What is the primary mechanism of action of tranexamic acid in treating heavy menstrual bleeding?
Q112
A 46-year-old woman presents with a 6-month history of irregular heavy bleeding. She reports cycles varying from 21 to 45 days with heavy bleeding lasting 7-10 days. Her BMI is 34 kg/m². Transvaginal ultrasound shows endometrial thickness of 18mm and a normal-sized uterus with no fibroids. What is the most appropriate next investigation?
Q113
A 37-year-old woman presents with heavy menstrual bleeding affecting her quality of life. She reports flooding and passing clots, requiring pad changes every 2 hours. Her cycles are regular at 28 days and last 8 days. She has completed her family. Pelvic examination is unremarkable and transvaginal ultrasound shows a normal-sized uterus with 12mm endometrial thickness and no structural abnormalities. Full blood count shows haemoglobin 102 g/L. What is the most appropriate first-line management?
Q114
A 33-year-old woman presents with 7 weeks amenorrhoea and mild left-sided abdominal discomfort. She has had one previous ectopic pregnancy treated with salpingectomy. Transvaginal ultrasound shows an empty uterus and a 15mm adnexal mass with no free fluid. Serum beta-hCG is 850 IU/L. She is haemodynamically stable and wishes to preserve her fertility. What is the most appropriate initial management?
Q115
A 31-year-old woman undergoes laparoscopic salpingotomy for a 2.5 cm unruptured left tubal ectopic pregnancy. Her pre-operative serum beta-hCG was 2100 IU/L. The procedure is completed successfully. What is the most important aspect of post-operative follow-up specific to salpingotomy compared to salpingectomy?
Q116
A 44-year-old woman presents with heavy prolonged menstrual bleeding for 8 months. She experiences periods lasting 10-12 days every 24-26 days. Her haemoglobin is 91 g/L with a mean corpuscular volume of 68 fL. Transvaginal ultrasound shows multiple small intramural fibroids (largest 3 cm), a bulky uterus of 11 cm length, and endometrial thickness of 9 mm on day 7 of cycle. She declines surgical management. After endometrial sampling shows benign endometrium, what is the most appropriate medical management?
Q117
A 23-year-old woman presents to the emergency department with sudden onset severe left-sided abdominal pain. She has a 4-week history of amenorrhoea. Urine pregnancy test is positive. Transvaginal ultrasound shows an empty uterus, a 3 cm left adnexal mass, and a moderate amount of free fluid in the pouch of Douglas. Her serum beta-hCG is 4500 IU/L. Observations: blood pressure 100/65 mmHg, heart rate 105 bpm. She reports the pain is severe but stable. What is the most appropriate management?
Q118
A 39-year-old woman with heavy menstrual bleeding has been using a levonorgestrel-releasing intrauterine system for 18 months with good symptom control. She now presents with a 6-week history of persistent irregular vaginal bleeding and lower abdominal discomfort. Clinical examination reveals a 12-week size uterus. Transvaginal ultrasound shows the intrauterine system in situ with appropriate positioning, an endometrial thickness of 15 mm, and increased vascularity on Doppler. What is the most appropriate next step?
Q119
A 27-year-old woman with a known ectopic pregnancy is being treated with methotrexate. On day 5 post-administration, she presents to the emergency department with severe abdominal pain and vomiting. Her observations show: blood pressure 110/70 mmHg, heart rate 88 bpm, temperature 37.2°C. Abdominal examination reveals generalised tenderness but no guarding or rebound. Her initial beta-hCG was 1800 IU/L on day 0. What is the most likely diagnosis?
Q120
A 47-year-old woman presents with a 9-month history of heavy menstrual bleeding. She reports flooding and passing clots, requiring double protection. Her periods occur regularly every 28 days and last 8 days. Pelvic examination is unremarkable. Haemoglobin is 102 g/L. Transvaginal ultrasound shows a normal-sized uterus with homogeneous myometrium and endometrial thickness of 7 mm on day 6 of cycle. She has tried tranexamic acid with minimal benefit. What is the most appropriate next management step?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 111: What is the primary mechanism of action of tranexamic acid in treating heavy menstrual bleeding?
