Revision on cases of Revision on cases of reproductivereproductiveendocrinologyendocrinology

DR MANAL Behery

CASE 1CASE 1

A 23-year-old G0 P0 female presents to the office A 23-year-old G0 P0 female presents to the office with complaints of irregular cycles since with complaints of irregular cycles since menarche. menarche.

She has noticed an increase in facial hair and She has noticed an increase in facial hair and acne for many years. acne for many years.

She denies any history of medical problems and She denies any history of medical problems and has a strong family history of diabetes. has a strong family history of diabetes.

On examination,On examination, ((B P), pulse, respiratory rate, and temperature are B P), pulse, respiratory rate, and temperature are

normal normal She is obese ,her (BMI) 34.She is obese ,her (BMI) 34. She have some hirsutism and acanthosis nigricans She have some hirsutism and acanthosis nigricans

(of neck and inner thighs). (of neck and inner thighs).

Her pelvic examination is normal.Her pelvic examination is normal. She does not desire pregnancy,and her pregnancy She does not desire pregnancy,and her pregnancy

test is negative.test is negative.

➤ ➤ What is the most likely diagnosis? What is the most likely diagnosis? Polycystic ovarian syndrome.Polycystic ovarian syndrome. ➤ ➤ What complications is the patient at risk for?What complications is the patient at risk for? Diabetes mellitus, endometrial cancer, and Diabetes mellitus, endometrial cancer, and

cardiovascular disease.cardiovascular disease. ➤ ➤ What is your next diagnostic step?What is your next diagnostic step? TSH, prolactin, serum testosterone, (DHEA-S), TSH, prolactin, serum testosterone, (DHEA-S),

and, pelvic ultrasound.and, pelvic ultrasound.

➤ ➤ What is your What is your therapeutic plan for this therapeutic plan for this

patient?patient? 1.Regulate menstrual cycles with combination oral 1.Regulate menstrual cycles with combination oral

contraceptivescontraceptives 2. Protect the endometrium from unopposed 2. Protect the endometrium from unopposed

estrogen and reduce risk of endometrial cancerestrogen and reduce risk of endometrial cancer 3. Encourage weight loss and healthy lifestyle 3. Encourage weight loss and healthy lifestyle

changeschanges 4. Induce ovulation when pregnancy is desired4. Induce ovulation when pregnancy is desired 5. Monitor for the development of diabetes and 5. Monitor for the development of diabetes and

cardiovascular diseasecardiovascular disease

A 32-year-old G0 P0 woman is noted to A 32-year-old G0 P0 woman is noted to have irregular menses and hirsutismhave irregular menses and hirsutism

Which of the following is consistent with Which of the following is consistent with polycystic ovarian syndrome?polycystic ovarian syndrome?

A. Elevated 17-hydroxyprogesterone levelA. Elevated 17-hydroxyprogesterone level B. Finding of a 9-cm right ovarian massB. Finding of a 9-cm right ovarian mass C. Vaginal bleeding after a 5-day course of C. Vaginal bleeding after a 5-day course of

progesterone oral therapyprogesterone oral therapy D. DEXA scan showing osteopeniaD. DEXA scan showing osteopenia

A 30 y old women present reporting A 30 y old women present reporting difficulty in becoming pregnantdifficulty in becoming pregnant

She always has irregular menses that regulated She always has irregular menses that regulated with COC pills .with COC pills .

System review reveal occasional palpitations that System review reveal occasional palpitations that she attribute to anxiety attacks.she attribute to anxiety attacks.

She has increased hair growth on face and is She has increased hair growth on face and is overweight, making evaluation of her adnexa overweight, making evaluation of her adnexa difficult.difficult.

