TEALE FENNING

Abik · Posted: Mon Feb 19, 2007 2:50 pm Post subject: Menorrhagia

A 44 year old woman is referred by her GP with a six month history of heavy periods. She has been sterilised in the past and has a BMI of 34.

a. Describe your initial assessment in clinic. (8 marks)
b. What further investigations might you need to perform? (4 marks)
c. Discuss her treatment options. (8 marks)

You must all be working very hard on del. suite or wherever!!
Laughing

Nick Raine-Fenning · Posted: Mon Feb 19, 2007 5:10 pm Post subject:

Nice question Abi.

I particularly like the division between section 1 and 2 and the use of the words 'assessment in clinic' and 'further tests'.

Makes the brain ache but that is the key to the new style essays.

I wonder whether you can scan in clinic or if this requires a second appointment. Not for me in real life as all my patients are scanned so I guess I would put this in section 1 and leave FBC, laparoscopy / hysteroscopy etc for section 2.
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vani s · Century Club Joined: 20 Jan 2007 Posts: 141

A
History regarding how much is this affecting her physical, mental, emotional and material world..... Razz

any treatment taken earlier and satisfaction with it?
any postcoital, intermenstrual bleeding, would warrant further exam n investigation.
history of diabetes, (corpus cancer..)
dysmenorrhea, deep dysparunia, etc point to endometriosis, .(..less chance)
a menstrual history associated with constipation, recent gain in weight, cold intolerance would point to hypothyroidism.
history of discharge, multiple partners, Pain: PID
nothing specific..DUB

exam for pallor, pulse( bradycardia).
per abd ? palpable ut
vaginal examination if suspecting some structural pathology by her symptoms..( pressure symp due to fibroid), size, fixity, nodularity, adnexal tenderness

Investigation : FBC for anemia..
Thyroid function test if any other associated symptoms for the same.

B further investigations

Ultrasound for fibroids n endo thickness (if ut palpable per abd, not responded to earlier treatment).
Pippelle,hysteroscopy n Bx if doubtful about ca endo.

C treatment options:

involve her in decision making... med or surgical.

can give trail of drugs without vag exam n TVS.

I line LNG IUS( adv: nearly 80 % reduction in bld loss,amennorhea in 30 % in 1 year, cost effective in long run, no risk of VTE , is for 5 yrs.) disadv: initial irregular bleeding for 6 months, acne, headache

II line antifibrinolytics trial for 3 months; adv effective, cheap, simultaneous with investigations, very few side effects.
NSAIDS if associated with dysm.
No COCP ( BMI n age)

III progestron Oral or inj ? avoid injectable?

GnRHa ..

Surgical

can offer II gen endometrial ablation if ut< 10 wk ,fibroid < 3 cm, wants to preserve ut

can offer UAE if enlarged ut, >10 wk , fibroid>10 wk, wants to preserve ut,

can offer myomectomy; hyst after adequate counselling...vag, abd, laproscopica...( adv disadv of all....)

Hey wondering what the BMI is for ?CI to COCP .., ?hypothyroidism...?ca endo..... Rolling Eyes

Nick Raine-Fenning · Posted: Mon Feb 19, 2007 5:32 pm Post subject:

Good answer with good use of the recent NICE Guideline on Heavy Mesntrual Bleeding (HMB).

As discussed above I would focus more on history and examination in section 1 and carefully choose my investigations. I would probably go for TVS / TAS and a Pipelle here.

I would put FBC, clotting (if relevant), TFTs, Hyst / Lap etc in section 2.

You need to do a few things here vani but mainly:

- justify all of your statements

- expand your examination description

You make good points but will not score highly unless each is justified.

A couple of examples ...

Nick Raine-Fenning · Posted: Mon Feb 19, 2007 5:35 pm Post subject:

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

thanks a lot Nick, very valuable and much neeeded advice.... Laughing

Abik · Posted: Tue Feb 20, 2007 11:20 am Post subject:

I absolutely agree with Nick - (as always!) Wink

The marking scheme will be lifted straight form the HMB guideline and once again Vani, you've got most points in the bubble, just need to order the thoughts a little.

A. All history and exam
1 mark for asking the woman about her expectations.
2 marks for Q.O.L (yawn!) this is the mainstay of the guidance!
1 mark for IMB/PCB to determine cancer risk
1 mark for FH of cancers for the same reason
1 mark for history suggesting other pathology (eg pain, pressure sx from fibroids)
1 mark for co-morbidity which would affect anaesthetic or treatment options
1 mark for noticing a mass on pelvic examination ( should get a gold star if she is that fat!!)

B. Investigations
1 mark for Hb = anaemia = signif HMB
1 mark for mentioning consideration of clotting and screening for vW if lifetime history
1 mark for USS if mass felt or treatment failure
1 mark for pipelle if IMB or treatment failure
hysteroscopy should be mentioned if USS shows abnormality of suggests submucosal fibroid.

C. You got pretty much all of this Vani, well done!

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

So I've lost 4 marks out right...... Crying or Very sad

1 i missed asking about her expectation,

2 family h/o ( though I dont know if it's so much of an issue with endometrial ca, unlike ca ovary... Question

)

3 co- morbidity

4 for clotting screen( i thought of it earlier, but thought it would have presented at menarche itself....) Rolling Eyes

Thanks Abik, was good marking scheme..

Abik · Posted: Tue Feb 20, 2007 1:31 pm Post subject:

I thought it was a good plan and if the essay reflected your points, it would be a clear pass so no problems there!

Nick Raine-Fenning · Posted: Tue Feb 20, 2007 9:00 pm Post subject:

vani s · Century Club Joined: 20 Jan 2007 Posts: 141

Thanks for the encouraging words, Nick Smile

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I wish I was born here or at least I wish we could write bullet points. I get most of the marks on my bubbling paper but I seriously struggle to put them down in a nice way! Abi has given me a nice excersise to practice on that but my girlfriend is just about to leave me as she thinks I'm overdoing with this! "A history of tiredness with audible bowel sounds suggests that I'm hungry! Why don't you make a pasta my dear?..."
I would disagree though with how the marks are shared in the questions. I put the USS and the FBC in the initial assesment and the other blood tests (TFTs bleeding disorders although unlikely from the history) and the endometrial biopsy (out/in-patient depending on the scan findings) under the second Q.

Nick Raine-Fenning · Posted: Thu Feb 22, 2007 7:13 pm Post subject:

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

That makes a lot of sense and is very useful advice Nick! I'm amazed with all the time you spend with us and all the effort you put in this forum!
Thank you so much!

Nick Raine-Fenning · Posted: Sat Feb 24, 2007 9:11 pm Post subject: