Abnormal Uterine Bleeding: Classification — MCQs
Most common uterine tumor is:-
35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?
Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:
A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
Identify the pathological condition shown in the image:
A 33-year-old female presents with heavy menstrual bleeding for 6 months. On examination, no abnormalities were found, and an ultrasound also appeared normal. After failing non-hormonal treatment, what is the next appropriate management step?
An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
Dysfunctional uterine bleeding (DUB) is best treated by:
A 32-year-old woman presents with irregular, heavy menstrual bleeding. After thorough evaluation including pelvic ultrasound, hormonal assays, coagulation profile, and endometrial sampling, no structural abnormalities, systemic disorders, or medication-related causes are identified. This clinical scenario is best described as:
A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:
Abnormal Uterine Bleeding: Classification Indian Medical PG Practice Questions and MCQs
Question 1: Most common uterine tumor is:-
- A. Adenomyoma
- B. Endometrial cancer
- C. Leiomyosarcoma
- D. Leiomyoma (Correct Answer)
Explanation: ***Leiomyoma*** - **Leiomyomas**, also known as **fibroids**, are the most **common benign tumors of the uterus**. - They are composed of **smooth muscle cells** and can vary in size and location within the uterus. *Adenomyoma* - An **adenomyoma** is a benign uterine tumor characterized by the presence of **endometrial glands and stroma** within the myometrium. - While it is a uterine tumor, it is significantly **less common** than leiomyomas. *Endometrial cancer* - **Endometrial cancer** is a **malignant tumor** arising from the endometrium and is the most common gynecologic malignancy. - However, malignant tumors are generally **less common** than benign tumors like leiomyomas. *Leiomyosarcoma* - **Leiomyosarcoma** is a **rare and aggressive malignant tumor** of the smooth muscle tissue of the uterus. - It accounts for a very small percentage of uterine masses and is much less common than benign leiomyomas.
Question 2: 35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?
- A. Hysterectomy
- B. Endometrial sampling (Correct Answer)
- C. Endometrial ablation
- D. Hormonal therapy
Explanation: ***Endometrial sampling*** - In a 35-year-old with **excessive uterine bleeding** not controlled by non-hormonal drugs and with normal imaging/clinical exam, endometrial sampling is crucial to **rule out endometrial hyperplasia or malignancy**. - This diagnostic step is essential before considering definitive treatments, as it provides a **histological diagnosis** of the endometrial lining. *Hysterectomy* - Hysterectomy is a **definitive surgical treatment** for excessive bleeding, but it is typically reserved for cases where conservative or less invasive treatments have failed, or if there's a serious underlying pathology like malignancy. - It involves removing the uterus and is a **major surgery** with potential complications, thus not usually the first step given an otherwise normal examination and imaging. *Endometrial ablation* - Endometrial ablation is a procedure to destroy the lining of the uterus, aiming to **reduce or stop menstrual bleeding**. - It is a treatment option for **abnormal uterine bleeding (AUB)**, but it's typically performed after other diagnostic steps (like endometrial sampling) have ruled out malignancy or high-risk hyperplasia, and when conservative medical management has failed. *Hormonal therapy* - Hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine device) is often a **first-line medical treatment** for excessive uterine bleeding. - However, the question states that non-hormonal drugs have already failed, and without a clear diagnosis, initiating new hormonal therapy without **evaluating the endometrium** is not the next best step for persistent bleeding.
Question 3: Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:
- A. Pap test
- B. Endometrial biopsy (Correct Answer)
- C. Transvaginal ultrasound examination
- D. CA-125 blood test
Explanation: ***Endometrial biopsy*** - This is the **most crucial investigation** for postmenopausal bleeding to rule out **endometrial cancer** or **hyperplasia**, especially in a patient with risk factors like diabetes and hypertension. - An endometrial biopsy directly samples the **uterine lining** for histological examination, providing a definitive diagnosis of any abnormal tissue changes. *Pap test* - A Pap test, or **Papanicolaou test**, primarily screens for **cervical cancer** by examining cells from the cervix. - It is **not effective** for detecting uterine (endometrial) abnormalities or cancer, which is the main concern with postmenopausal bleeding. *Transvaginal ultrasound examination* - While useful for assessing **endometrial thickness** and identifying structural abnormalities like polyps or fibroids, it is **not diagnostic** on its own. - An abnormal ultrasound finding, such as a thickened endometrium (usually >4-5mm in postmenopausal women), would typically prompt an endometrial biopsy for definitive diagnosis. *CA-125 blood test* - **CA-125** is a tumor marker primarily used for monitoring the response to treatment in **ovarian cancer** and can be elevated in other conditions like endometriosis or fibroids. - It is **not a screening tool** for endometrial cancer and is **not specific or sensitive enough** to be the primary investigation for postmenopausal bleeding.
