Question 1

A 30-year-old woman presents with amenorrhea, hirsutism, and acne. She has gained 10kg over the past year. Ultrasound shows multiple ovarian cysts. Testosterone and LH are elevated, FSH is normal. What is the most likely diagnosis?

Accepted Answer

Polycystic ovary syndrome. ***Polycystic ovary syndrome***- Amenorrhea, hirsutism, acne, and weight gain are classic signs of **hyperandrogenism** and **anovulation** characteristic of PCOS.- The presence of **multiple ovarian cysts** on ultrasound combined with **elevated testosterone** and an **elevated LH** with normal FSH strongly points to PCOS.  *Congenital adrenal hyperplasia*- Typically involves an enzyme deficiency (e.g., **21-hydroxylase deficiency**) leading to elevated adrenal androgens and often **abnormal cortisol precursors**.- While it can cause virilization, the hormonal profile would differ, usually showing very high **17-hydroxyprogesterone** and not primarily an elevated LH:FSH ratio characteristic of PCOS.  *Ovarian tumor*- An **androgen-secreting ovarian tumor** would cause rapid onset and more severe virilization, often with significantly **higher testosterone levels**.- The ultrasound findings of **multiple small cysts** and the specific hormonal imbalance (elevated LH) are more consistent with PCOS than a single tumor.  *Cushing's syndrome*- Caused by **excess cortisol**, leading to central obesity, striae, moon facies, and hyperglycemia.- While it can cause weight gain and menstrual irregularity, **hirsutism** and **acne** are less prominent, and the hormonal pattern (e.g., elevated cortisol, suppressed ACTH or pituitary adenoma) is different.  *Hypothyroidism*- Symptoms include **fatigue**, **weight gain**, **cold intolerance**, and **bradycardia**, with menstrual irregularities often manifesting as menorrhagia or oligomenorrhea.- It does not cause **hirsutism** or **acne**, and the hormonal profile would show elevated TSH and low free T4, not elevated androgens or LH. [Practice more Women’s Health questions on OnCourse]

Question 2

A 35-year-old woman with a 16-month history of heavy menstrual bleeding reports that her periods last 9 days and she passes large clots. She has tried tranexamic acid and mefenamic acid with minimal improvement. She has two children and does not wish for future pregnancy. Examination is normal and transvaginal ultrasound shows a normal uterus (8 cm length) with no fibroids and endometrial thickness of 6 mm on day 5 of cycle. Full blood count shows haemoglobin 101 g/L. She declines hormonal treatment. What is the most appropriate next management option?

Accepted Answer

Offer endometrial ablation. ***Offer endometrial ablation***
  - **Endometrial ablation** is the appropriate next step for **heavy menstrual bleeding** when medical treatments have failed, a woman has completed her family, and has **declined hormonal therapy**.
  - This patient meets all criteria: failed medical treatment, completed family, declined hormones, has a **normal uterus** (8 cm length), and her **anemia** (Hb 101 g/L) necessitates effective management.
*Prescribe oral norethisterone for cycle regulation*
  - The patient has explicitly **declined hormonal treatment**, rendering this option unsuitable based on her preferences.
  - **Oral norethisterone** is a hormonal agent and may not be sufficiently effective for severe **heavy menstrual bleeding** that has not responded to other medical therapies.
*Arrange hysterectomy*
  - While **hysterectomy** offers a definitive cure for heavy menstrual bleeding, it is a **major surgical procedure** and typically considered a last resort after less invasive options.
  - For a woman with a **structurally normal uterus** and no contraindications, **endometrial ablation** is generally preferred as a less invasive surgical alternative before considering hysterectomy.
*Increase dose of tranexamic acid and mefenamic acid*
  - The patient has already reported **minimal improvement** with these medications, suggesting that simply increasing their dose is unlikely to achieve adequate control of her **heavy menstrual bleeding**.
  - Her persistent symptoms and **anemia** indicate a need for a more effective intervention beyond dose adjustment of previously ineffective symptomatic treatments.
*Offer trial of levonorgestrel intrauterine system despite preferences*
  - The **levonorgestrel intrauterine system (IUS)** is a **hormonal treatment**, which the patient has specifically **declined**.
  - Offering a treatment despite a patient's clear refusal disregards **patient autonomy** and established shared decision-making principles. [Practice more Women’s Health questions on OnCourse]

Question 3

A 26-year-old woman presents to the emergency department with sudden onset severe left-sided pelvic pain, nausea, and one episode of syncope 2 hours ago. She has 7 weeks amenorrhoea. On examination, she is alert with heart rate 102 bpm, blood pressure 104/68 mmHg, and temperature 36.8°C. Abdominal examination reveals left iliac fossa tenderness with mild guarding but no rigidity. Transvaginal ultrasound shows an empty uterus, a 35 mm left adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. Serum beta-hCG is 5600 IU/L. What is the most appropriate management?