A. Decreasing prostaglandin synthesis
B. Inhibiting fibrinolysis by blocking plasminogen activation (Correct Answer)
C. Reducing endometrial proliferation
D. Stimulating platelet aggregation
E. Vasoconstriction of endometrial blood vessels
Explanation: ***Inhibiting fibrinolysis by blocking plasminogen activation***- Tranexamic acid is an **antifibrinolytic** agent that works by competitively inhibiting the activation of **plasminogen to plasmin**, which prevents the degradation of fibrin clots.- In heavy menstrual bleeding, endometrial **fibrinolytic activity** is often increased; by stabilizing clots, this medication reduces blood loss by approximately 40-50%.*Decreasing prostaglandin synthesis*- This is the primary mechanism of **NSAIDs** like mefenamic acid, which are used to reduce both menstrual blood flow and **dysmenorrhea**.- While effective for mild heavy bleeding, NSAIDs target **cyclooxygenase (COX)** enzymes rather than the fibrinolytic pathway.*Reducing endometrial proliferation*- This mechanism is characteristic of **hormonal treatments** such as the levonorgestrel intrauterine system (LNG-IUS) or **combined oral contraceptives**.- These agents cause thinning of the **endometrial lining** over time, whereas tranexamic acid is a non-hormonal treatment taken only during menses.*Stimulating platelet aggregation*- Tranexamic acid does not directly affect **platelet count** or the initial activation and **aggregation** of platelets at the site of vascular injury.- Its therapeutic benefit is derived strictly from preventing the dissolution of the **hemostatic plug** once it has already formed.*Vasoconstriction of endometrial blood vessels*- Vasoconstriction is a physiological response to endothelin or certain **prostaglandins**, but it is not the pharmacological effect of tranexamic acid.- Unlike some ergot alkaloids or specific hormones, this drug does not alter the **vascular tone** of the uterine arteries or endometrial vessels.
Question 112: A 46-year-old woman presents with a 6-month history of irregular heavy bleeding. She reports cycles varying from 21 to 45 days with heavy bleeding lasting 7-10 days. Her BMI is 34 kg/m². Transvaginal ultrasound shows endometrial thickness of 18mm and a normal-sized uterus with no fibroids. What is the most appropriate next investigation?
A. Endometrial biopsy (Correct Answer)
B. Hysteroscopy
C. MRI pelvis
D. Repeat ultrasound in 3 months
E. Serum CA-125
Explanation: ***Endometrial biopsy*** - A **transvaginal ultrasound** showing an **endometrial thickness of 18mm** in a 46-year-old woman with **abnormal uterine bleeding (AUB)** and risk factors like **obesity (BMI 34)** warrants **endometrial sampling** to rule out **endometrial hyperplasia** or **malignancy**. - **Endometrial biopsy** is the most appropriate initial investigation as it provides a **histopathological diagnosis**, which is crucial for definitive management. *Hysteroscopy* - While useful for direct visualization and targeted biopsy, **hysteroscopy** is generally performed after an initial endometrial biopsy, or if the biopsy is inconclusive, or if focal lesions like polyps are highly suspected and missed by initial sampling. - It is a more **invasive** procedure and not typically the *first* diagnostic step for diffuse endometrial pathology in the absence of a specific focal lesion identified by ultrasound. *MRI pelvis* - **MRI pelvis** is primarily used for **staging** known endometrial cancers, assessing myometrial invasion, or characterizing complex pelvic masses, rather than for the initial diagnosis of endometrial pathology causing AUB. - It is an imaging modality and does not provide a **histopathological diagnosis**, which is essential to definitively exclude hyperplasia or cancer. *Repeat ultrasound in 3 months* - Given the patient's age (46 years), **obesity (BMI 34)**, persistent **abnormal uterine bleeding**, and a significantly thickened endometrium of **18mm**, delaying investigation with a repeat ultrasound is **inappropriate** and potentially dangerous. - There is a clear indication for **prompt histological evaluation** to exclude **endometrial hyperplasia with atypia** or **endometrial carcinoma**. *Serum CA-125* - **Serum CA-125** is a tumor marker primarily associated with **ovarian cancer** and some other conditions like endometriosis or fibroids, but it is **not used for the initial investigation of abnormal uterine bleeding** or endometrial pathology. - It is a **non-specific marker** and does not provide information about the histological status of the endometrium, which is the primary concern here.
Question 113: A 37-year-old woman presents with heavy menstrual bleeding affecting her quality of life. She reports flooding and passing clots, requiring pad changes every 2 hours. Her cycles are regular at 28 days and last 8 days. She has completed her family. Pelvic examination is unremarkable and transvaginal ultrasound shows a normal-sized uterus with 12mm endometrial thickness and no structural abnormalities. Full blood count shows haemoglobin 102 g/L. What is the most appropriate first-line management?
