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

1. Revision on cases ofRevision on cases of
reproductivereproductive
endocrinologyendocrinology
DR MANAL Behery

2. 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.

3. 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.

4.  ➤➤ 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.

5. ➤➤ 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

6. 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

7. 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.

8. 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

9.  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

10.  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.

11. 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

12. 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.

13. 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.

14. Tanner StagingTanner Staging

15. 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

16. 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

17. 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

18.  ➤➤ 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)

19. 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

20. 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

21. 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

22. 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

23.  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

24. 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

25. 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

27.  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

28.  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

29. 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

30. 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

31. 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

32. 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)

33. 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.

34. 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

35. 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.

36.  ➤➤ 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.

37. Ferriman galawey scoreFerriman galawey score

38.  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

39.  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

40. Adrenal gland zone and hormonsAdrenal gland zone and hormons

41. Congenital Adrenal Hyperplasia

42.  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

43.  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.

44. 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

45. 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

46. 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

48. 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

49.  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

50. 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

51. 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.

52. 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

53.  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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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.

60. 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.

61. 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

62. 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.

63.  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?

64. 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

65. 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