Question 4: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
- A. Malignancy of the vulva
- B. Malignancy of the cervix
- C. Malignancy of the endometrium (Correct Answer)
- D. Malignancy of the ovary
Explanation: ***Malignancy of the endometrium*** - **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases. - **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure. *Malignancy of the vulva* - Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding. - While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding. *Malignancy of the cervix* - Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding. - Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population. *Malignancy of the ovary* - Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain. - **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.
Question 5: Identify the pathological condition shown in the image:
- A. Intramural fibroid
- B. Adenomyoma (Correct Answer)
- C. Endometriosis
- D. Myomatous polyp
Explanation: ***Adenomyoma*** - The image distinctly shows **endometrial glands and stroma** embedded within the **myometrium** (smooth muscle layer of the uterus), which is the hallmark of adenomyoma [1]. - This condition is essentially a localized form of **adenomyosis**, presenting as a mass [1]. *Intramural fibroid* - An intramural fibroid (leiomyoma) is a **benign tumor of smooth muscle cells**, typically showing a proliferation of uniform spindle cells with characteristic swirling patterns [2]. - It would lack the presence of **endometrial glands and stroma** within the lesion [2]. *Endometriosis* - Endometriosis involves the presence of **endometrial tissue outside the uterus**, such as on the ovaries, peritoneum, or bowel. - While it involves similar tissue, its location is **extrauterine**, whereas the image depicts a lesion within the uterine wall. *Myomatous polyp* - A myomatous polyp (or submucosal fibroid) is a **fibroid that protrudes into the uterine cavity**, often covered by endometrial tissue [2]. - The image does not show a polypoid growth extending into the cavity but rather glandular tissue directly within the muscle wall. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 475-476. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1024-1025.
Question 6: A 33-year-old female presents with heavy menstrual bleeding for 6 months. On examination, no abnormalities were found, and an ultrasound also appeared normal. After failing non-hormonal treatment, what is the next appropriate management step?
- A. Perform endometrial sampling.
- B. Initiate hormonal therapy. (Correct Answer)
- C. Consider hysterectomy.
- D. Perform dilation and curettage (D&C).
Explanation: ***Initiate hormonal therapy.*** - For unexplained **heavy menstrual bleeding (HMB)** in a young woman with a normal workup, hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, or a progestin-releasing IUD) is the first-line medical treatment after non-hormonal options fail. - These treatments stabilize the **endometrial lining** and reduce blood flow, effectively managing symptoms. *Perform endometrial sampling.* - **Endometrial sampling** is typically reserved for women at higher risk of endometrial hyperplasia or cancer, such as those over 45 with HMB, or younger women with persistent irregular bleeding, risk factors for endometrial cancer (e.g., obesity, PCOS), or unresponsive to initial medical therapy. - In this 33-year-old with normal ultrasound and no other identified risk factors, the likelihood of endometrial pathology is low, making sampling less urgent as a *next* step. *Consider hysterectomy.* - **Hysterectomy** is a definitive surgical procedure usually reserved for severe, persistent HMB that has failed all less invasive medical and surgical treatments, or for cases where there is significant uterine pathology (e.g., large fibroids, adenomyosis) not present here. - It is an irreversible procedure and generally not considered early in the management of heavy menstrual bleeding in a 33-year-old without uterine abnormalities. *Perform dilation and curettage (D&C).* - A **D&C** is a procedure to remove tissue from the uterus, often used for diagnostic purposes (like endometrial sampling) or to remove retained products of conception. - While it can temporarily reduce bleeding by removing some endometrial lining, it is not a long-term solution for treating abnormal uterine bleeding and is typically not indicated as a primary therapeutic step for chronic HMB in the absence of acute severe bleeding or suspected pathology requiring tissue removal.
Question 7: An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
- A. Urine pregnancy test
- B. Coagulation profile
- C. Dilatation and curettage (Correct Answer)
- D. Ultrasound uterus and adnexa
Explanation: ***Dilatation and curettage*** - This is an **invasive surgical procedure** used diagnostically and therapeutically for heavy uterine bleeding, but it is generally *not* the initial or routinely advised investigation for an 18-year-old unmarried girl with heavy menstrual bleeding. - In a young, unmarried patient, less invasive methods are preferred unless other investigations point to a structural abnormality requiring tissue diagnosis or therapeutic intervention. *Urine pregnancy test* - A urine pregnancy test is **essential** to rule out pregnancy-related complications (e.g., ectopic pregnancy, miscarriage) as a cause of heavy vaginal bleeding, even in unmarried individuals. - **Abnormal uterine bleeding** can be the presenting symptom of an early pregnancy loss. *Coagulation profile* - Heavy and prolonged bleeding, especially from a young age (as suggested by "18-year-old girl"), raises suspicion for an **underlying coagulopathy** (e.g., Von Willebrand disease). - A coagulation profile (including PT, aPTT, platelet count, and sometimes specific factor assays) is crucial to **assess bleeding risk** and guide management. *Ultrasound uterus and adnexa* - An ultrasound is a **non-invasive imaging technique** that can identify structural causes of abnormal uterine bleeding, such as **fibroids, polyps, adenomyosis**, or ovarian pathologies. - It helps in assessing the **uterine lining and ovarian morphology**, which is important in evaluating the cause of heavy menstrual bleeding.
