thromboembolic risk. In straightforward operative and postoperative period she is expected to be discharged between 3rd and 4th postoperative day.
		Posted by Sam M. Tue Aug 19, 2008 11:19 pm
a.She will be asked for her age of menarchae and length of menstrual cycle . Her subjective assessment of blood loss ,history of flooding or passage of clots and its affects on quality of life will be asked . Any treatment taken so far. Type of contraception like IUCD or hormonal are important. Her future desires for fertility will be asked.Family history of cancer of breast , ovaries and endometrium will be inquired..History of smoking is important as it is relatively protective against endometrial cancer but a risk factor for cervical cancer.History of PID and its treatment will be asked. b.There are a medical treatments for treatment of meorrhagia but not for structurally deformed endometrial cavity because of fibroid uterus so are only recommended for those where future fertility is desired. None is with out side effects .These includes mefnamic acid ,tranexamic acid ,OCP ,progestogens ,LNG-IUS ,danazol ,gestrinon and GnRH analogue . Mefnamic acid is taken for menstrual phase of cycle only and it reduces blood loss by 20% even those with IUCD and fibroid associated menorrhagia .It is very effective for menorrhagia associated with dysmenorrhoea which is not her case.It can cause gastric irriatation ,nausea may limit its use for those who are already having gastric irritation. ,.Tranexamic acid reduces blood loss by 50% and need to be taken during menstruation ,it is also effective for IUCD associated menorrhagia ,very effective for fibroid associated menorrhagia.Its use can also cause nausea and vomiting and diarrohea but not VTE .OCP very effectively reduces blood loss and provide contraception as well .Compliance is a problem for daily use of drug through out the cycle .It is relatively contraindicated for her if she has history of smoking and hypertension ,or focal migraine and absolutely contraindicated for history of VTE and thrombophilia .Progestogens in high doses are effective if given between day 4 to 25 of cycle but for uterus having multiple fibroids and distorted endometrial cavity their use is limited. These have side effects of weight gain ,acne, hirsutism, breast discomfort and compliance is issue here as well like OCP .LNGIUS are recommended if endometrial cavity is not distorted.Uterine perforation and lost device are rare complications. Within one year these can cause amenorrhea in 20% of women ,very effective contraceptive as well but irregular pattern for even 6 months or more can cause refusal of further continuation of this and return to fertility is not delayed after its removal.Danazol and gestrinon are not licensed for treatment of menorrhagia though these also reduces blood loss. GnRH analogues are not routinely used for treatment of menorrhagia except for 3 to 6 months for those who are waiting for definitive surgery . Anaemia can be corrected during this time period and fibroids size will be shrinked and operative blood loss will be reduced.Use for morethan 6 months can cause bone mineral loss and symptoms of menopause and need add back HRT therapy cShe will be told that removel of uterus will cause amenorrhoea so complete improvement of symptoms of menorrhagia but future fertility will also be lost.Detailed explanation of procedure from skin incision to closure will be given.Discussion regarding conservation or removal of ovaries will be done. Hysterectomy with preservation of ovaries can cause menopause 2to 3 years earlier than the natural but removal of ovaries will cause very early post operative menopause with severe symptoms and need of HRT will be explained.Removal of ovaries in case of strong family ,history of ovarian, breast cancer and suspicious looking ovaries during surgery are justified if discussed preoperatively and informed cansent is taken .Intraoperative and post operative complications and their treatment will be discussed . She will be explained about the risk of procedure related mortality which is 1:4000.Intraoprative complications as bladder ,ureter ,gut injuries and need of blood transfusion are relatively rare but are serious in nature. Increased length of procedure time for correcting these complications and re surgery for resutring will also be discussed .Some frequent complications as wound haematomas ,delayed healing ,keloid formation ,infection ,frequency of micturation will be discussed .Type of anaesthesia with its advantages and disadvantages will be discussed and if she wishes a meeting with anaesthetist will be arranged .she will be given written information .
		Posted by Iffat ara M. Wed Aug 20, 2008 02:38 am
A):I would ask about LMP, regularity of cycle & about contraceptive usage. As IUCD is mostly associated with heavy menses. I would ask about weakness fatigue, palpitations or shortness of breath for aniaemia .I would ask about any intermenstrual bleeding, dysmenorhea, post coital bleeding. I would enquire about the amount of bleeding either there is flooding or clothing & effect on life including time off work.i would as obout age ofmenarche & H/O anovular infertility, family H/O breast cancer, ovarian cancer which are risk factors for endometrial carcinoma. Previous H/O any treatment. H/O of bleeding after dental treatment which indicate bleeding diathesis. B): Regarding medical treatment:- Tranexamic acid reduces blood loss by 50% & is more effective then NSAIDS. Not associated with risk of DVT. Side effects of nausea, vomiting, diarhoea & disturbance in color vision. NSAIDS- Mefenic acid commonly used to reduce menstrual loss by 25%, have better side effects profile compared to trauexamic acid. Also effective in IUCD associated menorrhagia. Combined oral contraceptive pills reduce blood loss by 50%. Systemic progstogen such as norethisterone or medroxyprogeterone acetate one ineffective in treatment of ovulatory dysfunctional utrain bleeding, especially if given in low doses, when used for 5-10 days in luteal phase. However effective if high doses of norethisterone i.e. 5mg tds daily for three weeks. Depomedroxy progeteron acetate is associated with amenorhoea but there is risk of irregular viginal bleeding. Sequential combined HRT is effective in perimeno pausal women. Levonorgeslrel intra uterine system associated with reduction in meuslrual blood loss of 80%. But there is irregular bleeding during 1st 3-4 months after insertion. GnRH analogue- Result in amenorhoea but are associated with menopausal symptoms & loss of bone minerals density. May be used for short term prior to TCRE, to reduce the size of fibroid prior to myomectomy. Danazole reduces blood loss but it is associated with androgenic side effects like Fatigue, weight gain, acne, hirsuitism, irritability & hot flushes. These side effects are reversible on discontinuation of the therapy. C): About hystectomy I will tell her that it is definite treatment with high satisfactory rate. Surgical morbidity include urinary tract injury, haemorrhage, infection, DVT. Sub total operation may have advantage over total abdominal hystrectromy. She will be informed about regarding conservation or removal of ovaries depending upon her family history of ovarian cancer. In case of bilateral oophorectomy she may need HRT. So written information will be given & wishes of women will taken in to account.