In addition to pelvic ultrasound ,appropriate In addition to pelvic ultrasound ,appropriate lab evaluation should include all of the lab evaluation should include all of the following except following except

A –DHEAS and 17 hydroxy progesterone.A –DHEAS and 17 hydroxy progesterone. B –prolactin and TSHB –prolactin and TSH C- insulin function testC- insulin function test D – testosterone and androstendioneD – testosterone and androstendione E – basic metabolic panel E – basic metabolic panel

A 29-year-old G0 P0 woman with a diagnosis of A 29-year-old G0 P0 woman with a diagnosis of PCOS is being counseled about the dangers of PCOS is being counseled about the dangers of her condition. In particular, about the possibility of her condition. In particular, about the possibility of developing metabolic syndrome.developing metabolic syndrome.

Which of the following is the most significant Which of the following is the most significant consequence of metabolic syndrome?consequence of metabolic syndrome?

A. HyperthyroidismA. Hyperthyroidism B. Cardiovascular diseaseB. Cardiovascular disease C. Breast cancerC. Breast cancer D. Renal insufficiencyD. Renal insufficiency

A 28-year-old G0 P0 woman has a chronic A 28-year-old G0 P0 woman has a chronic history of oligomenorrhea,and amenorrhea.history of oligomenorrhea,and amenorrhea.

She undergoes an endometrial biopsy in light of She undergoes an endometrial biopsy in light of her long history of anovulation, which returns as her long history of anovulation, which returns as Grade 1 adenocarcinoma of the endometrium. Grade 1 adenocarcinoma of the endometrium.

MRI imaging seems to indicate that the endome-MRI imaging seems to indicate that the endome-trial cancer is isolated to the uterus. trial cancer is isolated to the uterus.

The patient desires to have children if possible. The patient desires to have children if possible.

Which of the following is Which of the following is the best therapy for this the best therapy for this

patient?patient? AA. Endometrial ablation. Endometrial ablation B. Radical hysterectomyB. Radical hysterectomy C. Cervical conizationC. Cervical conization D. High-dose progestin therapyD. High-dose progestin therapy E. Oral contraceptive agenE. Oral contraceptive agen

Case2 Case2

A 16-year-old adolescent female is referred for A 16-year-old adolescent female is referred for never having menstruated. She is otherwise in never having menstruated. She is otherwise in good health. good health.

She has an older sister who experienced She has an older sister who experienced menarche at age 12 years. She denies menarche at age 12 years. She denies excessive exercise or having an eating aversion. excessive exercise or having an eating aversion. There is no family history of depression. There is no family history of depression.

On examination,On examination, SShe is 50 in tall and weighs 100 lb. The neck is he is 50 in tall and weighs 100 lb. The neck is

supple and without masses. supple and without masses. Her breasts appear to be Tanner stage I, and her Her breasts appear to be Tanner stage I, and her

pubic hair pattern is also consistent with Tanner pubic hair pattern is also consistent with Tanner stage I. stage I.

Abdominal examination reveals no masses. The Abdominal examination reveals no masses. The external genitalia are normal for a prepubescent external genitalia are normal for a prepubescent female.female.

Tanner StagingTanner Staging

Stage1 Stage1 stage2stage2Prepupertal: elevation of Prepupertal: elevation of papilla- no pubic hairpapilla- no pubic hair

Elevation of breast and Elevation of breast and papilla on asmall papilla on asmall mount,increase in areola – mount,increase in areola – libial hairlibial hair

Stage 3 Stage 3 stage4stage4Further breast enlargment,Further breast enlargment,

hair extend to mons pubis hair extend to mons pubis

Secondary mound of areola Secondary mound of areola and papilla ,hair extend and papilla ,hair extend laterllaterl

And increases pigmention And increases pigmention

Stage5 Stage5

Recession of arola to contour of the breastRecession of arola to contour of the breast

Adult pubertal hair with striaght upper Adult pubertal hair with striaght upper bordedborded

➤ ➤ What is the most likely diagnosis?What is the most likely diagnosis? Gonadal dysgenesis (Turner Gonadal dysgenesis (Turner

syndrome).syndrome). ➤ ➤ What is the next step in diagnosis?What is the next step in diagnosis?

