Gynaecology Pg No 71 -80
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Questions and Answers

What is the recommended action when endometrial thickness is greater than 12 mm in a reproductive age female with normal ultrasound and persistent bleeding?

  • Start hormone therapy
  • Administer tranexamic acid
  • Schedule a follow-up ultrasound
  • Perform an endometrial biopsy (correct)

    • The average age of menopause is the same in India and worldwide.

    False

    What is the gold standard for diagnosing endometrial pathology in postmenopausal females?

    Fractional curettage and hysteroscopy

    In perimenopausal women, the age considered for menopause is typically over ______ years.

    <p>40</p> Signup and view all the answers

    Match the following drugs to their general use for the management of AUB:

    <p>Tranexamic acid = Control menstrual bleeding OCP = Hormonal regulation Progesterone = Menstrual cycle regulation</p> Signup and view all the answers

    Which of the following is NOT a cause of abnormal uterine bleeding in a pubertal female?

    <p>Diabetes</p> Signup and view all the answers

    Urgent ultrasound (USG) is mandatory for investigating abnormal uterine bleeding in pubertal females.

    <p>False</p> Signup and view all the answers

    What initial treatment is recommended for severe bleeding with hemoglobin less than 8 g/dL?

    <p>IV estrogen (high dose) or Ethinylestradiol</p> Signup and view all the answers

    For mild bleeding with hemoglobin levels between 10-12 g/dL, patients should maintain a __________.

    <p>menstrual diary/calendar</p> Signup and view all the answers

    Match the treatment regimen with its severity:

    <p>Mild Bleeding = Oral iron tablets and reassurance Moderate Bleeding = Combined Oral Contraceptives Severe Bleeding = IV estrogen treatment or Ethinylestradiol Treatment for all AUB = Tranexamic acid, OCP, or Progesterone only</p> Signup and view all the answers

    What is the primary mechanism of action of Ormeloxifene?

    <p>Antagonizes the effect of estrogen on the endometrium</p> Signup and view all the answers

    Hysterectomy is indicated for all females with Atypical Uterine Bleeding.

    <p>False</p> Signup and view all the answers

    What is the dosage of IV Estrogen/Ethinyl estradiol for managing severe bleeding?

    <p>50 mg x 5 days</p> Signup and view all the answers

    Endometrial ablation can destroy the endometrial lining up to ____ mm deep.

    <p>6</p> Signup and view all the answers

    Match the following surgical management techniques with their indications:

    <p>Endometrial ablation = Severe AUB Uterine arterial embolization = Fibroid Hysterectomy = Concomitant uterine pathology IV Estrogen = Severe bleeding management</p> Signup and view all the answers

    What is the most common cause of precocious puberty?

    <p>Idiopathic</p> Signup and view all the answers

    Peripheral precocious puberty is characterized by premature activation of the HPO axis.

    <p>False</p> Signup and view all the answers

    Name one psychological consequence of precocious puberty.

    <p>Psychological and emotional stress</p> Signup and view all the answers

    In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.

    <p>GnRH</p> Signup and view all the answers

    Match the following types of precocious puberty with their characteristics:

    <p>Central/True = Increased estrogen due to HPO axis Peripheral = Increased estrogen and/or androgen with negative feedback</p> Signup and view all the answers

    Which of the following statements about estrogen in precocious puberty is correct?

    <p>There is an increase in estrogen in both types of precocious puberty.</p> Signup and view all the answers

    In peripheral precocious puberty, FSH and LH levels are significantly increased.

    <p>False</p> Signup and view all the answers

    What is a common risk associated with the underlying causes of precocious puberty?

    <p>Underlying health problems</p> Signup and view all the answers

    Which of the following describes the mechanism of action of progesterone?

    <p>Decreases endometrial shedding and downregulates estrogen receptors</p> Signup and view all the answers

    Oral progesterone should be administered for 1 week without interruption for effective treatment of AUB.

    <p>False</p> Signup and view all the answers

    What is the preferred treatment for thick endometrium with estrogen upregulation?

    <p>Combined Oral Contraceptives (OCP)</p> Signup and view all the answers

    The Mirena is a progesterone-releasing ______ that causes endometrial atrophy.

    <p>IUCD</p> Signup and view all the answers

    Match the treatment with its indication for AUB:

    <p>Combined Oral Contraceptives = Thick endometrium, estrogen upregulation Progesterone only = Thin endometrium or prolonged/severe bleeding IUCD: Mirena = Relief from AUB in 30-40% of cases Cyclical progesterone = Anovulatory DUB support</p> Signup and view all the answers

    What is the primary function of tranexamic acid in the management of abnormal uterine bleeding (AUB)?

    <p>Antifibrinolytic agent</p> Signup and view all the answers

    Mefenamic acid is typically the first-line treatment for AUB.