		Posted by Srivas P. Wed Aug 20, 2008 07:23 am
(a) I would enquire about nature of bleeding-its regularity, and effect on her quality of life, the treatments she has received so far and if they have helped. Obstetric history and need for fertility or contraception and her views on preserving or removal of her uterus. H/o smoking will be taken. High risk sexual history like having several partners is relevant when considering IUS as treatment option. I will enquire about family history of endometrial cancers, ovarian cancers or colorectal cancers to assess if she could be part of BRCA1, 2 or HNPCC families. Her cervical smear history should be taken. (b) IUS is effective for treatment of menorrhagia even in the presence of fibroids. It reduces menstrual bleeding by 97% over 12 months and improves her quality of life and should be first option for this woman if immediate contraception is acceptable but wants to retain fertility. It is more effective than oral treatment options for menorrhagia. Complications include irregular bleeding, possible perforation, infection within 20 days of insertion, difficulty in insertion requiring GA/Para cervical block. Some woman may have breast tenderness, head ache and acne. Oral progestogens, COC’s, mefenamic acid, tranexamic acid may provide sufficient symptomatic improvement but generally not effective for HMG with fibroids. COC’s, Oral progestogens are not suitable if she does not want contraception and NSAID and tranexamic acid preferred then. Uterine artery embolizations help shrink fibroids almost 70% by ischemic necrosis but requires experienced interventional radiologists. This technique is not available in all hospitals. If available may be offered as 1st option if HMG with fibroids is severely affecting her QOL. It also potentially allows her to retain fertility. Possible effect if pregnancy does occur still needs evaluation. Complications include fever, infection, sometimes septicemia, persistent vaginal discharge, pain, cramping, hematoma and rarely premature ovarian failure. Antiprogesterones like Mifeprestone can shrink fibroids and cause amenorrhea but studies are in preliminary stage. GnRH analogues significantly reduce size of fibroids and reduce menstrual bleeding. But serious side effects like vertebral bone loss limit its use to 6 months though it can be given for further 6 months by using add back estrogen-progesterone therapy. Uterine volume may decrease by 35% after 3months use. But the effect lasts as long as therapy is given. Hence it is primarily used pre operatively or in perimenopausal woman or when all options including surgery or UAE is contra indicated. Pre operatively improves Hb levels, decreases operative blood loss. Side effects include hot flushes, head ache and vaginal dryness. Danazol and gestrinone are not routinely recommended for HMB die to unfavourable side effects. (c) I would try to find out her reasons for preferring this treatment, her knowledge of the procedure, its benefits and risks and whether she has weighed all other treatment options including medical treatment. I would tell her that it involves removing her uterus and cervix through abdominal incision. Her menstruation will cease but the operation is major and 2/100 woman face serious risks which includes risks of bladder/ ureter injury(7/1000) bowel injury(4/10000) VTE 4/1000 and rarely even death 1/4000. These serious risks may necessitate further surgeries to deal with the complications. She may require blood transfusion as risk of hemorrhage more with fibroids. She may get infected. Hysterectomy may decrease sexual libido, bladder dysfunction and may affect her psychologically. She may have possible loss of ovarian function and premature menopause even if ovaries are retained and may need HRT. I would also tell her about possible other routes of hysterectomy which have advantages and she may like to reconsider. If she is obese vaginal route could be preferred. If she prefers abdominal route both subtotal and total hysterectomy will be discussed with her. Advantages of subtotal operation includes shorter anesthetic and operation time, reduced risk of primary hemorrhage and damage to surrounding structures like bladder and ureters and vault granulations. Potential disadvantages include menstruation from endometrial remnants and need to continue cervical smears. I will also discuss laparoscopic assisted vaginal hysterectomy but it requires appropriate expertise and equipment. If she has significant family history of breast or ovarian cancer she should have genetic counseling prior to a decision about oophorectomy. If oopherectomy is decided then the need for HRT should be discussed. The type of anesthesia should also be discussed with her and her preference if any noted. She should be told that mean length of hospital stay is 7 days with expected return to normal activities within 4-8 weeks. Information leaflet should be given to the woman prior to surgery.
		Posted by San S. Wed Aug 20, 2008 11:59 am
(a) Which information would you obtain from the history? [3 marks] I would like to enquire about the amount of bleeding e.g with clots or flooding,and regularity of her menstrual cycle. It is also useful to know if she had been anaemic to assess severity and the treatment and her response to the treatment given by her GP if any. Any associated symptoms e.g. intermentrual bleed or post coital bleed should be noted. It is also useful to enquire about the mode of delivery of her 2 children and if she is currently on contraception or has she completed her family. Her history of cervical smear is also important noting any previous abnormal smear or precancerous changes. (b) She is found to have a 14 weeks size uterus with multiple intra-mural fibroids. Critically evaluate the non-surgical treatment options [7 marks] Non-hormonal treatment e.g. tranexamic acid is useful to decrease amount of bleeding. It can be used in conjunction with mefenamic acid with coexisting dysmenorrhoea and other hormonal preparations. It can be used if she is still planning for a family. However, it is not good in regulating the menstrual cycle. Hormonal treatments include COCP and norethisterone. COCP is good at regulatingcycle and reducing menstrual bleed. It can be used up to 1 to 2 years after natural menopause if there is no other comorbidity risk factors. It is also an effective contraception. Norethisterone can reduce and regulate menstrual bleed but is less effective than COCP. There is also associated side effects e.g. weight gain, acne, breast tenderness, etc. GnRH analogue is effective but only gives temporary relieve of symptoms i.e. for short term use. It is associated with menopausal symptoms and long term use is associated with osteoporosis. Mirena IUS can decrease menorrhagia significantly and is recommended by the NICE guidelines as 1st line treatment. It is also a reliable contraception but is associated with risk of infection, discomfort and irregular bleeding in the first 6 months after insertion. (c) She wishes to have an abdominal hysterectomy. What will you tell her about this procedure in order to obtain informed consent? [10 marks] I would inform her that this is a major operation involving 5 to 7 days of hospital inpatient stay. She should be aware of alternative treatment options to her symptoms which are associated with lower morbidity and mortality. I would explain the surgical procedure in simple terms and avoid using medical jargons. The benefit of the procedure should be explain. Risks associated including bleeding and necessary blood transfusion and risk of general anaesthetic should be explained. Risk of infection including urinary, chest, pelvic, wound and hospital-acquired infection should be made aware. There is also risk of damage to other anatomical structures e.g. bowels, bladder and ureters which would be repaired during the procedure. There id also increased risk of thromboembolism due to a major operation and immobility which can be fatal. She should be made aware of the risk of voiding, bowel and sexual dysfunction post hysterectomy. There is also an association of early menopause and hysterectomy. She should be given a chance to ask questions related to the procedure. Visual aids and leaflets should be provided.