Serum follicle-stimulating Serum follicle-stimulating hormone (FSH)hormone (FSH)

Patients with turner’s syndrome Patients with turner’s syndrome will most commonly display which will most commonly display which of the following endocrine of the following endocrine profiles?profiles?

A –elevated TSH ,normal FSH,normal prolactinA –elevated TSH ,normal FSH,normal prolactin B –elevated FSH,normalTSH,normal prolactinB –elevated FSH,normalTSH,normal prolactin C –elevated prolactin,normal TSH,normal FSH C –elevated prolactin,normal TSH,normal FSH D- normal FSH,normal TSH,normal ProlactinD- normal FSH,normal TSH,normal Prolactin

Which of the following Which of the following statement about amenorrhea statement about amenorrhea is the most correct ?is the most correct ? A -A -The majority of amenorrheic patients The majority of amenorrheic patients

have an abnormal physical have an abnormal physical exam ,prolactin or TSHexam ,prolactin or TSH

B – imperforate hymen is the second most B – imperforate hymen is the second most common cause of primary amenorrheacommon cause of primary amenorrhea

C –Gondal dysgensis is the most common C –Gondal dysgensis is the most common causec of primary amenorrheacausec of primary amenorrhea

D –the term hypothalemic amenorrhea D –the term hypothalemic amenorrhea applies to normal GNRH secretion but applies to normal GNRH secretion but elevated FSH level elevated FSH level

The first evidence of pubertal The first evidence of pubertal development in the female is development in the female is

usuallyusually  

a. Onset of menarchea. Onset of menarche b. Appearance of breast budsb. Appearance of breast buds c. Appearance of axillary and c. Appearance of axillary and

pubic hairpubic hair d. Onset of growth spurtd. Onset of growth spurt

The events that occur in changes The events that occur in changes from a child to adult female from a child to adult female usually occur in the following usually occur in the following sequence:sequence: 1 1 Growth spurtGrowth spurt 2 2 Breast developmentBreast development 3 3 Pubic hair growthPubic hair growth 4 4 MenstruationMenstruation

A 15-year-old adolescent female is diagnosed with A 15-year-old adolescent female is diagnosed with gonadal dysgenesis based on delayed puberty, gonadal dysgenesis based on delayed puberty, short stature, and elevated gonadotropin levels. short stature, and elevated gonadotropin levels.

Which of the following is generally present?Which of the following is generally present? A. Secondary amenorrheaA. Secondary amenorrhea B. 69,XXY karyotypeB. 69,XXY karyotype C. Tanner stage IV breast developmentC. Tanner stage IV breast development D. OsteoporosisD. Osteoporosis E. Polycystic ovariesE. Polycystic ovaries

A A 15-year-old adolescent female is brought 15-year-old adolescent female is brought into the pediatrician’s office due to no breast into the pediatrician’s office due to no breast development. development.

The patient’s mother notes that both of The patient’s mother notes that both of patient’s sisters had onset of breast patient’s sisters had onset of breast development at age 10, and also all of her development at age 10, and also all of her friends have already begun menstruating.friends have already begun menstruating.

Examination reveals Tanner stage I breast Examination reveals Tanner stage I breast and pubic/axillary hair, and is otherwise and pubic/axillary hair, and is otherwise unremarkableunremarkable

Which of the following is Which of the following is the most likely the most likely

diagnosis?diagnosis? A. Delayed pubertyA. Delayed puberty B. Development is within normal limits and B. Development is within normal limits and

should be observedshould be observed C. Primary amenorrheaC. Primary amenorrhea D. Likely craniopharyngiomaD. Likely craniopharyngioma

A 16-year-old adolescent female is evaluated for A 16-year-old adolescent female is evaluated for lack of pubertal development. She is diagnosed lack of pubertal development. She is diagnosed with gonadal dysgenesis. with gonadal dysgenesis.

Which of the following laboratory findings is Which of the following laboratory findings is likely to be elevated in this patient?likely to be elevated in this patient?

