Heavy Menstrual Bleeding

1. A 48-year-old woman had a Mirena IUS inserted 2 years ago for heavy menstrual periods. She was initially amenorrhoeic for almost one and half years but has now developed heavy menstrual bleeding again. Ultrasound done showed Thick endometrium and Endometrial biopsy showed complex endometrial hyperplasia with atypia. The best treatment option is:

2. A 55-year-old woman has been referred to the postmenopausal bleeding clinic following an ultrasound organised by her GP for abdominal bloating. This showed the presence of cystic spaces in the endometrium and an endometrial thickness of 15 mm. She has previously used tamoxifen for 5 years for breast cancer. What is the best management option?

3. A 46-year-old para 2 who has completed her family presents with a history of painful heavy menstrual bleeding in association with infrequent cycles (every 2–3 months) for 1 year. Her BMI is 44. She is currently on iron supplements for anaemia and is prescribed proton pump inhibitors for GORD. She is otherwise fit and well. Abdominopelvic examination is unremarkable. Pelvic ultrasound shows an endometrial thickness of 12 mm with a bulky uterus and normal ovaries with no pelvic pathology. A pipelle biopsy suggests a proliferative endometrium. What treatment is most suited to her?

4. A 46-year-old para 2 woman is referred to your gynaecology clinic complaining of regular but heavy menstrual bleeding which is affecting her quality of life. Which of the following associated features indicates the need for endometrial biopsy?

5. You prescribe hormone replacement therapy (HRT) for vasomotor instability in a healthy 51-year- old woman who has no significant past medical or family history. During her appointment you counsel her regarding the risks of estrogen and progestogen HRT. How many estimated additional cases of breast cancer are there per 1000 women using HRT for five years?

6. A 22-year-old medical student presents with a request for contraception. Her menstrual cycle is irregular, and she complains of acne and hirsutism. Previous investigation has diagnosed polycystic ovary syndrome (PCOS). She wishes to have a combined oral contraceptive with the best risk profile and most impact on her androgenic symptoms. Which one of the following is the best available option to recommend for her?

7. A 16-year-old girl presents to the gynaecology outpatient clinic with primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI 24.7). Breast development is assessed as Tanner stage 2 and her pubic hair is noted to be sparse. Further examination identifies cubitus valgus. She has no other dysmorphic features. What is the most likely diagnosis?

8. A 65-year-old postmenopausal woman attends the clinic having been found to have a 4.9 cm simple cyst arising from the right ovary. There is no other abnormality on scan. Her Ca 125 is 29. She is asymptomatic and the cyst was picked up on investigation for haematuria. What is the most appropriate management?

9. A 17-year-old girl presents with a 12-hour history of lower abdominal pain. She had unprotected intercourse a week ago, which was 6 days after her last period. Her pulse is 110 beats per minute, her blood pressure is 110/70 mmHg, her temperature 37.8°C and she is tender over her lower excitation. Her Hb is 137g/l (normal 115– 165) and her white cell count 17.6 x 10*9/l (normal 4–11). What is the most likely diagnosis?

10. A 16-year-old girl attends the gynaecology clinic for heavy periods and confides that she is being forced to undergo female genital mutilation (FGM) by her parents. What is the estimated number of children at risk of FGM in the UK?

11. A 42-year-old para 2 woman is referred to your gynaecology clinic complaining of regular but heavy menstrual bleeding that is affecting her quality of life. Which of the following investigations is most appropriate at the first clinic visit?

12. A 63-year-old woman with a history of postmenopausal bleeding returns to the gynaecology clinic. Recent endometrial biopsy shows complex hyperplasia without atypia. She wants to know what the risk is of these abnormal cells progressing to cancer. What is the risk of her complex hyperplasia progressing to endometrial cancer over 10 years?

13. A 46-year-old nulliparous woman has been referred by her GP having been treated for heavy regular menstrual bleeding with cyclical progestogens for a period of 6 months. The treatment has failed to improve her symptoms. What is the most appropriate next line of management?