		Posted by Manoj M. Wed Aug 20, 2008 10:39 pm
A healthy 40 year old mother of 2 children presents with a 2 year history of heavy regular periods but no other symptoms. (a) Which information would you obtain from the history? [3 marks]. (b) She is found to have a 14 weeks size uterus with multiple intra-mural fibroids. Critically evaluate the non-surgical treatment options [7 marks]. (c) She wishes to have an abdominal hysterectomy. What will you tell her about this procedure in order to obtain informed consent? [10 marks] A detailed history regarding any associated pain, dysmenorrhea, dyspareunia needs to be taken as this would suggest endometriosis. A history of intermenstrual or post coital bleeding may be due to infection, submucosal fibroids or polyp. A history regarding her cervical smears needs to be obtained. Her present contraceptive history and details as to whether she considers her family complete is necessary. Her obstetric history, the mode of delivery needs to be considered as this information is important if considering surgical options. Associated medical history like hypothyroidism needs to be considered. The non-surgical options available can be non-hormonal and hormonal. Non-steroidal anti-inflammatory medications are not effective in reducing the blood loss, however anti- fibrinolytics like tranexamic acid is effective in reducing blood loss upto 50%. It can be associated with side efects like diarrhoea and vomiting. Combined oral contraceptives are effective in reducing fibroid associated menorrhagia upto 50% and additionally provides contraception. However any contraindications like venous thromboembolism, smoking, raised BMI must be ruled out. Progesterone only medications like Depo Medroxy progesterone acetate(DMPA) may be considered. It is effective in reducing the blood loss, and reduces the size of the fibroid but can be associated with break through bleeding. Levonorgesytel intrauterine ( Mirena IUS) can be considered; it would gradually reduce blood loss and additionally provide contraception. However if cavity is distorted or in the presence of submucosal fibroids the expulsion rate can be high. Androgens like Danazol can be considered for short term as it is effective in reducing the size of the fibroid and therefore menorrhagia. But the androgenic side effects may be irreversible and therefore not be acceptable for the patient. Gestrinone which is an androgenic anti-progesterone may be acceptable when compared to Danazol due to its reduced side-effects. Gonadotropin releasing hormone analogues can be considered as they are effective in reducing the blood loss, however once stopped the fibroids grow and can become symptomatic again. For this reason usually it is advocated prior to surgical intervention for short term ( 3months). It also produces post menopausal symptoms when used for about 6 months (long term)for which a low dose add back HRT can be used. Medications like Mifepristone are still being used under trial, therefore currently it is not licenced for treatment. Total abdominal hysterectomy involves removal of the uterus through the abdominal route. This would stop her cycles permanently and therfeore she can get relief from menorrhagia. It is done under general anaesthetic. It usually takes less than an hour to perform the operation and if well post operatively she could go home in 3 to 4 days. The serious complications involved would be injury to bowel, bladder or ureter, blood clots- venous thromboembolism, return to theatre for securing haemostasis and pelvic collection for which surgical intervention may become necessary. 2 out of 100 women go through any one of the mentioned serious complication. There is a 1:4000 risk of death as it is an operation. Frequently occurring problems are infection, urinary tract infection, pain, urinary retention. She will be observed post operatively for all the complications and she would have a dose of antibiotics in theatre to minimise the risk of infection. Additional procedures that may become necessary would be removal of one or both ovaries in case of any incidental finding of an abnormality, and blood transfusion if severe blood loss. In case both ovaries are removed she can have HRT post operatively. Subtotal hysterectomy also needs to be discusssed as she is being operated for 14 week sized fibroid. In that case she should be informed that she would need cervical smears and there may be cyclical bleeding. Alternatives to hystercetomy like myomectomy, uterine artery embolsation and medical therapy should also be discussed. Written information should be provided and if she wants to think about it she should be given another appointment for the same.