A. Follicle-stimulating hormone levelsA. Follicle-stimulating hormone levels B. Estrogen levelsB. Estrogen levels C. Progesterone levelsC. Progesterone levels D. Prolactin levelsD. Prolactin levels E. Thyroxine levelsE. Thyroxine levels

A 20-year-old individual with a 46,XY karyotype is A 20-year-old individual with a 46,XY karyotype is noted to be sexually infantile phenotypic female and noted to be sexually infantile phenotypic female and diagnosed as having gonadal dysgenesis.diagnosed as having gonadal dysgenesis.

Which of the following is the most important Which of the following is the most important treatment for this patient?treatment for this patient?

A. Progestin therapy to reduce osteoporosisA. Progestin therapy to reduce osteoporosis B. Estrogen and androgen therapy to enhance heightB. Estrogen and androgen therapy to enhance height C. Progesterone therapy to prevent endometrial C. Progesterone therapy to prevent endometrial

cancercancer D. GonadectomyD. Gonadectomy E. Estrogen therapy to initiate breast developmentE. Estrogen therapy to initiate breast development

Case 3Case 3 A 26-year-old GA 26-year-old G22PP22 woman with LMP= 6 months woman with LMP= 6 months

ago presents with a concern regarding no ago presents with a concern regarding no periods. periods.

She delivered two full term healthy children She delivered two full term healthy children vaginally and their ages are 5 and 3. She stopped vaginally and their ages are 5 and 3. She stopped breastfeeding 2 years ago.breastfeeding 2 years ago.

She has noted a persistent breast discharge, but She has noted a persistent breast discharge, but no breast masses. no breast masses.

Occasional hot flashes. Fatigue. Headaches. Occasional hot flashes. Fatigue. Headaches. Difficulty losing the pregnancy weight gain.Difficulty losing the pregnancy weight gain.

She is not using any contraceptionShe is not using any contraception

Surgical and family history Surgical and family history are are irreleventirrelevent

Past medical history: Past medical history: Postpartum Postpartum depression, which resolved after one year depression, which resolved after one year on an SSRI.on an SSRI.

Physical examPhysical examVS: BP= 120/80, P= 64, R= 18, Ht= 5’8”, VS: BP= 120/80, P= 64, R= 18, Ht= 5’8”,

Wt= 160 poundsWt= 160 pounds

BreastsBreasts: bilateral milky white discharge : bilateral milky white discharge with expression. No masses, dimpling or with expression. No masses, dimpling or retractionretraction

What investigation you What investigation you need to do ?need to do ?

Serum pregnancy testSerum pregnancy test FSH FSH TSHTSH Serum prolactin Serum prolactin MRI pitutary if serum MRI pitutary if serum

prolactin >100 ng/mlprolactin >100 ng/ml

Laboratory/studies:Laboratory/studies: HCG= negativeHCG= negative FSH,TSH are normal FSH,TSH are normal Prolactin= 130 ng/mL; repeat on fasting, Prolactin= 130 ng/mL; repeat on fasting,

100ng/mL100ng/mL MRI of the head reveals a 0.8 cm mass in the MRI of the head reveals a 0.8 cm mass in the

anterior pituitaryanterior pituitary

What is the most likely diagnosis?What is the most likely diagnosis? AmenorrheaAmenorrhea GalactorrheaGalactorrhea Prolactinoma (Pituitary microadenoma)Prolactinoma (Pituitary microadenoma)

What is the best treatment What is the best treatment option option

for her ?for her ? This patient was treated with This patient was treated with CabergolineCabergoline (a (a

dopamine agonist) on a weekly basis and the dopamine agonist) on a weekly basis and the dose was increased until her prolactin level was dose was increased until her prolactin level was in the normal range. in the normal range.

She tolerated the medication well. She tolerated the medication well. She had return of menses within a few months She had return of menses within a few months

time. time. Her galactorrhea slowly resolved. Her galactorrhea slowly resolved.

Case4 Case4

A 42-year-old parous woman has noticed A 42-year-old parous woman has noticed increasing hair growth on her face and abdomen increasing hair growth on her face and abdomen over the past 8 months. over the past 8 months.