    <p>False</p> Signup and view all the answers

    At what average age do females typically experience the onset of puberty?

    <p>10.5 years</p> Signup and view all the answers

    What is the dose of tranexamic acid prescribed for treating AUB?

    <p>1 gm thrice daily for 3-4 days</p> Signup and view all the answers

    Males typically experience their growth spurt earlier and for a shorter duration than females.

    <p>False</p> Signup and view all the answers

    OCPS provide contraceptive benefits when started between days __ to __ of the menstrual cycle.

    <p>1, 5</p> Signup and view all the answers

    Match the following drugs to their mechanisms of action:

    <p>Tranexamic acid = Antifibrinolytic Mefenamic acid = Prostaglandin receptor blocker Ethamsylate = Reduces capillary fragility OCPS = Hormonal regulation of menstrual cycle</p> Signup and view all the answers

    What is the first visible sign of puberty in females?

    <p>Breast budding</p> Signup and view all the answers

    The average age for menarche in females is ______ years.

    <p>12.5</p> Signup and view all the answers

    Match the following features with the correct gender:

    <p>1st sign: Growth spurt = Females 1st visible sign: Breast budding = Females Appearance of pubic hair = Both Menarche = Females</p> Signup and view all the answers

    What characterizes the initial phase of the menstrual cycle?

    <p>Anovulatory</p> Signup and view all the answers

    Irregular menstrual cycles are typically painless.

    <p>True</p> Signup and view all the answers

    What is the term used for menstruation that occurs earlier than expected?

    <p>Precocious Menstruation</p> Signup and view all the answers

    Heavy bleeding during the menstrual cycle is often described as ______.

    <p>Menorrhagia</p> Signup and view all the answers

    Match the following terms related to the menstrual cycle with their definitions:

    <p>Anovulatory = Not involving ovulation Irregular = Not following a consistent cycle Heavy Bleeding = Excessively prolonged bleeding Painless = Without associated pain</p> Signup and view all the answers

    What is the primary advantage of using continuous progesterone in the treatment of AUB?

    <p>Reduces the need for hysterectomy</p> Signup and view all the answers

    Blood transfusions are only indicated for patients with hemoglobin levels below 7 g/dL.

    <p>False</p> Signup and view all the answers

    What is the maximum duration for the use of GnRH analogues in managing AUB?

    <p>6 months</p> Signup and view all the answers

    In cases of AUB with persistent bleeding, blood transfusion may be necessary if hemoglobin levels drop below _______ g/dL.

    <p>7</p> Signup and view all the answers

    Match the following conditions with their corresponding hemoglobin thresholds for transfusion:

    <p>Puberty menorrhagia = &lt; 7 g/dL Stable vitals pre-surgery = &lt; 10 g/dL Severe anemia = &lt; 5 g/dL</p> Signup and view all the answers

    What is the primary change that occurs in the body during puberty?

    <p>Development of secondary sexual characteristics</p> Signup and view all the answers

    The HPO axis remains inactive throughout childhood until puberty.

    <p>True</p> Signup and view all the answers

    What role does adipose tissue play in puberty?

    <p>Adipose tissue converts androgens to estrogen via aromatase.</p> Signup and view all the answers

    In central precocious puberty, there is an increase in __________ due to activation of the HPO axis.

    <p>gonadotropins</p> Signup and view all the answers

    Match the following components of puberty with their descriptions:

    <p>GABA = Inhibitory neurotransmitter that keeps the HPO axis dormant Androgens = Produced by the adrenal gland during puberty Aromatase = Enzyme that converts androgens to estrogen Neuropeptide Y = Another inhibitory neurotransmitter in childhood</p> Signup and view all the answers

    Study Notes

    Precocious Puberty

    • Two Types: Central/True (80%) and Peripheral (20%)
    • Central/True: Premature activation of hypothalamic-pituitary-ovarian (HPO) axis
    • Peripheral: Not related to HPO axis; ovary/adrenal gland
    • Central/True: ↑ GnRH → ↑ FSH, ↑ LH → ↑ Estrogen
    • Peripheral : ↑ Estrogen/↑ Androgen → Negative feedback → ↓ FSH, ↓ LH
    • Central/True: Depends on Gonadotropin, FSH, LH, and Estrogen levels
    • Peripheral: Does not depend on Gonadotropin, FSH, or LH levels; Estrogen or Androgen levels are elevated
    • Central/True: Premature Ovulation
    • Peripheral: No premature Ovulation
    • Central/True: May have psychological and emotional stress, Estrogen exposure at a young age, and risk related to the underlying cause

    Atypical Uterine Bleeding (AUB)