		Posted by H P. Thu Aug 21, 2008 12:59 am
H (a)I will take menstrual history regarding duration of bleeding, clotting, flooding and its effect on her quality of life. I will inquire about symptoms of iron deficiency anemia like easy fatigue or shortness of breath. I will inquire about her obstetric history, contraceptive history and future fertility plans. I will ask about her cervical smear history which is important if subtotal hysterectomy (STH) is planned. I will inquire if she has received any treatment and whether it was effective. I will inquire about family history of breast/ ovarian cancer which will modify surgical treatment. (b) Tranexemic acid as anti-fibrinolytic reduces heavy menstrual bleeding (HMB) even due to fibroids by upto 50%. It does not reduce fibroid size and has side effects like nausea, vomiting, diarrhoea and disturbed colour vision. NSAIDs are not effective in HMB associated with fibroids. Combined oral contraceptive pills (COCP) are effective in reducing blood loss .Added benefit of contraception. High dose preparations are more effective. But need to take regularly and increased risk of VTE. Both Danazol (synthetic androgen) and Gestrinone (androgenic antiprogesterone) decrease blood loss and reduce size of fibroid. Both have androgenic side-effects and need to be used with barrier contraception as can virilise female fetus. Gestrinone has milder side effects and twice weekly dosage, so can be used for short term. Progestogens do not shrink fibroids but in high doses decrease blood loss. Long term use precluded by side effects of headache, nausea, bloating and breast tenderness. LNG-IUS can be used if the uterine cavity is not distorted and patient wants contraception. However, there is higher rate of spontaneous expulsion and no systematic studies for its use with fibroids. GNRH agonists induce a state of ovarian suppression which causes amenorrhoea and shrinks fibroid. Rapid regrowth occurs after cessation. It causes menopausal symptoms like vagina dryness, hot flushes and loss of bone mineral density. Preoperative use reduces fibroid size and helps correct iron deficiency anaemia with iron supplementation. Add-back therapy with low dose HRT (estrogen+ progesterone) or tibolone prevents bone loss and vasomotor symptoms and allows its use for upto 2 years. Antiprogesterone Mifepristone causes amenorrhoea and reduces fibroid size without bone loss. But it is not currently available for treatment of fibroids. c) I will tell her that abdominal hysterectomy involves removal of the womb by a cut on the abdomen. It will be done by an experienced surgeon. The surgery will stop her HMB and remove fibroids but future fertility will be lost. She will be admitted for about 4-5 days and would be able to resume her normal routine by 6-8 weeks. I would discuss her views about conservation of ovaries. I will explain that at her age removal will cause menopausal symptoms and need for HRT while conserving them may require a further surgery at a later date. In case of any unexpected pathology during surgery, if she consents, ovaries may be removed. I will discuss regarding subtotal vs. total hysterectomy. While subtotal reduces blood loss, operative time and risk of damage to bladder it will necessitate regular cervical screening and may cause cyclical bleeding by few endometrial glands. The effect on bladder function, risk for future prolapse and sexual activity is same. I will explain the procedure to her by visual aids. She will be given prophylactic antibiotics to prevent wound infection and prophylactic heparin injections and stockings to prevent clotting of blood in her veins. I will explain serious risks of bladder/ ureter injury (7/1000), bowel injury (4/1000), need for blood transfusion (15/1000), pelvic infection 2/1000, return to theatre for additional stitches 6/1000 and venous thromboembolism (4/1000). These will need further interventions (blood transfusion) and surgery ( repair of bowel/ bladder) and increase her hospital stay. I will document her view regarding blood transfusion. I will tell her that overall risks are one in 200 women undergoing surgery. The risk of death is rare. I will tell her about frequent risks of wound infection, bruising, delayed wound healing or keloid formation and urinary tract infection. I will tell her about non surgical options for fibroids and information about alternative surgical procedures like laparoscopic assisted vaginal hysterectomy, endometrial ablation, and uterine artery embolizaion. I will tell her about the form of anaesthesia planned and arrange a meeting to discuss with anaesthetist. I will give her information leaflets about the procedure and arrange a further meeting if she has any concerns. I will take her statement regarding any procedure which should not be carried out without further discussion.
		Posted by N K. Thu Aug 21, 2008 01:38 am
(a) Which information would you obtain from the history? [3 marks]. First of all I will ask about the amount of bleeding she has i.e. passage of clots and size, no of sanitary pads or tampons, episodes of flooding if any. It is important to know whether she has any symptoms of anemia or any Hb results from the GP and past and present history of contraception and if any recent change to the regime. Any other treatment tryied in the past is also vital to know. I will also inquire about the impact of this bleeding on her quality of life and whether she is looking for a reassurance or definitive treatment, and also her wish for future fertility. (b) She is found to have a 14 weeks size uterus with multiple intra-mural fibroids. Critically evaluate the non-surgical treatment options [7 marks]. Anti fibrinolitic drug tranexamic acid along with mefanamic acid or other NSAID could be tried. This may be effective in reducing the bleeding but will not reduce the size of the fibroids. and not suitable if asthmatic or with peptic ulcer. A hormonal preparation are acceptable, Mirena is an option, but it will not be suitable for a uterus of 14 weeks size with possible distoted cavity and will have high chances of expulsion and further bleeding problems. She is also not ideally suitable for the option of COCP because of her age associated risks; however she could try this after full counseling regarding associated risks. She may benefit from high dose progesterone regimes such as Norethisterone or Depot preparations for symptomatic relief. However long term effect not good and progesteronic side effects and irregular bleeding makes is less desirable. GnRH analogue could be tried. Menapausal symptoms and bone density loss is the side effects of this treatment. Add back HRT will be needed if longer than 6 months therapy is needed. May be useful reduce the size of fibroids prior to surgery and symptoms can reoccur when stopped. (c) She wishes to have an abdominal hysterectomy. What will you tell her about this procedure in order to obtain informed consent? [10 marks] I will make sure that she has no desire to further fertility and she aware of all the other options and they have failed/ contraindicated ( she is not suitable for endometrial ablation because of her cavity size and mayomectomy/embolisation is indicated only if fibroid size exceed 3cms) or she do not wish to try those. I will discuss with her the possibility of early menopause and the risks of osteoporosis and menopausal symptoms. I will also inquire about her wishes to retain her ovaries. Route of surgery could be vaginal, abdominal, or laparoscopic assisted. This will depend on her suitability and the surgeon’s expertise. I will tell her benefit of the surgery which is amenorrhea. Common risk associated is infection and less common risks are haemorrhage, damage to adjacent organs such as ureter, bowels or bladder and as a result can have urinary dysfunction – incontinence. Rarely, can get DVT or PE and very rare death. Menopausal symptoms if oophorectomy. I will enquire about her ideas about blood transfusion and document it and also possible types of anaesthesia she will have for the surgery, however she will have a chance to discuss this with an anaesthetist. I will also get consent for additional procedures such as repairs if she incurs any which will be done only in her best interest and if unavoidable. I will make sure that she understood everything and document all the discussion in the notes and consent form and get her to sign the form. I will provide her with a copy of the consent form and also written information on hysterectomy.
