revision on cases of reproductive endocrinology
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Undergraduate course lectures in Gynecology prepared by DR Manal Behery ,FACULTY OF MEDICINE ,Zagazig UNIVERSITY,EGYPT

Undergraduate course lectures in Gynecology prepared by DR Manal Behery ,FACULTY OF MEDICINE ,Zagazig UNIVERSITY,EGYPT

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revision on cases of reproductive endocrinology revision on cases of reproductive endocrinology Presentation Transcript

  • Revision on cases ofRevision on cases of reproductivereproductive endocrinologyendocrinology DR MANAL Behery
  • CASE 1CASE 1  A 23-year-old G0 P0 female presents to theA 23-year-old G0 P0 female presents to the office with complaints of irregular cycles sinceoffice with complaints of irregular cycles since menarche.menarche.  She has noticed an increase in facial hair andShe has noticed an increase in facial hair and acne for many years.acne for many years.  She denies any history of medical problems andShe 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 areB P), pulse, respiratory rate, and temperature are normalnormal  She is obese ,her (BMI) 34.She is obese ,her (BMI) 34.  She have some hirsutism and acanthosis nigricansShe 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 pregnancyShe 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, andDiabetes 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 therapeutic planWhat is your therapeutic plan for this patient?for this patient?  1.Regulate menstrual cycles with combination oral1.Regulate menstrual cycles with combination oral contraceptivescontraceptives  2. Protect the endometrium from unopposed2. Protect the endometrium from unopposed estrogen and reduce risk of endometrial cancerestrogen and reduce risk of endometrial cancer  3. Encourage weight loss and healthy lifestyle3. 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 and5. Monitor for the development of diabetes and cardiovascular diseasecardiovascular disease
  • A 32-year-old G0 P0 woman is noted toA 32-year-old G0 P0 woman is noted to have irregular menses and hirsutismhave irregular menses and hirsutism  Which of the following is consistent withWhich 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 ofC. 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 reportingA 30 y old women present reporting difficulty in becoming pregnantdifficulty in becoming pregnant  She always has irregular menses that regulatedShe always has irregular menses that regulated with COC pills .with COC pills .  System review reveal occasional palpitations thatSystem review reveal occasional palpitations that she attribute to anxiety attacks.she attribute to anxiety attacks.  She has increased hair growth on face and isShe has increased hair growth on face and is overweight, making evaluation of her adnexaoverweight, making evaluation of her adnexa difficult.difficult.
  • In addition to pelvic ultrasound ,appropriateIn addition to pelvic ultrasound ,appropriate lab evaluation should include all of thelab evaluation should include all of the following exceptfollowing 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 panelE – basic metabolic panel
  •  A 29-year-old G0 P0 woman with a diagnosis ofA 29-year-old G0 P0 woman with a diagnosis of PCOS is being counseled about the dangers ofPCOS is being counseled about the dangers of her condition. In particular, about the possibility ofher condition. In particular, about the possibility of developing metabolic syndrome.developing metabolic syndrome.  Which of the following is the most significantWhich 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 chronicA 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 ofShe undergoes an endometrial biopsy in light of her long history of anovulation, which returns asher 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 the bestWhich of the following is the best therapy for this patient?therapy for this 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
  • Case2Case2  A 16-year-old adolescent female is referred forA 16-year-old adolescent female is referred for never having menstruated. She is otherwise innever having menstruated. She is otherwise in good health.good health.  She has an older sister who experiencedShe has an older sister who experienced menarche at age 12 years. She deniesmenarche 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 ishe 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 herHer breasts appear to be Tanner stage I, and her pubic hair pattern is also consistent with Tannerpubic hair pattern is also consistent with Tanner stage I.stage I.  Abdominal examination reveals no masses. TheAbdominal examination reveals no masses. The external genitalia are normal for a prepubescentexternal genitalia are normal for a prepubescent female.female.
