Menstrual Disorders
Board Questions
A premenopausal 48-year-old female comes to your office because of a 3-month history of increased frequency and volume of vaginal bleeding. She typically menstruates every 24 days but now has bleeding every 10–14 days and notes an increased volume of blood as well. She feels well otherwise. Her cervical cancer screening is current. A bimanual examination reveals blood at the cervical os. Otherwise the cervix appears normal, the uterus is normal to palpation, and there are no adnexal masses.
Which one of the following should be the next step in the evaluation?
A) Reassurance that irregular menses are common in the perimenopausal period
B) HPV testing
C) CT of the pelvis with and without contrast
D) An endometrial biopsy
ANSWER: D
This patient has abnormal uterine bleeding characterized by an increased frequency and volume of vaginal bleeding. Due to the increased risk of endometrial cancer, current guidelines recommend that all women >45 years of age presenting with abnormal uterine bleeding undergo endometrial sampling. Irregular menses can occur during the perimenopausal period but this patient’s increased frequency and volume of vaginal bleeding combined with her age warrant further evaluation. In a patient with an up-to-date Papanicolaou smear and normal-appearing cervix, HPV testing would have no role in the evaluation. Transvaginal ultrasonography is recommended if a bimanual examination is abnormal or if symptoms persist despite treatment. CT is rarely indicated if imaging is necessary, because transvaginal ultrasonography is preferred.
A 42-year-old female presents to your office with heavy menstrual periods and pelvic pressure. Her symptoms began several years ago and have gradually worsened. Laboratory findings are notable for a mild microcytic anemia. Pelvic ultrasonography identifies a 7-cm submucosal mass. She wants to avoid a hysterectomy but desires a treatment that will provide symptom relief, decrease the volume of the mass, and have a sustained effect.
Which one of the following would be most appropriate for this patient?
A) Expectant management
B) A GnRH agonist
C) A selective estrogen receptor modulator
D) A levonorgestrel-releasing IUD (Mirena)
E) Uterine artery embolization and occlusion
ANSWER: E
This patient presents with a symptomatic fibroid. Although she does not express a desire to maintain fertility, she prefers uterine preservation. The Agency for Healthcare Research and Quality Effective Health Care Program review found consistent evidence that uterine artery embolization and occlusion is effective for reducing fibroid size, with lasting effects up to 5 years and moderate evidence for reducing bleeding and improving quality of life. Expectant management is an appropriate option only for patients who have asymptomatic fibroids. GnRH agonists are effective for providing symptom relief and reducing fibroid size, but their use results in a hypoestrogenized state and should not be continued long term for a sustained effect in premenopausal women. Treatment with a selective estrogen receptor modulator such as raloxifene does not affect fibroid size or bleeding patterns. There is limited data regarding the efficacy of a levonorgestrel-releasing IUD for the treatment of uterine fibroids.
A 28-year-old female who was recently diagnosed with polycystic ovary syndrome presents to discuss treatment of irregular menses. She has 2–3 menstrual periods every 6 months that happen at irregular times and can often produce heavy bleeding. She is not obese and has no significant acne or hirsutism. She does not desire pregnancy and her primary goal is to decrease the heavy menstrual bleeding.
Which one of the following would be the most effective initial recommendation?
A) Dietary modifications aimed at weight loss
B) Clomiphene
C) Metformin (Glucophage)
D) Spironolactone (Aldactone)
E) Placement of a levonorgestrel IUD (Mirena)
ANSWER: E
Polycystic ovary syndrome can significantly affect multiple organ systems, and menstrual irregularities from anovulatory cycles are very common. Treatment should be based on the patient’s goals and modified based on her desire for fertility. In a patient who is not interested in near-term fertility and whose goal is to control menstrual irregularities, a levonorgestrel IUD is most likely to reduce the frequency, duration, and volume of bleeding. Metformin is used to treat insulin resistance, dietary modifications are used to treat obesity, spironolactone can be used to treat hirsutism or acne, and clomiphene is used to induce ovulation and fertility.