		Posted by g.b. D. Thu Aug 21, 2008 02:17 pm
A healthy 40 year old mother of 2 children presents with a 2 year history of heavy regular periods but no other symptoms. (a) Which information would you obtain from the history? [3 marks]. (b) She is found to have a 14 weeks size uterus with multiple intra-mural fibroids. Critically evaluate the non-surgical treatment options [7 marks]. (c) She wishes to have an abdominal hysterectomy. What will you tell her about this procedure in order to obtain informed consent? [10 marks] gb a) I will ask for details of any previous investigations and treatments for menorragia . I will ask history of the current contraceptive method being used and her wishes for future fertility.i will ask if she has any positive family history of familial cancers like colon or breast or ovarian cancers. I will ask if there is a history of polycystic ovaries , long standing infertility and its treatments.these cause unopposed ostrogen exposure and predispose to endometrial hyperplasia. I will ask past cervical smear history. b) At age of 40 an endometrial biopsy must be done to rule out endometrial hyperplasia before giving conservative treatments. Tranexemic acid is an antifibrinolytic.It decreases the blood loss by 50%. Nsaids like Mefenamic acid can also be used .They have a advantage of reducing pain but they reduce blood loss by 26-30%. The combination of these two reduces the blood loss by 56-60% and are quite effective as first line treatments. Progestogens like medroxy progesterone acetate and norethisterone can be used in oral / depot preparations .They reduce the blood loss by 60% but can cause sideeffects like bloating mastalgia and weight gain.Breakthrough bleeding can be particularly troublesome. Coc pills can be used for short term in such healthy patients it will reduce the blood loss but have serious sideeffects like thrombosis in 15-20/100,000 patients and they will not reduce the size of fibroids. Another option is GnRh analogues. They cause downregulation of hypothalamic pituitary axis and reduce the blood loss by 75% and more. However their use for long term is precluded by hypoestrogenic adverse effects like vasomotor symptoms and bone density reduction. They can be used for short term in patients waiting for surgery. They shrink the fibroids but regrow again after cessation of treatment. Levonorgesterol IUCD is a good option if there is minimal distorsion of the endometrial cavity. It decreases the blood loss by 80% , cause complete amenorrhea in 30% patients in 1 yr of treatment, and causes high patient satisfaction rates. However the patients do experience progestogenic side effects due to systemic absorption and there is irratic breakthrough bleeding in the initial months. In all the above methods the fibroids are not cured and there is always a possibility of carcinomatous change in them, although rare. c) I will tell her that the surgery involves removal of womb from an incision over her lower tummy. The intended benefir it the remove fibroids and womb and cure memorragia. She will not have menstruation or will not be able to bear children after the surgery. The approximate duration of hospital stay will be 5-7 days. The surgery involves risk complications like bleeding requiring blood transfusion in 2% of patients and I will ask if she has any objections for the same.there is a risk of ureteric and bladder injury in 1-2% of cases and risk of death in 1/4000 women. The surgery will be done by a trained and expert person. It may involve repair of organs like blader or bowel if injured during the operation. There is an option of leaving the cervix behind. This reduces the surgery and anesthesia time and the complications like ureteric or bladder injury associated with the surgery. However she has to follow up with regular cervical smears to rule out precancerous /cancerous change. Normally in healthy women the ovaries are not removed routinely at surgery and hence they will be retained.
		Posted by Farina A. Thu Aug 21, 2008 04:19 pm
A) I would like to know about the extent of impairment of her routine life, any treatment she took and any history of investigation like diagnostic DNC she ever head. Besides symptoms of palpitation tremours, heat intolerance, weight loss and diarrhea goes with the diagnosis of hyperthyroidism. Any history of bleeding disorders is also important to know. B) Medical treatment with mefanemic acid reduces menstrual blood loss upto 25%. Tranexamic acid have been shown to reduce the menstrual blood flow by approximately 40%. Side effect like nausea, vomiting, gastritis and diarrhea usually limits the duration of their use and patient compliance is an important factor in the success of the treatment. Hormonal therapy like 21 days progesterone therapy effectively reduces the menstrual flow however progestational side effect limits long term use. COCPs have been found to be effective and reduces the menstrual blood flow by 50%. Use of danazole and GNRH analogues may reduce the menstrual blood flow, however the use in case of fibroid uterus is limited. Mirena may be use with severely distorted uterine cavity may make its use technically difficult. Newer agents like progestasert is meant for a distorted uterine cavity as it anchors the fundus. LING-IUS is found to reduce the menstrual flow 80-90% with high (85%) patient satisfaction. It has reduces the waiting lists of hysterectomy and 50% of the patient may avoid hysterectomy. Ammenohrrea (40%) and functional ovarian cysts are the common side effect. It is an effective contraception. C) I would like to tell her about the procedure, its intended benefit, inherent risk and risks of not performing the procedure. It is important to tell about the incision, the local hospital statistics regarding the complications. The known incidents of per operative complications are ureteric injury 7 per 1000. Bowel injury is 4 per 10000. Requirement of blood transfusion 15 per 1000. Patient may return to theatre in 6 per 1000 cases and a rare complication of maternal death occurs in 25 per 1million. Possibility of unintended procedures like removal of ovaries, repair of bladder or bowel and colostomy stoma is important to discuss. Patient may not be expecting a catheter post-op so should be informed about. Minor but common complications like wound infection and frequency or retension of urine after removal of catheter should be discuss. Thromboprophylaxis (heparin subcutaneous injections) specially if she is in a high risk category for thromboprophylaxis is important. Patient should be ensured for 100% ammenohrrea rate with total abdominal hysterectomy. Ideally, anesthetic details and appointments should be arranged pre-operatively. Information about her duration of hospital stay and return to work may be required by the patient. All information should be given in black and white and a consent form be signed by the patient, interpreter and the surgeon.