A. Combined oral contraceptive pill
B. Endometrial ablation
C. Levonorgestrel intrauterine system (Correct Answer)
D. Oral tranexamic acid
E. Total abdominal hysterectomy
Explanation: ***Levonorgestrel intrauterine system***
- For women with **heavy menstrual bleeding (HMB)** and no identified **structural abnormalities**, the **levonorgestrel intrauterine system (LNG-IUS)** is the recommended first-line treatment according to **NICE guidelines**.
- It is highly effective, reducing menstrual blood loss significantly, and is particularly suitable since the patient has **completed her family**, as it also provides contraception.
*Combined oral contraceptive pill*
- While **COCPs** can reduce menstrual blood loss and regulate cycles, they are generally considered less effective than the **LNG-IUS** for significant HMB.
- They also carry risks like **thromboembolism** and require daily adherence, which may not be ideal for long-term management of heavy bleeding.
*Endometrial ablation*
- This is a **surgical procedure** that ablates the endometrial lining, reserved for women who have completed their family and failed medical management.
- It is not considered a **first-line management** option when effective medical treatments like **LNG-IUS** have not yet been tried.
*Oral tranexamic acid*
- **Tranexamic acid** is an **antifibrinolytic** taken only during menstruation to reduce blood loss, offering symptomatic relief but not addressing the underlying cause hormonally.
- It is less effective for long-term reduction of flow compared to the **LNG-IUS** and does not offer **contraceptive benefits** or sustained endometrial suppression.
*Total abdominal hysterectomy*
- **Hysterectomy** is a **definitive surgical treatment** for HMB but is a major, irreversible procedure, only considered after all other medical and less invasive surgical options have failed.
- It is inappropriate as a **first-line** intervention given the availability of highly effective and less invasive treatments.
Question 114: A 33-year-old woman presents with 7 weeks amenorrhoea and mild left-sided abdominal discomfort. She has had one previous ectopic pregnancy treated with salpingectomy. Transvaginal ultrasound shows an empty uterus and a 15mm adnexal mass with no free fluid. Serum beta-hCG is 850 IU/L. She is haemodynamically stable and wishes to preserve her fertility. What is the most appropriate initial management?
A. Emergency laparoscopy with salpingectomy
B. Expectant management with serial beta-hCG monitoring
C. Intramuscular methotrexate 50 mg/m² single dose (Correct Answer)
D. Laparoscopic salpingotomy
E. Repeat transvaginal ultrasound in 48 hours
Explanation: ***Intramuscular methotrexate 50 mg/m² single dose*** - Medical management with **methotrexate** is indicated because the patient is **hemodynamically stable**, has a **beta-hCG of 850 IU/L** (meeting criteria typically < 5000 IU/L), and the adnexal mass size is **15mm** (< 35mm). - This approach is ideal for women wishing to **preserve fertility** and avoids the risks associated with surgery when specific clinical criteria are met, especially given her previous salpingectomy. *Emergency laparoscopy with salpingectomy* - **Emergency surgery** is reserved for patients who are **hemodynamically unstable** or have signs of **tubal rupture**, neither of which is present in this stable patient. - **Salpingectomy** involves removing the tube, which is undesirable given her desire to **preserve fertility** and her history of a previous salpingectomy. *Expectant management with serial beta-hCG monitoring* - **Expectant management** is typically reserved for patients with very low and **decreasing beta-hCG levels** (often < 200-1000 IU/L), or a confirmed resolving ectopic. - Given the clinical presentation and hCG level of 850 IU/L with a confirmed adnexal mass, active medical intervention is generally preferred to ensure resolution of the **ectopic pregnancy**. *Laparoscopic salpingotomy* - While **salpingotomy** preserves the tube, it is a surgical procedure that carries risks and is typically considered if **medical management** with methotrexate is contraindicated or fails. - Since the patient meets the criteria for **methotrexate**, a non-invasive medical approach is the most appropriate first-line treatment, aligning with her fertility preservation wishes. *Repeat transvaginal ultrasound in 48 hours* - Repeating the **ultrasound** in 48 hours is more relevant for a **pregnancy of unknown location (PUL)** where the diagnosis is not yet confirmed. - In this case, an **adnexal mass** has already been identified, confirming the diagnosis of ectopic pregnancy and necessitating active management rather than delay.
Question 115: A 31-year-old woman undergoes laparoscopic salpingotomy for a 2.5 cm unruptured left tubal ectopic pregnancy. Her pre-operative serum beta-hCG was 2100 IU/L. The procedure is completed successfully. What is the most important aspect of post-operative follow-up specific to salpingotomy compared to salpingectomy?