  • Tanner StagingTanner Staging
  • Stage1 stage2Stage1 stage2 Prepupertal: elevation ofPrepupertal: elevation of papilla- no pubic hairpapilla- no pubic hair Elevation of breast and papillaElevation of breast and papilla on asmall mount,increase inon asmall mount,increase in areola – libial hairareola – libial hair
  • Stage 3 stage4Stage 3 stage4 Further breast enlargment,Further breast enlargment, hair extend to mons pubishair extend to mons pubis Secondary mound of areolaSecondary mound of areola and papilla ,hair extend laterland papilla ,hair extend laterl And increases pigmentionAnd increases pigmention
  • Stage5Stage5 Recession of arola to contour of the breastRecession of arola to contour of the breast Adult pubertal hair with striaght upper bordedAdult pubertal hair with striaght upper borded
  •  ➤➤ What is the most likely diagnosis?What is the most likely diagnosis?  Gonadal dysgenesis (Turner syndrome).Gonadal dysgenesis (Turner syndrome).   ➤➤ What is the next step in diagnosis?What is the next step in diagnosis?  Serum follicle-stimulating hormone (FSH)Serum follicle-stimulating hormone (FSH)
  • Patients with turner’s syndrome will mostPatients with turner’s syndrome will most commonly display which of the followingcommonly display which of the following endocrine profiles?endocrine 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 FSHC –elevated prolactin,normal TSH,normal FSH  D- normal FSH,normal TSH,normal ProlactinD- normal FSH,normal TSH,normal Prolactin
  • Which of the following statement aboutWhich of the following statement about amenorrhea is the most correct ?amenorrhea is the most correct ?  A -A -The majority of amenorrheic patientsThe majority of amenorrheic patients have an abnormal physical exam ,prolactinhave an abnormal physical exam ,prolactin or TSHor TSH  B – imperforate hymen is the second mostB – imperforate hymen is the second most common cause of primary amenorrheacommon cause of primary amenorrhea  C –Gondal dysgensis is the most commonC –Gondal dysgensis is the most common causec of primary amenorrheacausec of primary amenorrhea  D –the term hypothalemic amenorrheaD –the term hypothalemic amenorrhea applies to normal GNRH secretion butapplies to normal GNRH secretion but elevated FSH levelelevated FSH level
  • The first evidence of pubertalThe first evidence of pubertal development in the female is usuallydevelopment in the female is usually     a. Onset of menarchea. Onset of menarche  b. Appearance of breast budsb. Appearance of breast buds  c. Appearance of axillary and pubic hairc. Appearance of axillary and pubic hair  d. Onset of growth spurtd. Onset of growth spurt
  • The events that occur in changes from a childThe events that occur in changes from a child to adult female usually occur in the followingto adult female usually occur in the following sequence:sequence:  11 Growth spurtGrowth spurt  22 Breast developmentBreast development  33 Pubic hair growthPubic hair growth  44 MenstruationMenstruation
  •  A 15-year-old adolescent female is diagnosed withA 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
  • AA 15-year-old adolescent female is brought15-year-old adolescent female is brought into the pediatrician’s office due to no breastinto the pediatrician’s office due to no breast development.development.  The patient’s mother notes that both ofThe patient’s mother notes that both of patient’s sisters had onset of breastpatient’s sisters had onset of breast development at age 10, and also all of herdevelopment at age 10, and also all of her friends have already begun menstruating.friends have already begun menstruating.  Examination reveals Tanner stage I breastExamination reveals Tanner stage I breast and pubic/axillary hair, and is otherwiseand pubic/axillary hair, and is otherwise unremarkableunremarkable
  • Which of the following is theWhich of the following is the most likely diagnosis?most likely diagnosis?  A. Delayed pubertyA. Delayed puberty  B. Development is within normal limits andB. 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 forA 16-year-old adolescent female is evaluated for lack of pubertal development. She is diagnosedlack of pubertal development. She is diagnosed with gonadal dysgenesis.with gonadal dysgenesis.  Which of the following laboratory findings isWhich 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 isA 20-year-old individual with a 46,XY karyotype is noted to be sexually infantile phenotypic female andnoted to be sexually infantile phenotypic female and diagnosed as having gonadal dysgenesis.diagnosed as having gonadal dysgenesis.  