		Posted by SK K. Thu Aug 21, 2008 08:09 pm
a) I would enquire for the severity of bleeding , affection of the quality of life, associated symptoms like dysmenorrhea, intermenstural bleeding as these would guide investigations. I would ask for history of any previous treatment received and their outcome. It is important to know her desires with respect to fertility as this will help in deciding the nature of treatment to be instituted . Her wishes regarding expectant, medical, surgical options should also be noted. I will also go through any previous treatment and investigations notes that she may be carrying. b) non surgical treatment options include both hormonal and non hormonal. However these provide only symptomatic relief and there is risk of recurrence on stopping them. Nonhormonal medications includes antifibrinolytics agents like tranexemic acid. There is 50% decrease in the blood loss. It is relatively well tolerated with sideeffects of nausea, headache. It should be offered as primary line of management. NSAIDS also decrease blood loos by 20 % but are associated with sideeffects frequently like nausea, vomiting, peptic ulcer ,gastritis. Hormonal therapy involves combined oral contraceptives & depo provera. Both of them have proved to be protective against fibroids in the long term. However ther role of depoprovera in reducing blood loss is not well evaluated. At age of 40 years standard COCs are relatively contraindicated and low dose COCs may not attain the intended benfit. However along with provision of protection against fibroids they also provide contraception. LNG IUS does decrease the menstrual blood loos but there is a risk of expulsion due to the distorted uterine cavity. Gestrinone & danazol both are antiestrogenic and antiprogetogenic and do cause a decrease in fibroid size. But danazol is associated with unacceptable androgenic sideeffects. Gestrinone has lesser androgenic profile and may be preferred for short term use. Mifepristone does cause amenorrhea & decrease fibroids growth but is not licensed for use of fibroids. GNRHa use for a period of 3 months without add back or for around 6 months with add back causes a definitive reduction in size of fibroids & menorrhagia.Its use preoperatively has been adovocated as it decreases fibroid size, thereby enabling transverse incision, decreasing blood los s and operation time. However there is a risk of recurrence on stopping the therapy. It is costly and carries risk of bone loss, hot flushes, vaginal dryness when add back is not used. C ) providing detailed information regarding the nature of surgery, options available and risks and benfits is the first step towards obtaining consent. Firstly as patient herself is requesting for abdominal hysterectomy, I would explore the cause of such a request. I would ask her if she is aware of all other options of alternative therapies & surgeries. I would inform her that apart from surgery ,expectant and medical options are also available. If she prefers to have surgery then also she could choose between myomectomy or hysterectomy as per her fertility wishes. I would explain to her that vaginal hysterectomy & laproscopically assisted vaginal hysterectomy, are associated with decreased postoperative morbidities, decreased blood loss, faster recovery, shorter hospital stay. But these procedures will require preoperative use of GNRHa atleast 3 months to shrink the fibroid size. Also I will make her aware of complications of laproscopy. I will proceed to explain to her nature of surgery while comtemplating abdominal hysterectomy. I would give her the option of total hysterectomy v/s subtotal which is associated with lesser operation time, leser blood loss, better preservation of sexual function. But has the disadvantage of continuing cyclical bleeding vaginally, necessitating to continue cervical screening, and difficult repeat surgery. Also I would discuss the issue of oopherectomy in case of detection of intraoperative pathology. She should also be explained & her opinion sought as transeverse & midline incision if necessary. I would inform her of possible intraoperative, potoperative & long term complication due to the procedure. It would necessitate inpatient stay atleast for 4-5 days. The possibility of postponement of surgery in case of unavailability of beds and operative theatre slots should also be priorily informed. It is better to involve her relatives during the briefing .Written consent should be obtained from the patient but she should be informed that she has right to withdraw at any time till before the surgery. Documentation of this detailed briefing will be made.
		Posted by Farkhanda A. Thu Aug 21, 2008 08:40 pm
A---which information would you obtained from the history. I will ask about the heavy periods that if she passes clots or not and if there is any associated pain. This information is to check that heavy periods have any impact on her social life or on daily duties performance. I will also ask about contraceptive method which she is using currently. It may be possible that when she came off the combine contraceptive pills (OCP), then her normal heavy periods which were unmasked with OCP, came back to in normal heavy form. If this is not the case, then it is possible she is having copper intra-uterine contraceptive device in situ which may be cause of her heavy regular periods. I will enquire about any drug history including anticoagulants, which may be responsible of her heavy periods. I will ask about any medical condition such as hypothyroidism or hyperthyroidism. B---Critically evaluate non surgical options of treatment. Non surgical options are medical and mechanical. In medical, it is non hormone and hormonal. In non hormonal tranexamic acid 500mg 6 hourly especially in first 3-4 days reduce menstrual loss by 50%. It also reduces fibroid related menorrhagia. Other option is prostaglandin inhibitors like mefanemic acid . It is useful in reducing blood loss as well as help in relieving dysmenorrhoea, but it is less effective than tranexamic acid and any way this lady has no other symptom other than heavy periods. If this lady has not any contra indication to use of OCP( such as hypertention, headache, migraine, breast cancer, smoking, ect), then she can be given OCP. She can be given progesterone only pills, Medroxiprogesterone acetate depo injection which is very reliable contraception and can control her heavy periods by causing secondry amenorrhea. This form of hormone preparation is not beneficial in 100 % cases and it also cause osteoporosis if used for prolonged periods in this age group which is already near to menopause. Contraceptive progesterone only containing implants can help this woman as in 25-30% women it causes amenorrhea and there is no reported risk of osteoporosis. She can be offered gonadotrophic releasing hormone analogue like ”Zoladex”which will produce pseudo pregnancy state and will give menopausal symptoms, It can be use d for 6 months after that there is need of add back therapy to control her menopause symptoms. No doubt, it suppress ovarian function but still she needs some contraception as there is a risk of pregnancy. Other hormone preparation is danazol. It is very effective in controlling her heavy periods but its use is limited due to its androgenic side effects. In mechanical method, she can be offered fitting of intrauterine system (mirena) after good counselling. Mirena can cause amenorrhea. It may cause irregular bleeding in first 4-5 months and it can only be fitted if uterine cavity is not distorted. Fitting of mirena is invasive procedure and associated with risk of fitting such as perforation, infection, expulsion and cervical shock. C---To take the informed consent. I will tell her that hysterectomy will definitively cure her heavy periods but it is a major procedure. It can be subtotal hysterectomy if multiple fibroids have distorted the cavity and attempt to do total hysterectomy may cause injury to bladder at the time of dissection. Besides this hysterectomy can cause injury to ureters . There is increase risk of vascular injury causing haemorrhage and need of blood transfusion. There may be injury to any nerve in the pelvis and letter on it can cause pelvic organ prolapse. Hysterectomy can unmask concealed urinary incontinence. She needs to inform that on laparotomy if her ovaries are found diseased or any other abnormality, then oophorectomy can be done and if it is bilateral she may need to use hormone replacement therapy(HRT). She needs to warn that by performing hysterectomy, on one side there will be scar on her abdominal wall and on other side even if she has hysterectomy she will have earlier menopause. She will be informed that she will have risk of venous thrombo embolism. To prevent that risk she has to use deterrent stockings and use of heparin at least for 4-5 days until she is is discharged from the Hospital. She will also be informed that there will be a plastic tube in her bladder which will be inserted in the theatre before her operation and removed when she will be mobilised. All these verbal information will be backed by written information in the form of leaflet.
