BCS/PBL
Menopause: 3 symptom clusters with 3 symptoms each
Vasomotor (hot flushes, night sweats, palpitations)
Urogenital (frequency, atrophic vaginitis, vainal dryness)
Psychogenic (depression/anxiety, poor memory, sleep disturbances)
Differentiate Co-Test from Cervical screening test
Co-test: diagnostic tool that checks for both HPV and abnormal cells on the same sample. SYMPTOMATIC with symptoms of cervical cancer
Cervical screening test: primarily checks for HPV, the main cause of cervical cancer, in ASYMPTOMATIC women
8 ways to avoid boundary violation during CST?
1 Clear communication throughout
2 Obtain explicit, informed consent
3 Maintain privacy and dignity
4 Offer chaperone / use appropriately
5 Respect cultural and personal sensitivities e.g. offer female doctor
6 Maintain professional physical conduct
7 Ensure professional environment and documentation
8 Reflect on power dynamics and maintain boundaries
Female patient presents with heavy menstrual bleeding, factor VIII deficiency and prolonged aPTT. Diagnosis?Why not ____?
Von Willebrand Disease - vW factor prevents factor VIII breakdown, so results in low factor VII and prolonged aPTT
Why not haemophilia A? Rare. vWD much more common and also X linked so far more common in men.
Define AUB, what are the normal parameters of menstrual cycle, how does anovulatory cycles lead to AUB?
Definition: Abnormal uterine bleeding (AUB) refers to bleeding from the uterus occurring outside pregnancy in reproductive-aged women that is abnormal in the parameters of regularity, frequency, volume, or duration.
Normal parameters:
•Frequency: 24-28 days
•Regularity: < 7-9 days
•Duration: < 8 days of bleeding per cycle
•Volume: < 80mL. Clinically, patient’s description of volume (frequency of product change)
•Age of menarche: 10-16 years old
Anovulatory cycles
Anovulation - absence of corpus luteum - no progesterone - unopposed oestrogen stimulation of the endometrium
A 35-year-old woman presents with irregular bleeding 6 months after a normal delivery and currently lactating. Explain the hormonal physiology underlying AUB in this context.
Lactational anovulation from elevated prolactin suppresses GnRH and LH surges, leading to unopposed oestrogenic stimulation of endometrium with irregular shedding once partial follicular recovery begins.
3 complications of chronci HRT use?
Endometrial hyperplasia (unopposed estrogen)
If with progesterone, can increase breast cancer risk
CVD: DVT, coronary heart disease, PE, stroke
Explain why transvaginal ultrasound performed on day 21 of a 30-day cycle may miss a structural lesion, and how to optimize timing for accurate evaluation.
The secretory endometrium on day 21 is thickened and echogenic, potentially obscuring small polyps or submucosal fibroids; optimal imaging is in early proliferative phase (days 5–9) when endometrium is thin and uniform.
How do you interpret endometrial biopsy findings of “proliferative endometrium” in a 52-year-old woman with AUB?
Indicates persistent oestrogen stimulation without progesterone opposition (anovulatory cycles); warrants evaluation for endogenous oestrogen source (e.g. granulosa cell tumor, obesity) or exogenous exposure, given her age and cancer risk.
Describe change in levels of estrogen, progesterone, inhibin during uterine cycle, what tissues/cells are secreting these, changes in LH/FSH levels, targets of LH/FSH.
Estrogen increases during proliferative stage and peaks at ovulation. Theca cells --> Granulosa cells.
Progesterone increases after ovulation, during secretory phase. Corpus luteum: granulosa lutein cells.
Inhibin peaks following progesterone peak during secretory phase. Granulosa cells.
LH surge --> ovulation. Targets granulosa cells to induce ovulation.
FSH does not surge as it is continuously secreted at low levels.
LH targets theca cells (surge as above), FSH targets granulosa cells
Outline how you would differentiate AUB secondary to a coagulation disorder from ovulatory dysfunction, based on menstrual history alone.
Coagulopathy often presents since menarche, with prolonged menses (>7 days), passage of clots, post-surgical bleeding, or family history
Ovulatory dysfunction tends to have variable cycle length, intermenstrual spotting, and correlates with endocrine symptoms (e.g. hirsutism, hot flushes).
A patient with AUB and BMI > 35 is at increased risk for endometrial carcinoma. Describe the mechanisms linking obesity and AUB.
Aromatization of androgens to oestrogens in adipose tissue increases unopposed oestrogen exposure
Hyperinsulinemia decreases SHBG and increases free oestrogen
Chronic inflammation promotes proliferative endometrial milieu → hyperplasia → AUB.
Compare how chronic anovulation in PCOS versus perimenopause leads to endometrial hyperplasia and AUB.
In both, unopposed oestrogen stimulates proliferative endometrium without progesterone-induced differentiation
PCOS this arises from LH-driven ovarian androgen excess and peripheral aromatization
Perimenopause it results from erratic follicular recruitment and intermittent anovulation.
Explain why the levonorgestrel IUD is superior to combined OCPs for long-term control of idiopathic heavy menstrual bleeding.
IUD delivers high local progestin concentrations causing endometrial atrophy and glandular suppression with minimal systemic effect, reducing blood loss by up to 95%
Systemic hormonal regulation and endometrial stabilization from OCPs (~40–50% reduction).
Discuss the evidence and indications for endometrial ablation versus hysterectomy in chronic AUB unresponsive to medical therapy.
Ablation effective for benign AUB without uterine pathology in women not desiring fertility; hysterectomy definitive, indicated for refractory cases or concurrent pathology (e.g. large fibroids, atypical hyperplasia). Randomized trials show comparable satisfaction but higher re-intervention rates post-ablation.