Question 8: Dysfunctional uterine bleeding (DUB) is best treated by:
- A. Curettage of uterus
- B. Progestogen (Correct Answer)
- C. Estrogen
- D. Clomiphene
Explanation: ***Progestogen*** - **Progestogen** therapy helps stabilize the **endometrium**, reducing excessive or irregular bleeding in DUB by counteracting unopposed estrogen. - It induces a more organized shedding of the uterine lining, which can regularize the menstrual cycle. *Curettage of uterus* - While **curettage** can provide temporary relief by removing the endometrial lining, it is primarily a diagnostic procedure to rule out pathology rather than a primary long-term treatment for DUB. - It does not address the underlying hormonal imbalance that causes DUB, leading to a high recurrence rate of symptoms. *Estrogen* - **Estrogen** therapy alone is generally not used to treat DUB because unopposed estrogen is often the cause of DUB, leading to **endometrial overgrowth** and irregular shedding. - Administering estrogen without a progestin could exacerbate the condition and increase endometrial proliferation. *Clomiphene* - **Clomiphene** is an anti-estrogen medication primarily used to induce **ovulation** in women with infertility. - It is not indicated for the management of dysfunctional uterine bleeding or for regulating menstrual cycles directly.
Question 9: A 32-year-old woman presents with irregular, heavy menstrual bleeding. After thorough evaluation including pelvic ultrasound, hormonal assays, coagulation profile, and endometrial sampling, no structural abnormalities, systemic disorders, or medication-related causes are identified. This clinical scenario is best described as:
- A. Presence of systemic causes
- B. Presence of iatrogenic causes
- C. No identifiable causes present (Correct Answer)
- D. Presence of identifiable organic causes
Explanation: ***No identifiable causes present*** - As per its definition, **dysfunctional uterine bleeding (DUB)** is diagnosed when no structural, systemic, or iatrogenic etiology for abnormal uterine bleeding can be found. - The diagnosis of DUB is essentially a **diagnosis of exclusion**, meaning it is made after ruling out other potential causes of bleeding. *Presence of systemic causes* - If systemic causes, such as **coagulation disorders** or **thyroid dysfunction**, are identified, the bleeding is attributed to these conditions, and it is not considered DUB. - DUB specifically implies that systemic factors have been investigated and found to be absent or not the primary cause of the bleeding. *Presence of iatrogenic causes* - **Iatrogenic causes** refer to abnormal bleeding induced by medical interventions, such as specific medications (e.g., anticoagulants, hormonal contraceptives) or medical devices (e.g., IUDs). - If such causes are identified, the bleeding is categorized accordingly, and the diagnosis of DUB is excluded. *Presence of identifiable organic causes* - **Organic causes** include structural abnormalities of the uterus or reproductive tract, such as **fibroids**, **polyps**, **adenomyosis**, or **malignancy**. - The presence of any of these identifiable pathology rules out DUB, as DUB is by definition non-organic.
Question 10: A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:
- A. Synthetic progestogens (Correct Answer)
- B. Testosterone propionate
- C. Curettage followed by progestogens
- D. Conjugated equine oestrogens
Explanation: ***Synthetic progestogens*** - **Synthetic progestogens** are the **classic first-line medical treatment** for dysfunctional uterine bleeding (DUB) in the perimenopausal age group. - They work by **stabilizing the endometrium**, counteracting unopposed estrogen effects, and inducing organized withdrawal bleeding. - For **continuous moderate bleeding**, cyclic or continuous progestogens (e.g., norethisterone 5 mg BD for 21 days) are effective and non-invasive. - This represents the **traditional textbook approach** for anovulatory DUB management. *Testosterone propionate* - **Testosterone propionate** is an androgen with no role in managing dysfunctional uterine bleeding in women. - Its use is limited to male hypogonadism and specific anabolic requirements. *Curettage followed by progestogens* - While **curettage (D&C)** is both diagnostic and therapeutic, it is an **invasive procedure**. - In clinical practice, especially for a **45-year-old woman**, endometrial sampling is often warranted to rule out hyperplasia or malignancy, making this a reasonable clinical approach. - However, **medical management with progestogens alone** is traditionally considered first-line when the patient is hemodynamically stable and malignancy risk is low. - This option represents sound clinical practice but is not the classic "first choice" in exam contexts. *Conjugated equine oestrogens* - **High-dose estrogens** (25 mg IV every 4-6 hours) are actually used for **acute severe bleeding** and can stop bleeding within 24 hours by rapidly proliferating the endometrium. - However, for **continuous moderate bleeding** over 15 days in a perimenopausal woman, estrogen alone would not address the underlying issue of **unopposed estrogen** causing anovulatory cycles. - Estrogen is reserved for acute emergency management, not for the scenario described in this question.
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