		Posted by Drxyz A. Fri Aug 22, 2008 04:49 am
DRXYZ a) History will be taken about previous menstrual cycle pattern, contraception like IUCD and treatment done for menorrhagia. History of vaginal discharge, lower abdominal pain, dysmenorrhea, dyspareunea. Future fertility wishes b) Among non surgical transemic acid is important as it reduces 50% blood loss due to menorrhagia but it cannot be given if patient has history of VTE. NSAID is less effective than the transamin, it reduces 20% of blood loss. OCPs can be used which can also reduce 50% of blood loss. OCPs cannot be given to the patients, who are smoker, have hypertension or history of VTE. Marina can be used in the fibroid uterus where the endometrial cavity is not distorted. Gastrinon and Danazole can be used but these have low efficacy. GnRH analogue can be used for short term as it can decrease the size of fibroid upto 50%. These are used preoperatively to decrease the size of the fibroid, decrease the blood loss during surgery and change the mode of surgery from abdominal to vaginal. GnRH analogues decrease the bone mass when used for more than 6 months so addback therapy should be given. It can be given to those patients who cannot tolerate major surgery. Uterine artery embolisation can be offered to those patients who don’t wish to conceive. This procedure needs interventional radiological expertise. There is risk of ovarian failure with this procedure. c) Patient will be explained about the procedure that her uterus will be removed by abdominal incision and she will not be able to carry a baby in future and she will not have menstruation in TAH. She will be explained about the risk of bladder, bowel injury and multiple blood transfusions and need of ICU admission. She may have increased surgery time if such complications occur. The types of anaesthesia will be explained and arranged consultation with anaesthetist. Indications for removal or conservation of ovaries will be discussed. Need and risk of HRT in case of oophorectomy will be explained. Patient will be explained about TAH and subtotal hysterectomy. If intra-operatively difficult to remove cervix then subtotal hysterectomy will be decided. Monthly shedding of the cervical endometrium will be explained. To avoid the VTE the use of thromboprophylaxis will be explained. Patient will be given printed information and or video aids about the procedure.
		Posted by Atashi S. Fri Aug 22, 2008 01:40 pm
(a) I will obtain information from history including LMP, age at menarche and contraceptive history, whether she use any IUCD or any other contraceptive .Her future reproductive intention need to be asked. She should be asked whether she has any symptoms of anaemia including fatigue, shortness of breath and palpitation. Subjective assessment of blood loss is to be done by asking her passing of clot, flooding and its effect on quality of life. Cervical smear history need to be asked. (b)Oral iron preparation can be given to her to restore anaemia. Tranaxemic acid can be given which is not so effective in presence of fibroid. Cyclical progesterone is also not effective in case of fibroid. Levonorgesterol containing IUCD is effective in controlling menorrhagia as well as it act as a contraceptive. Gonadotrophin releasing hormone agonist is effective. It induce amenorrhoea and reduce size of the fibroid. It can be used for facilitate surgery but it is associated with side effect like menopausal symptom. Add back therapy is needed to overcome it. Uterine artery embolisation is effective in controlling menorrhagia associated with fibroid. It require technical expertise. (c) I will tell her regarding the procedure and risk &benefit associated with it. It involve removal of uterus through abdominal route. She will lost her reproductive function but it will ensure amenorrhoea. It is a major operation and associated with risk of haemorrhage, injury to vital organ like ureter, bladder. In case of haemorrhage she will require blood transfusion and risk associated with it need to be discussed with her. Whether she prefer total or subtotal hysterectomy need to be discussed after giving her explanation of risk and benefit of removal of cervix. She may need removal of one or both ovary if any pathology is found after opening of abdomen. Informed consent need to be taken for that. Other alternative treatment option need to be informed her like hysteroscopic resection of myoma, momentum and risk &benefit associated with it.