Which of the following is the most importantWhich 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 endometrialC. 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 monthswoman with LMP= 6 months ago presents with a concern regarding noago presents with a concern regarding no periods.periods.  She delivered two full term healthy childrenShe delivered two full term healthy children vaginally and their ages are 5 and 3. Shevaginally and their ages are 5 and 3. She stopped breastfeeding 2 years ago.stopped breastfeeding 2 years ago.  She has noted a persistent breast discharge,She has noted a persistent breast discharge, but no breast masses.but 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 historySurgical and family history areare irreleventirrelevent Past medical history:Past medical history: PostpartumPostpartum depression, which resolved after one yeardepression, which resolved after one year on an SSRI.on an SSRI. Physical examPhysical exam VS: 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 orwith expression. No masses, dimpling or retractionretraction
  • What investigation you need toWhat investigation you need to do ?do ?  Serum pregnancy testSerum pregnancy test  FSHFSH  TSHTSH  Serum prolactinSerum prolactin  MRI pitutary if serum prolactin >100MRI pitutary if serum prolactin >100 ng/mlng/ml
  • Laboratory/studies:Laboratory/studies:  HCG= negativeHCG= negative  FSH,TSH are normalFSH,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 inMRI of the head reveals a 0.8 cm mass in the anterior pituitarythe anterior 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 optionWhat is the best treatment option for her ?for her ?  This patient was treated withThis patient was treated with CabergolineCabergoline (a(a dopamine agonist) on a weekly basis and thedopamine agonist) on a weekly basis and the dose was increased until her prolactin level wasdose 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 monthsShe had return of menses within a few months time.time.  Her galactorrhea slowly resolved.Her galactorrhea slowly resolved.
  • Case4Case4  A 42-year-old parous woman has noticedA 42-year-old parous woman has noticed increasing hair growth on her face and abdomenincreasing 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, andHer 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 areHer 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 hairShe 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 arecardiac and pulmonary examinations are normal.normal.  The abdominal examination reveals no massesThe 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 andPelvic 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 breastA 6-year-old girl is noted to have breast development and vaginal spotting. No abnormaldevelopment and vaginal spotting. No abnormal hair growth is noted.hair growth is noted.  A 10-cm ovarian mass is palpated on rectalA 10-cm ovarian mass is palpated on rectal examination.examination.  Which of the following is the most likelyWhich 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 andShe also has a deepening voice and clitoromegaly.clitoromegaly.  There have been two neonatal deaths in theThere have been two neonatal deaths in the family.family.  Which of the following is the best diagnosticWhich 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 hormonsAdrenal gland zone and hormons
  • Congenital Adrenal Hyperplasia
  •  A 22-year-old nulliparous woman with irregularA 22-year-old nulliparous woman with irregular menses of 7 years’duration complains of primarymenses of 7 years’duration complains of primary infertility. She has a family history ofdiabetes. Andinfertility. She has a family history ofdiabetes. And mild hirsutism on examination.mild hirsutism on examination.  Which of the following is the most likelyWhich 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 ofA 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 adnexalThe pelvic examination does not reveal adnexal masses.masses.  The serum DHEA-S, testosterone,The serum DHEA-S, testosterone, and 17-hydroxyprogesteroneand 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 the most 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 5Case 5  A 46 y old women comes to your office worriedA 46 y old women comes to your office worried about her decreased sexual desire andabout her decreased sexual desire and perimenopausal symptoms.perimenopausal symptoms.  