14. A 45-year-old woman is due to have a total abdominal hysterectomy and bilateral salpingo oopherectomy for chronic pelvic pain. You receive a letter from her GP informing you that her recent cervical smear has shown borderline changes in endocervical cells. What arrangement will you make, if any, prior to her admission?

15. A 40-year-old woman has regular heavy menstrual bleeding. The history and investigations indicate that pharmacological treatment is appropriate. Her GP has tried tranexamic acid without success. What is the most appropriate next pharmaceutical treatment?

16. A 67-year-old woman is referred to the rapid access clinic with a 2-day history of postmenopausal bleeding, which has since resolved. She is otherwise fit and well. The endometrial thickness is 7 mm on transvaginal ultrasound scan, the endometrium appears polypoidal at hysteroscopy and histology on an endometrial sample is reported as showing irregular and tightly packed glands with large and vesicular nuclei containing prominent nucleoli. What is the most appropriate management for this woman?

17. A 51-year-old woman attends your clinic with history of severe vasomotor symptoms (hot flushes, night sweats). She has a family history of breast cancer and would like to avoid hormone replacement therapy (HRT). Which non-hormonal medication is most likely to control her symptoms?

18. A 36-year-old parous woman was diagnosed with stage 3 endometriosis. She was on GnRH (gonadotrophin releasing hormone) analogue for 12 months. Subsequently she had laparoscopic excision of recto-vaginal endometriosis. She continues to be in pain despite medical and surgical management. What is the next most appropriate management option for her?

19. A 38-year-old Para 1 has a symptomatic fibroid uterus (5 cm intramural fibroid found on ultrasound scan). She has been commenced on ulipristal acetate 5 mg OD for heavy menstrual bleeding associated with this fibroid. She is keen to avoid surgery at present. What is the electronic Medicines Compendium (eMC) guidance for the maximum permissible dose of ulipristal acetate in the UK for this purpose?

20. A woman who has recently had a uterine artery embolization performed for a fibroid uterus (18 weeks size – intramural and submucous fibroids) presents to the emergency department with fever, nausea, vomiting, and foul-smelling vaginal discharge. Which investigation is best suited to guide further management?

21. Ms XY is a 27-year-old para 0 with a BMI of 22. She presents with a history of post-coital bleeding for 6 months. She feels this is often unpredictable and is affecting her relationship. She is otherwise fit and well. She is using a COCP over the last year for contraception. Gynaecological examination is within normal limits with the exception of a cervical ectropion. Swabs for Chlamydia and an HVS are negative. Smears are upto date and is normal. Pelvic USS shows an endometrial thickness of 10 mm with a normal uterus, rest of the pelvic anatomy being normal. What treatment is most suited to her?

22. 47-year-old woman with complains of a 2-year history of heavy menstrual bleeding. P3L3, all born by normal vaginal deliveries, with regular cycles and the bleeding lasts for 6 days. However, recently it has become associated with clots and flooding. Her BMI is 38, occasionally smokes, living with her partner, and her smears are up-to-date. On vaginal examination revealed stage I cystocele, stage II rectocele and stage II uterine descent. Transvaginal scan done reveals a bulky uterus with endometrial thickness of 8 mm and intramural fibroids measuring 2, 4 and 5 cm size respectively in the anterior and posterior walls of the uterus. The current waiting list for benign gynaecological surgery in your hospital is 4 months. What is the next most appropriate step in her management?

23. 43 years old with 2 previous normal deliveries who has regular menstrual cycles has now presented with few cycles of heavy menstrual bleeding, she does not have any intermenstrual bleeding. She is sexually active and had been treated once for STI at the sexual health clinic. She is working at a beauty salon and this HMB is affecting her work very badly. She gives a history of increase in weight, tiredness but is otherwise active and has no other symptoms. On examination, no abnormalities detected on both abdominal and pelvic examination. What is the investigation of choice?