		Posted by Latha H. Sun Aug 24, 2008 12:57 am
MKP First I would ask the detialed menstrual history to ascertain her heavy periods, and how much this problem is interfering with her quality of life. Heavy periods of such long duration may be associated with anaemia, so i will ask history pertaining to this. I will ask her use of any contraception, COCP, IUCD or any medications she has taken for thiscomplaint which will give us an idea about the further use and efficacy of these medications.I will ask in detail her obstetric history, especially mode of delivery, as if previous caesarean will have an implication on surgical management. I will ask her whether she still desires future pregnancy, as any furhter treatment will depentd on this. Any medical history keeping in mind she may need surgery, for anaesthetic fitness, and cervical smear history also to be asked. b) To begin with, one can give her NSAIDS and antifibrinolytoc agents to control her heavy peroids, like tranexamic acid, mefenamic acid. These may cause gastritis, nausea and vomiting.Haemolytic agents like diosmin can also be tried, although nit proven. One can also give her combined OCPs, which may helpreduce her menorrhagia, also has contraceptive benefit. Major side effects include weight gain,risk of thromboembolism.If not tolerated, we can give her progesterone only medications ( pills or injectables) which can be given cyclically, or monthly injections. This may help reduce bleeding, maybe even achieve amenorrhoea,but has side effectslike bloating, breast tenderness. Danazol mayalso be given, helps correct menorrhagia, but has severe androgenic effects like acne, hirsuitism and even change of voice which is irreversible. On the other hand gestrinone, may be better tolerated due to fewer androgenic side effects. GnRH analogues maybe given every 28 days. These act at the hypothalamic pituitary axis and eventually causes amenorrhoea.Longterm use maycause hypoestrogenic side effects, and also bone loss. Addback estrogen given alongwith may help reduce these problems. The disadvantageof GnRH a is that although they shrink the fibroids, once stopped, the fib regrow. Hence they are best used before surgery to reduce the fib size, making them easier to operate. Iron therapy to be given if found to be anaemic. Uterus saving procedure like fibroid embolisation may be attempted, although fertility may be jeopardised, needs expert involvement, radiological assistance and facilities for the same. c) If she wishes to have an abdominal hysterectomy, Iwill explain to her in detail that this is a procedure by which her uterus will be removed by incising her abdomen. Thisis amajor surgery and willbe done by expert, usually may take about an hour. I will explain to her that this surgery carries risk of bladder, bowel injury and excessive bleeding, for which additional surgical procedures may be needed and also there may be need for blood transfusion. Being young we may not remove her ovaries, but depend on intra operative findings, if any major pathology of the ovary/ovaries is detected, one may need to do this also. As the uterus is 14 weeks size, intra operative difficulty may make us resort tosubtotal hysterectomy, where we leave the cervix behind, with its potential consequences of regular cx smear followup, maybe intermittent bleeding, and risk of cx malignancy.
		Posted by Ephia Y. Sun Aug 24, 2008 10:08 pm
A healthy 40 year old mother of 2 children presents with a 2 year history of heavy regular periods but no other symptoms. (a) Which information would you obtain from the history? [3 marks]. From her history information on severity of bleeding and effect on quality of life will be obtained. Her desire for future pregnancies and contraceptive needs will be ascertained. Any prior treatment she has had so far and her wishes and expectations will be identified. (b) She is found to have a 14 weeks size uterus with multiple intra-mural fibroids. Critically evaluate the non-surgical treatment options [7 marks]. The non surgical treatment options depend on severity, her need for future fertility, contraception and wishes. Anaemia is corrected by iron supplementation.The LNG-IUS will not be suitable for her because the size of the uterus is more than 12 weeks. It will also be inappropriate if there is increased distortion as it has increased expulsion rates. Oral progestagens can be used from day 5 to day 26 but effect in reduction of bleeding is not as high as 80% as in DUB. Depot medroxy progesterone acetate can also cause relief by causing amenorrheoa in about 30%. Side effects of progesterone are weight gain, breast tenderness and acne. Oral contraceptives can be used if she wishes contraception but may not be effective in the presence of a large uterus and multiple fibroids. GnRH agonists can be used. It works by causing amenorrheoa in about 80-90%. It will also cause shrinkage of fibroids by 40-60%. However they have menopausal side effects such as hot flushes, night sweats and mood swings. Long term, it carries risk of osteoporosis. Add back therapy can be used to minimise symptoms without reducing efficacy. GnRHa can also be used prior to surgery to reduce size and bleeding. Contraception should be used alongside if she does not wish to be pregnant. Future fertility will not be affected. GnRH is expensive and not appropriate for long term use. Danazol is not used due to side effects. If she wishes pregnancy, tranexamic and mefenamic acid can be used but their efficacy in the presence of fibroids is unknown. Uterine artery embolisation (UAE) can be performed by the radiologist. It is appropriate if she wishes to retain her uterus. Pregnancy is possible after procedure. It is effective in abut 60% cases. It may be less effective if there are multiple small fibroids compared to single large fibroid.There are post procedure side effects like vaginal discharge and fever. Loss of ovarian function can occur in 1% of cases. (c) She wishes to have an abdominal hysterectomy. What will you tell her about this procedure in order to obtain informed consent? [10 marks] The procedure is described to her and that the uterus is removed through an abdominal incision. Benefits are relief of symptoms and appropriate if she wishes total amenorrhoea. Two types of abdominal hysterectomy are available, total where cervix is removed and subtotal where cervix is left intact. The benefit of subtotal is reduced operative time, blood loss and risk of bladder and ureteric injury. However she will need continued screening. Risk of stump carcinoma is about 0.3% and may experience bleeding on and off due to residual endometrium. Effect of no treatment is continuation of symptoms and anaemia. Risk of malignancy very low. Alternatives to surgery are UAE, myomectomy, resection of fibroids and endometrial ablation. The frequently occurring risks of hysterectomy are urinary tract infections, bruising, bleeding. Serious risks are bladder, ureteric and bowel injury which are less than 1%,, thromboembolism, and very small risk of death. Blood transfusion may be required. Unexpected pathology such as ovarian, endometriosis may be detected. Additional procedures that may be required are repair of visceral injury including colostomy. Oophorectomy not performed unless high risk of ovarian cancer and consent obtained beforehand. But ovarian function declines after hysterectomy in about 2 years. Written information is provided
		Posted by H H. Fri Aug 29, 2008 05:03 pm
model answer please