She denies the use of steroid medications, She denies the use of steroid medications, weight changes, or a family history of hirsutism. weight changes, or a family history of hirsutism.

Her menses previously had been monthly, and Her menses previously had been monthly, and now occur every 35 to 70 days.now occur every 35 to 70 days.

Her past medical and surgical histories are Her past medical and surgical histories are unremarkableunremarkable

On examination,On examination, thyroid is normal to palpation. thyroid is normal to palpation. She has excess facial hair and male pattern hair She has excess facial hair and male pattern hair

on her abdomen. Acne is also noted on the face. on her abdomen. Acne is also noted on the face. cardiac and pulmonary examinations are normal. cardiac and pulmonary examinations are normal. The abdominal examination reveals no masses The abdominal examination reveals no masses

or tenderness. Examination of the externalor tenderness. Examination of the external genitalia reveals possible clitoromegaly. genitalia reveals possible clitoromegaly. Pelvic examination shows a normal uterus and Pelvic examination shows a normal uterus and

cervix and an 8-cm, right adnexal mass.cervix and an 8-cm, right adnexal mass.

➤ ➤ What is the most likely diagnosis?What is the most likely diagnosis? An ovarian tumor, probable Sertoli–Leydig cellAn ovarian tumor, probable Sertoli–Leydig cell ➤ ➤ What is the probable management?What is the probable management? Ovarian cancer (surgical) staging.Ovarian cancer (surgical) staging.

Ferriman galawey scoreFerriman galawey score

A 6-year-old girl is noted to have breast A 6-year-old girl is noted to have breast development and vaginal spotting. No abnormal development and vaginal spotting. No abnormal hair growth is noted. hair growth is noted.

A 10-cm ovarian mass is palpated on rectal A 10-cm ovarian mass is palpated on rectal examination. examination.

Which of the following is the most likely Which of the following is the most likely diagnosis?diagnosis?

A. Benign cystic tumor (dermoid)A. Benign cystic tumor (dermoid) B. Idiopathic precocious pubertyB. Idiopathic precocious puberty C. Sertoli–Leydig cell tumorC. Sertoli–Leydig cell tumor D. Congenital adrenal hyperplasiaD. Congenital adrenal hyperplasia E. Granulosa-theca cell tumorE. Granulosa-theca cell tumor

A 15-year-old G0 P0 complains ofA 15-year-old G0 P0 complains of increasing hair over her face and chest. increasing hair over her face and chest. She also has a deepening voice and clitoromegaly. She also has a deepening voice and clitoromegaly. There have been two neonatal deaths in the family. There have been two neonatal deaths in the family. Which of the following is the best diagnostic Which of the following is the best diagnostic

test for the likely diagnosis?test for the likely diagnosis? AA. . Testosterone levelTestosterone level B. Dexamethasone suppression testB. Dexamethasone suppression test C. 17-hydroxyprogesterone levelC. 17-hydroxyprogesterone level D. LH and FSH levelsD. LH and FSH levels E. KaryotypeE. Karyotype

Adrenal gland zone and Adrenal gland zone and hormons hormons

Congenital Adrenal Hyperplasia

A 22-year-old nulliparous woman with irregular A 22-year-old nulliparous woman with irregular menses of 7 years’duration complains of primary menses of 7 years’duration complains of primary infertility. She has a family history ofdiabetes. And infertility. She has a family history ofdiabetes. And mild hirsutism on examination. mild hirsutism on examination.

Which of the following is the most likely Which of the following is the most likely therapy?therapy?

A. Cortisol and mineralocorticoid replacementA. Cortisol and mineralocorticoid replacement B. Excision of an adrenal tumorB. Excision of an adrenal tumor C. Surgical excision of an ovarian tumorC. Surgical excision of an ovarian tumor D. Oral clomiphene citrateD. Oral clomiphene citrate E. Intrauterine inseminationE. Intrauterine insemination

A 24-year-old woman complains of A 24-year-old woman complains of bothersome hirsutism and skipping periods.bothersome hirsutism and skipping periods.