Her medical and surgical history are significantHer 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 ,andOn 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 ovaryAfter 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 thatYou tell her that  A –nearly all testosterone production is fromA –nearly all testosterone production is from her remaning ovary and her concern areher remaning ovary and her concern are justifiedjustified  B –one fourth of her testostrone production isB –one fourth of her testostrone production is from her ovary ,one fourth from herfrom her ovary ,one fourth from her adrenals,and the remaning half from prepheraladrenals,and the remaning half from prepheral conversionconversion  C –testosterone production is not linked to theC –testosterone production is not linked to the woman’s ovarywoman’s ovary  D –given that she is perimenopausal ,sheD –given that she is perimenopausal ,she likely has testosterone circulating any waylikely has testosterone circulating any way
  • The patient asks you if she is going throughThe patient asks you if she is going through menopause which of the following statement ismenopause which of the following statement is is the SINGLE best answeris the SINGLE best answer??  A –the patient past menstrual history is notA –the patient past menstrual history is not important in reaching diagnosis .important in reaching diagnosis .  B –serum FSH>50 IU/ML is diagnostic ofB –serum FSH>50 IU/ML is diagnostic of menopausemenopause  C- serum estradiol level <0.11 mmol /LC- serum estradiol level <0.11 mmol /L indicate ovarian failureindicate ovarian failure  D –Teastosterone level <60% decline is theD –Teastosterone level <60% decline is the best predictor of menopausebest predictor of menopause
  •  50 years old healthy women present to the50 years old healthy women present to the office for routine gynecologic visitoffice for routine gynecologic visit complaining of new onset episodes ofcomplaining of new onset episodes of intense heat through her neck and chestintense heat through her neck and chest followed by profuse sweating.followed by profuse sweating.  This episodes interfere wake her up fromThis episodes interfere wake her up from sleep and interfere with her ability to worksleep and interfere with her ability to work
  • What is the most effect therapyWhat is the most effect therapy for her symptomsfor her symptoms  A –Venlafxine(sertonine reuptake inhibitors)A –Venlafxine(sertonine reuptake inhibitors)  B –ClonidineB –Clonidine  C –Estrogen replacementC –Estrogen replacement  D- progesteroneD- progesterone
  • Cause of hot flushesCause of hot flushes •Caused by noradrenalin, which disturbs theCaused by noradrenalin, which disturbs the thermoregulatory system.thermoregulatory system. •Oestrogen deficiency reduces hypothalamicOestrogen deficiency reduces hypothalamic endorphins, which release moreendorphins, 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 comes to yourA 58 years old ,healthy G0P0 comes to your office complaning about her vaginal bleedingoffice complaning about her vaginal bleeding  She reports hot flushes and mood swingsShe reports hot flushes and mood swings starting about 10 years age.starting about 10 years age.  She stopped bleeding a few years ago and thenShe 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 hyperplasiaB –endometrial hyperplasia  C- endometrial cancerC- endometrial cancer  D – endometrial atrophyD – endometrial atrophy
  •  57 years old Aferican Aamerican woman has57 years old Aferican Aamerican woman has been 7 years ago.been 7 years ago.  She denies any medical problems but hadShe denies any medical problems but had fracture hip 2 years agofracture hip 2 years ago ..  On examOn exam:: she is 5 feet,5 inches tall,and 165she is 5 feet,5 inches tall,and 165 pounds weightpounds weight  PV:PV: slightly atrophic vaginal mucosa andslightly atrophic vaginal mucosa and otherwise normal examotherwise normal exam
  • You give this patient referal forYou give this patient referal for DEXA because of herDEXA because of her  A- raceA- race  B – postmenopausal state combined withB – postmenopausal state combined with physical exam findingphysical exam finding  C – history of a fractureC – history of a fracture  D – height and weightD – height and weight
  • Case 7Case 7  A 58 – year old women .menopause 6 – 7A 58 – year old women .menopause 6 – 7 years ago.years ago.  2 months ago she had a few days of vaginal2 months ago she had a few days of vaginal bleeding which was like the end of period andbleeding 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 replacementShe has never been on hormone replacement therapy (HRT).therapy (HRT). Case 6 7