Accepted Answer

Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery. ***Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery***- The patient's symptoms including **syncope**, severe left-sided pelvic pain, tachycardia (HR 102 bpm), and ultrasound findings of an **empty uterus**, **35 mm adnexal mass**, and **free fluid** in the pouch of Douglas are highly indicative of a ruptured or actively bleeding ectopic pregnancy, requiring immediate surgical intervention.- Surgical management via **laparoscopy** is the most appropriate approach, allowing for direct confirmation of the ectopic, assessment of blood loss, and definitive treatment, either **salpingectomy** for extensive damage or **salpingotomy** for tubal preservation where feasible, considering the high beta-hCG of 5600 IU/L which also contraindicates medical management.*Emergency laparoscopy*- While surgery is urgently indicated,  [Practice more Women’s Health questions on OnCourse]

Question 4

A 41-year-old woman with a 10-month history of heavy menstrual bleeding undergoes hysteroscopy which reveals a 3 cm type 2 submucosal fibroid partially extending into the myometrium (>50% intramural component). She wishes to preserve her fertility. Transvaginal ultrasound confirms no other significant fibroids and normal endometrial cavity. What is the most appropriate initial management?

Accepted Answer

Abdominal myomectomy. ***Abdominal myomectomy***- A **type 2 submucosal fibroid** with **>50% intramural component** makes hysteroscopic removal technically challenging, increasing the risk of **incomplete resection** or **uterine perforation**.- Given the patient's desire for **fertility preservation**, an open or laparoscopic **abdominal myomectomy** allows for complete removal of the fibroid and meticulous **myometrial reconstruction**, which is crucial for subsequent pregnancies.*Hysteroscopic myomectomy*- This technique is primarily suitable for **type 0 and 1 fibroids**, which are largely or entirely within the uterine cavity.- For a **type 2 fibroid** with a substantial intramural component, hysteroscopic removal is often difficult, risks **uterine injury**, and may require multiple procedures for complete resection.*Trial of levonorgestrel intrauterine system*- The **levonorgestrel intrauterine system (LNG-IUS)** has reduced efficacy and higher rates of **expulsion** in the presence of **submucosal fibroids**.- It does not address the underlying anatomical distortion of the **endometrial cavity** caused by a 3 cm fibroid, which can hinder fertility.*Uterine artery embolisation*- **Uterine artery embolisation (UAE)** is generally not recommended for women who desire **future fertility** due to potential risks to **ovarian reserve** and increased complications like **placental abnormalities** in subsequent pregnancies.- **Myomectomy** remains the preferred surgical option for fertility preservation.*GnRH agonist therapy for 6 months*- **GnRH agonists** are typically used as a short-term **pre-operative adjunct** to reduce fibroid size and improve anemia, making surgery easier, rather than as a definitive treatment.- Fibroids commonly **regrow** after cessation of therapy, and long-term use is limited by side effects such as **bone mineral density loss** and vasomotor symptoms. [Practice more Women’s Health questions on OnCourse]

Question 5

A 31-year-old woman presents to the emergency department with left-sided pelvic pain and 7 weeks amenorrhoea. Transvaginal ultrasound demonstrates an empty uterus and a 20 mm left adnexal mass. Initial serum beta-hCG is 1450 IU/L. She is clinically stable. Repeat beta-hCG 48 hours later is 1380 IU/L. What is the most appropriate management?

Accepted Answer

Expectant management with weekly beta-hCG monitoring. ***Expectant management with weekly beta-hCG monitoring***  - This patient is **clinically stable** with a small **adnexal mass (<35 mm)** and a **declining beta-hCG** (from 1450 to 1380 IU/L), indicating a spontaneously resolving tubal ectopic pregnancy.  - **Expectant management** is appropriate when initial beta-hCG levels are low (<2000 IU/L) and declining, requiring weekly monitoring until levels fall below **20 IU/L**. *Intramuscular methotrexate*  - **Methotrexate** is a medical management option typically reserved for patients whose beta-hCG levels are **rising or plateauing** rather than declining.  - It carries risks of side effects like **hepatotoxicity** and **stomatitis**, which are unnecessary to risk if the ectopic is already resolving on its own. *Diagnostic laparoscopy*  - This is an **invasive surgical procedure** indicated for patients who are **hemodynamically unstable**, have severe pain, or have a high risk of rupture.  - Given the patient's **clinical stability** and resolving biochemical markers, surgery presents an unnecessary risk of **anesthesia and operative complications**. *Repeat beta-hCG in 48 hours to confirm declining trend*  - A 48-hour repeat is used to establish the **initial trend**; once the decline is confirmed (as seen here from 1450 to 1380 IU/L), the protocol shifts to **weekly follow-ups**.  - Frequent 48-hour monitoring beyond the initial diagnostic phase is not required for a patient who remains **asymptomatic** and stable. *Arrange MRI pelvis to confirm ectopic location*  - **Transvaginal ultrasound (TVUS)** is the gold standard for diagnosing ectopic pregnancy; the presence of an empty uterus and an **adnexal mass** is sufficient for diagnosis.  - **MRI** is expensive, time-consuming, and adds no clinical value to the management of a **stable, resolving** ectopic pregnancy. [Practice more Women’s Health questions on OnCourse]

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Pregnancy Medicine

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