She does not have evidence of voice changes, She does not have evidence of voice changes, hair loss, or cli-toromegaly. hair loss, or cli-toromegaly.

The pelvic examination does not reveal adnexal The pelvic examination does not reveal adnexal masses.masses.

The serum DHEA-S, testosterone, The serum DHEA-S, testosterone,

and 17-hydroxyprogesterone and 17-hydroxyprogesterone

Levels are normal.Levels are normal. The LH to FSH ratio is 2:1. The LH to FSH ratio is 2:1.

Which of the following is theWhich of the following is themost likely diagnosis?most likely diagnosis?

AA. Polycystic ovarian syndrome. Polycystic ovarian syndrome B. Familial hirsutismB. Familial hirsutism C. Ovarian tumorC. Ovarian tumor D. Adrenal tumorD. Adrenal tumor E. Cushing syndromeE. Cushing syndrome

Case 5 Case 5 A 46 y old women comes to your office worried A 46 y old women comes to your office worried

about her decreased sexual desire and about her decreased sexual desire and perimenopausal symptoms.perimenopausal symptoms.

Her medical and surgical history are significant Her medical and surgical history are significant only for Rt salpingo oophrectomy 10 years ago.only for Rt salpingo oophrectomy 10 years ago.

On examination you feel Lt adnexal fullness ,and On examination you feel Lt adnexal fullness ,and pelvic sonogram show 8 cm cyst.pelvic sonogram show 8 cm cyst.

After discussion of potential removal of the ovary After discussion of potential removal of the ovary , sho worried that this will leave her without , sho worried that this will leave her without testosteronetestosterone

You tell her that You tell her that A –nearly all testosterone production is from A –nearly all testosterone production is from

her remaning ovary and her concern are her remaning ovary and her concern are justified justified

B –one fourth of her testostrone production is B –one fourth of her testostrone production is from her ovary ,one fourth from her from her ovary ,one fourth from her adrenals,and the remaning half from prepheral adrenals,and the remaning half from prepheral conversionconversion

C –testosterone production is not linked to the C –testosterone production is not linked to the woman’s ovary woman’s ovary

D –given that she is perimenopausal ,she likely D –given that she is perimenopausal ,she likely has testosterone circulating any way has testosterone circulating any way

The patient asks you if she is going through The patient asks you if she is going through menopause which of the following statement is menopause which of the following statement is is the SINGLE best answer is the SINGLE best answer? ?

A –the patient past menstrual history is not A –the patient past menstrual history is not important in reaching diagnosis .important in reaching diagnosis .

B –serum FSH>50 IU/ML is diagnostic of B –serum FSH>50 IU/ML is diagnostic of menopause menopause

C- serum estradiol level <0.11 mmol /L C- serum estradiol level <0.11 mmol /L indicate ovarian failure indicate ovarian failure

D –Teastosterone level <60% decline is the D –Teastosterone level <60% decline is the best predictor of menopause best predictor of menopause

50 years old healthy women present to the 50 years old healthy women present to the office for routine gynecologic visit office for routine gynecologic visit complaining of new onset episodes of complaining of new onset episodes of intense heat through her neck and chest intense heat through her neck and chest followed by profuse sweating.followed by profuse sweating.

This episodes interfere wake her up from This episodes interfere wake her up from sleep and interfere with her ability to work sleep and interfere with her ability to work

What is the most effect What is the most effect therapy for her therapy for her

symptoms symptoms A –Venlafxine(sertonine reuptake inhibitors)A –Venlafxine(sertonine reuptake inhibitors) B –ClonidineB –Clonidine C –Estrogen replacement C –Estrogen replacement D- progesterone D- progesterone

Cause of hot flushesCause of hot flushes•Caused by noradrenalin, which disturbs the Caused by noradrenalin, which disturbs the thermoregulatory system.thermoregulatory system.