  • What are the most likely causesWhat are the most likely causes of her bleeding?of her bleeding?  Endometrial cancerEndometrial cancer  •• Atrophic vaginitisAtrophic vaginitis  •• Local cervical lesionLocal cervical lesion  •• Cervical cancerCervical cancer  •• IatrogenicIatrogenic  •• Chlamydia i n f e c t i o nChlamydia i n f e c t i o n
  • What further questions would help toWhat further questions would help to establish the diagnosis?establish the diagnosis?  A -woman ' s last normal menstrual period.A -woman ' s last normal menstrual period.  B -amount and duration of bleedingand anyB -amount and duration of bleedingand any associated symptoms.associated symptoms.  C -Try to clarify the site of bleeding toC -Try to clarify the site of bleeding to confirm that it is vaginal and not rectal orconfirm that it is vaginal and not rectal or urinaryurinary  D -Drug like tamoxifen or HRTD -Drug like tamoxifen or HRT  E -all of the aboveE -all of the above
  • On examinationOn examination  Her vulva is normal and she has mildHer vulva is normal and she has mild atrophic changes of her vagina and heratrophic changes of her vagina and her cervix.cervix.  She has some laxity of the vaginal walls butShe 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 investigationsWhat further investigations must you now consider?must you now consider?  Transvaginal ultrasound scanningTransvaginal ultrasound scanning  Report of TV US results The uterus contains a regularReport of TV US results The uterus contains a regular thickening measuring 8 mm thickness.thickening measuring 8 mm thickness.  (This could represent a polyp).(This could represent a polyp).  Neither ovary can be identified and there are noNeither ovary can be identified and there are no adnexal masses or free fluid.adnexal masses or free fluid.
  • What do you do next?What do you do next?  As her endometrial thickness is > 4 mm, sheAs her endometrial thickness is > 4 mm, she requires further investigation.requires further investigation.  1- Saline sonohystrography1- Saline sonohystrography better delination of cavitybetter delination of cavity 2-2- Endometrial biopsy.Endometrial biopsy. However If the scan findingHowever If the scan finding represents a polyp, it is unlikely torepresents 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 polypsIt is a sensitive means of identifying polyps and submucous fibroid .and submucous fibroid .  It can be used in the outpatient settingIt 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 sentThe polyp is removed using biopsy forceps and sent for histologyfor histology  The pathology report confirms a simple endometrialThe 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 bePolyp 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 toAs she is not on HRT this may be related to obesity because of peripheral conversion ofobesity because of peripheral conversion of androgens (androstenidione) in subcutaneous fatandrogens (androstenidione) in subcutaneous fat to oestrogens.to oestrogens.  Polyps may recur but there is no need for followPolyps may recur but there is no need for follow upup .. Is any further management required?
  • Imaging of 38 ys old G2p2,with post menstrualImaging of 38 ys old G2p2,with post menstrual spotting ,Is best performed by which of thespotting ,Is best performed by which of the following?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 mostB –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 toC – CT scan of the pelvis due to its ability to diagnose rtiologiesdiagnose rtiologies  D –hematology consult ,giving your high suspecionD –hematology consult ,giving your high suspecion of coagulopathyof coagulopathy
  • A 43 ys old G1P1 with morbid obesityA 43 ys old G1P1 with morbid obesity ,hypertension ,and COPD comes to office,hypertension ,and COPD comes to office complaning of heavy vaginal bleedingcomplaning of heavy vaginal bleeding  Work up reveals normal lab work, ultrasound, andWork up reveals normal lab work, ultrasound, and Endometrial biopsy.The patient desires the safest longEndometrial biopsy.The patient desires the safest long term management of her bleeding.term management of her bleeding.The best option isThe 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 volumeB –NSAID because they reduce menstrual volume by 80-90%by 80-90%  C -Admission to hospital for hystrectomyC -Admission to hospital for hystrectomy  D –discussion and placement of Mirna IUDD –discussion and placement of Mirna IUD 