    • Investigatory Algorithm for Atypical Uterine Bleeding (AUB) depends on age
    • Reproductive Age: Endometrial thickness > 12mm
    • High Risk Factors for AUB: PCOS, granulosa cell tumor, obesity
    • Perimenopausal:
      • Menopause: India (47 years) | Worldwide (51 years)
      • Perimenopause: Over 40 years (FOGSI) | Over 45 years (ACOG)
      • UPT (regardless of ultrasound) → TVS + Endometrial Biopsy
    • Postmenopausal:
      • Endometrial thickness < 4mm: Tranexamic acid + Bleeding
      • Endometrial thickness ≥ 24mm: Endometrial biopsy
      • Fractional Curettage + Hysteroscopy: Gold standard for endometrial pathology
    • Fractional Curettage + Hysteroscopy done under general anesthesia (GA) in the operating theater (OT)

    Management of AUB

    • Drugs:
      • Tranexamic acid
      • OCP (oral contraceptive pills)
      • Progesterone

    Pubertal Menorrhagia

    • Abnormal uterine bleeding (AUB) in a pubertal female
    • Causes: Amenorrhea, coagulation defect, thyroid dysfunction

    Management of Pubertal Menorrhagia

    • History
    • Physical examination
    • Per vaginal examination (contraindicated in virgins)

    Investigations

    • Ultrasound (USG): Not mandatory
    • Routine investigations
    • Urine pregnancy test (UPT): If sexually active

    Treatment

    • Three drugs for any AUB:
      1. Tranexamic acid
      2. Combined Oral Contraceptives (OCP) (estrogen + progesterone)
      3. Progesterone only

    Mild Bleeding (Hb: 10-12 g/dL)

    • Oral iron tablets
    • Reassurance
    • Maintain menstrual diary/calendar

    Moderate Bleeding (Hb: 8-10 g/dL)

    • Combined Oral Contraceptives (OCP)
    • Maintain regular menstrual cycle

    Severe Bleeding (Hb < 8 g/dL)

    • Initial treatment: IV estrogen (high dose) - unavailable in India
    • Alternative: Ethinylestradiol (50mg x 5 days)
    • Or combined oral contraceptives (OCP) (20-30mg estrogen), 2 days every 8 hours, for 5 days every 12 hours, for 2 weeks, followed by maintenance dose
    • Maintenance:
      • Progesterone pills (OD: daily during menstruation cycle) D5 (5th day of period) x 6 cycles
      • OCP (OD): D25 x 6 cycles
      • Progesterone - 1 day every 24 hours of the cycle x 6 cycles

    Ormeloxifene

    • Obsolete
    • Selective estrogen receptor modulator (SERM)
    • MOA: Antagonizes the effect of estrogen on endometrium → Atrophy
    • Dose: 60mg twice daily x 12 weeks

    Surgical Management

    1. Endometrial ablation:
      • Uterine arterial embolization:
        • Indication: Fibroid
    2. Hysterectomy: In perimenopausal female with concomitant uterine pathology

    Scenario

    • Indications: Both conditions to be fulfilled:
      • a. Failure of medical mx
      • b. Complete family
    • Severe bleeding x 15 days
    • USG: N
    • UPT: -ve
    • Endometrial biopsy: N

    Medical Management

    • IV Estrogen/Ethinyl estradiol: 50mg x 5 days (If/b)
    • Progesterone
    • OCPS:
      • First 2 days: 4 - 8th hourly
      • Next 5 days: 12th hourly
      • Next 14 days: Once daily

    Endometrial Ablation

    • Endometrial lining destroyed upto 4-6mm deep
      • 1st Generation:
        • Rollerball, laser, TCRE
        • Done under hysteroscopic guidance → Increased risk of fluid
      • 2nd Generation:
        • Cryosurgery, hydrothermal ablation
        • Not done under hysteroscope → No risk of fluid overload

    Contraindications (C/I)

    • Pregnancy
    • Incomplete family/Desires pregnancy
    • Endometrial hyperplasia/Cancer
    • Active pelvic infection
    • UCCD

    Tranexamic Acid

    • Antifibrinolytic
    • Reduces AUB by 50%
    • Dose: 1 gm thrice daily x 3-4 days
    • Well tolerated in cyclical bleeding with normal size uterus

    Mefenamic Acid

    • Prostaglandin synthetase inhibitor
    • MOA: Blocks prostaglandin receptor
    • AUB/Dysmenorrhoea: Mediated by prostaglandin
    • Indication: C/O AUB + Dysmenorrhoea
    • Usage:
      • Not used as 1st line drug
      • Used with tranexamic acid
    • Dose: 500mg thrice daily

    Ethamsylate

    • ↓ Capillary fragility
    • Not effective in mixed AUB

    OCPS

    • Estrogen (E) + Progesterone (P)

    • Stabilize endometrium - ↓ Bleeding

    • -ve feedback on LH, FSH → Anovulation

      • → contraception
      • → suppression of ovaries

    • Pack of 21 tablets

    • For contraceptive benefit:

      • Started between D1 to D5 of cycle → 21 days → Progesterone withdrawal → Bleeding → Repeat cycle

    • In AUB:

      • Hb < 10 g/dL ↓ (causes anemia)
      • Hb ≥ 10 g/dL (normal level)

    • Continuously for 3 months:

      • Advantage:
        • Control blood loss
        • Regularise cycles (DOC by regularising cycles: OCP)
        • Contraceptive benefit
      • 3 weeks of ocp f/b 1 week off x 3 cycles

    MOA (OCPS)

    • Estrogen (e): Upregulates progesterone receptors on the endometrium
    • Progesterone (P): Acts only on primed endometrium; downregulates estrogen receptors on endometrium

    Indications of Drugs for AUB

    Condition Treatment
    Thick endometrium, estrogen upregulation of progesterone(+) Combined Oral Contraceptives (OCP)
    Thin endometrium or prolonged/severe bleeding Progesterone only

    Progesterone

    • MOA:
      • Supports the endometrium, decreasing shedding
      • Downregulates estrogen receptors, leading to less blood loss
      • (If given continuously) Results in endometrial atrophy
      • Protects the endometrium from the proliferative effects of estrogen

    Supplementation

    • Oral Progesterone/Cyclic Progesterone: Effective in treating AUB
    • Continuously for 3-6 months (without interruption): This method results in endometrial atrophy. Preferred mode of therapy for AUB.
    • IUCD: Mirena:
      • Progesterone-releasing intrauterine device
      • Causes endometrial atrophy
      • Relief from AUB occurs in 30-40% of cases

    Puberty and Precocious Puberty

    • Growth Spurt:
      • Females: Earlier and shorter
      • Males: Later and longer
      • Same until 10.5 years

    Puberty in Females vs Males

    Feature Females Males
    Age 10.5 years 11.5 years
    Sequence 1st sign: Growth spurt (Skeletal growth) * 1st visible sign: Breast budding (Thelarche: most specific) * Appearance of pubic & Axillary hair (pubarche) * Peak height velocity (6 months) * Menarche (12.5 years) * 2° sexual characters appear Growth spurt (Skeletal growth) * Appearance of pubic & Axillary hair (pubarche) * Increase in testicular size (most specific sign) * Penis growth * Peak height velocity (14 years) * Change in voice * Facial hair * 2° sexual characters appear

    Menstrual Cycle

    • Initially: Anovulatory
    • Irregular
    • Heavy Bleeding
    • Painless
    • Precocious Menstruation: Menstruation before 10 years of age

    Preferred Treatments for AUB

    • For:
      • Reproductive age females
      • Perimenopausal females
    • To prevent endometrial proliferation
    • Advantages:
      • Good compliance
      • Reduces the need for hysterectomy
    • If patient refuses continuous progesterone: Minimum 12 days/month of protective effect is required

    SPECIFIC MANAGEMENT of AUB

    • Structural Lesion:

      • Mx of Cause: Bleeding controlled
      • Oral iron + Maintenance drugs

    • Non-structural Lesion:

      • Bleeding persists:
        • Blood transfusion (if needed)
        • Second-line medical mx (or) Sx

    Indications for Blood Transfusion

    • Puberty menorrhagia: Hb < 7 g/dL
    • Hb < 5 g/dL or unstable vitals
    • Before planned surgery (Sx): Hb < 10 g/dL

    Second-line Drugs for Medical Management

    • GnRH analogues:
      • ↓ LH, FSH, ↓ E on continuous administration:
        • ↓ Endometrial proliferation
        • ↓ blood loss
    • Disadvantages:
      • Expensive
      • Menopause-like symptoms due to ↓ e
    • Use:
      • Maximum duration of use: 6 months
      • Before surgery (Sx) or endometrial ablation

    Definition of Puberty

    • Period which involves childhood to adulthood
    • Onset of development of secondary sexual characters
    • Attainment of reproductive capacity

    Physiology of Puberty

    • Occurs due to activation in the HPO axis

    HPO Axis

    • Dormant: After birth (Intra-uterine life)

    • Activated: At puberty

    • Central Inhibition (Dormant):

      • Neurotransmitters: GABA, Neuropeptide Y (Inhibitory)

    • Hormonal Processes (Activated):

      • Adrenal gland: Produces androgens
      • Adipose tissue: Converts androgens to estrogen via aromatase.

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    Description

    Test your knowledge on the management and diagnosis of abnormal uterine bleeding (AUB) in different age groups and situations. This quiz covers essential practices including ultrasound use, treatment options, and understanding of endometrial pathology. Evaluate your comprehension of AUB guidelines and recommendations for reproductive-age females and postmenopausal women.

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