•Oestrogen deficiency reduces hypothalamic Oestrogen deficiency reduces hypothalamic endorphins, which release more endorphins, which release more norepinephrine and serotonin.norepinephrine and serotonin.

•This leads to inappropriate heat lossThis leads to inappropriate heat loss

mechanism.mechanism.

A 58 years old ,healthy G0P0 A 58 years old ,healthy G0P0 comes to your office complaning comes to your office complaning about her vaginal bleeding about her vaginal bleeding She reports hot flushes and mood swings She reports hot flushes and mood swings

starting about 10 years age.starting about 10 years age. She stopped bleeding a few years ago and then She stopped bleeding a few years ago and then

started having irregular peroids 6 months agostarted having irregular peroids 6 months ago The most likely diagnosis isThe most likely diagnosis is A –endometrial polypA –endometrial polyp B –endometrial hyperplasia B –endometrial hyperplasia C- endometrial cancer C- endometrial cancer D – endometrial atrophyD – endometrial atrophy

57 years old Aferican Aamerican woman has 57 years old Aferican Aamerican woman has been 7 years ago.been 7 years ago.

She denies any medical problems but had She denies any medical problems but had fracture hip 2 years ago fracture hip 2 years ago ..

On examOn exam: : she is 5 feet,5 inches tall,and 165 she is 5 feet,5 inches tall,and 165 pounds weightpounds weight

PV:PV: slightly atrophic vaginal mucosa and slightly atrophic vaginal mucosa and otherwise normal exam otherwise normal exam

You give this patient You give this patient referal for DEXA because referal for DEXA because

of her of her A- raceA- race B – postmenopausal state combined with B – postmenopausal state combined with

physical exam findingphysical exam finding C – history of a fracture C – history of a fracture D – height and weight D – height and weight

Case 7Case 7 A 58 – year old women .menopause 6 – 7 years A 58 – year old women .menopause 6 – 7 years

ago. ago.

2 months ago she had a few days of vaginal 2 months ago she had a few days of vaginal bleeding which was like the end of period and bleeding which was like the end of period and since then she has continued to spot most days.since then she has continued to spot most days.

She has no pain or any associated symptoms.She has no pain or any associated symptoms.

She has never been on hormone replacement She has never been on hormone replacement therapy (HRT).therapy (HRT).

Case 6 7

What are the most likely What are the most likely causes causes

of her bleeding? of her bleeding? Endometrial cancer Endometrial cancer • • Atrophic vaginitis Atrophic vaginitis • • Local cervical lesion Local cervical lesion • • Cervical cancer Cervical cancer • • Iatrogenic Iatrogenic • • Chlamydia i n f e c t i o Chlamydia i n f e c t i o

nn

What further questions What further questions would help to establish the would help to establish the

diagnosis?diagnosis? A -woman ' s last normal menstrual period.A -woman ' s last normal menstrual period. B -amount and duration of bleedingand any B -amount and duration of bleedingand any

associated symptoms. associated symptoms. C -Try to clarify the site of bleeding to C -Try to clarify the site of bleeding to

confirm that it is vaginal and not rectal or confirm that it is vaginal and not rectal or urinary urinary

D -Drug like tamoxifen or HRT D -Drug like tamoxifen or HRT E -all of the above E -all of the above

On examinationOn examination Her vulva is normal and she has mild Her vulva is normal and she has mild

atrophic changes of her vagina and her atrophic changes of her vagina and her cervix. cervix.

She has some laxity of the vaginal walls but She has some laxity of the vaginal walls but no signifi ant prolapse. no signifi ant prolapse.

She has a small anteverted mobile uterus. She has a small anteverted mobile uterus. You are unable to feel any adnexal massesYou are unable to feel any adnexal masses

What further What further investigations investigations must you now consider? must you now consider?

Transvaginal ultrasound scanningTransvaginal ultrasound scanning Report of TV US results The uterus contains a Report of TV US results The uterus contains a

regular thickening measuring 8 mm regular thickening measuring 8 mm thickness. thickness.

(This could represent a polyp). (This could represent a polyp).

Neither ovary can be identified and there are Neither ovary can be identified and there are no adnexal masses or free fluid.no adnexal masses or free fluid.

What do you do next?What do you do next? As her endometrial thickness is > 4 mm, she As her endometrial thickness is > 4 mm, she

requires further investigation. requires further investigation. 1- Saline sonohystrography1- Saline sonohystrographybetter delination of cavitybetter delination of cavity

2-2- Endometrial biopsy. Endometrial biopsy.

However If the scan finding However If the scan finding

represents a polyp, it is unlikely to represents a polyp, it is unlikely to

be removed by EB. be removed by EB.

3- Hysteroscopy.3- Hysteroscopy.

Allows direct inspection of the endometrium.Allows direct inspection of the endometrium. It is a sensitive means of identifying polyps It is a sensitive means of identifying polyps

and submucous fibroid .and submucous fibroid . It can be used in the outpatient setting It can be used in the outpatient setting

using a paracervical block for anaestheticusing a paracervical block for anaesthetic

At hysteroscopyAt hysteroscopy the cervical canal is normal,the cervical canal is normal, the uterine cavity is smooth andthe uterine cavity is smooth and

regular with a fundal polyp. regular with a fundal polyp. Both uterine coruna are seen. Both uterine coruna are seen. The polyp is removed using biopsy forceps and sent The polyp is removed using biopsy forceps and sent

for histology for histology The pathology report confirms a simple endometrial The pathology report confirms a simple endometrial

polyp with no evidence of hyperplasia or malignancy. polyp with no evidence of hyperplasia or malignancy.

Patient agrees to have an outpatient hysteroscopy with a paracervical block.

Pt does not require any further treatment. Pt does not require any further treatment. Polyp formation after the menopause can be Polyp formation after the menopause can be

related to tamoxifen or oestrogens. related to tamoxifen or oestrogens. As she is not on HRT this may be related to As she is not on HRT this may be related to

obesity because of peripheral conversion of obesity because of peripheral conversion of androgens (androstenidione) in subcutaneous fat androgens (androstenidione) in subcutaneous fat to oestrogens.to oestrogens.

Polyps may recur but there is no need for follow Polyps may recur but there is no need for follow up up ..

Is any further management required?

Imaging of 38 ys old G2p2,with post Imaging of 38 ys old G2p2,with post menstrual spotting ,Is best performed menstrual spotting ,Is best performed by which of the following?by which of the following?

A –TVS alone,because this is abettorA –TVS alone,because this is abettor

diagnostic tool in perimenopausal womendiagnostic tool in perimenopausal women

B –saline infusion sonography as it is the most B –saline infusion sonography as it is the most

senstive non invasive to diagnose polyp.senstive non invasive to diagnose polyp. C – CT scan of the pelvis due to its ability to C – CT scan of the pelvis due to its ability to

diagnose rtiologiesdiagnose rtiologies D –hematology consult ,giving your high suspecion of D –hematology consult ,giving your high suspecion of

coagulopathy coagulopathy

A 43 ys old G1P1 with morbid A 43 ys old G1P1 with morbid obesity ,hypertension ,and COPD obesity ,hypertension ,and COPD comes to office complaning of heavy comes to office complaning of heavy vaginal bleeding vaginal bleeding Work up reveals normal lab work, ultrasound, and Work up reveals normal lab work, ultrasound, and

Endometrial biopsy.The patient desires the safest long Endometrial biopsy.The patient desires the safest long term management of her bleeding.term management of her bleeding.The best option is The best option is

A –OCP taper and then long term OCP useA –OCP taper and then long term OCP use B –NSAID because they reduce menstrual volume B –NSAID because they reduce menstrual volume

by 80-90%by 80-90% C -Admission to hospital for hystrectomy C -Admission to hospital for hystrectomy D –discussion and placement of Mirna IUDD –discussion and placement of Mirna IUD