A. Weekly serum beta-hCG monitoring until undetectable (Correct Answer)
B. Repeat transvaginal ultrasound at 1 week post-operatively
C. Prescription of prophylactic methotrexate
D. Routine hysterosalpingography at 6 weeks
E. Daily measurement of urinary beta-hCG for 2 weeks
Explanation: ***Weekly serum beta-hCG monitoring until undetectable***
- **Salpingotomy** is a conservative surgical approach that leaves the fallopian tube intact, creating a risk (5-20%) of **persistent trophoblastic tissue** remaining in the tube.
- **Serial quantitative serum beta-hCG** monitoring is crucial to ensure levels steadily decline to zero, as a plateau or rise indicates **persistent ectopic pregnancy** requiring further intervention (e.g., methotrexate or repeat surgery).
*Repeat transvaginal ultrasound at 1 week post-operatively*
- While ultrasound may be used to assess for complications like hematoma, it is **not sensitive** enough to reliably detect microscopic **persistent trophoblast** when hCG levels are low after salpingotomy.
- The primary follow-up for persistent trophoblastic disease relies on **biochemical monitoring** of beta-hCG levels, rather than imaging.
*Prescription of prophylactic methotrexate*
- **Prophylactic methotrexate** is not routinely given after salpingotomy; it is typically reserved for cases where **beta-hCG levels** fail to decline appropriately, indicating **persistent disease**.
- Administering methotrexate prophylactically to all patients is unwarranted due to potential **side effects** and the fact that most patients will not develop persistent disease.
*Routine hysterosalpingography at 6 weeks*
- **Hysterosalpingography (HSG)** is primarily used to assess **tubal patency** and uterine cavity integrity for future fertility planning, usually performed several months post-procedure.
- Performing HSG at 6 weeks post-salpingotomy is too early to evaluate long-term tubal function and does not provide information about the resolution of **trophoblastic tissue**.
*Daily measurement of urinary beta-hCG for 2 weeks*
- **Urinary beta-hCG tests** are typically qualitative or semi-quantitative and lack the necessary precision to accurately monitor the **rate of decline** in hCG levels.
- **Quantitative serum beta-hCG** measurement is essential for detecting subtle changes, such as a plateau or rise, which are indicative of **persistent trophoblastic activity**.
Question 116: A 44-year-old woman presents with heavy prolonged menstrual bleeding for 8 months. She experiences periods lasting 10-12 days every 24-26 days. Her haemoglobin is 91 g/L with a mean corpuscular volume of 68 fL. Transvaginal ultrasound shows multiple small intramural fibroids (largest 3 cm), a bulky uterus of 11 cm length, and endometrial thickness of 9 mm on day 7 of cycle. She declines surgical management. After endometrial sampling shows benign endometrium, what is the most appropriate medical management?
A. Tranexamic acid and mefenamic acid combination
B. Levonorgestrel-releasing intrauterine system (Correct Answer)
C. Cyclical oral progestogens (days 15-26 of cycle)
D. Combined oral contraceptive pill
E. Gonadotropin-releasing hormone agonist
Explanation: ***Levonorgestrel-releasing intrauterine system***
- The **LNG-IUS** is the first-line medical recommendation for **heavy menstrual bleeding (HMB)** and is effective for patients with small **fibroids (<3 cm)** that do not distort the uterine cavity.
- It provides a superior reduction in menstrual blood loss (up to 94%), which is critical here given the patient's **iron deficiency anaemia** (Hb 91 g/L).
*Tranexamic acid and mefenamic acid combination*
- While these reduce blood loss by approximately 20-50%, they are considered less effective than the **LNG-IUS** and are typically used intermittently during menses.
- They do not provide the continuous endometrial suppression needed to optimally manage severe **menorrhagia** and allow iron stores to fully recover.
*Cyclical oral progestogens (days 15-26 of cycle)*
- This regimen is largely ineffective for **heavy menstrual bleeding** and is no longer recommended as it does not significantly reduce blood loss.
- High-dose **progestogens** must be taken from day 5 to 26 of the cycle to be effective, but even then, they remain second-line to the **LNG-IUS**.
*Combined oral contraceptive pill*
- The **COCP** is an option for HMB, but it carries higher risks (e.g., **venous thromboembolism**) in women over 35, especially if other cardiovascular risk factors exist.
- It is generally less effective than the **LNG-IUS** in controlling bleeding and managing symptoms associated with a **bulky uterus**.
*Gonadotropin-releasing hormone agonist*
- **GnRH agonists** are primarily used for short-term management to shrink fibroids before surgery rather than long-term maintenance.
- They induce a **hypoestrogenic state** leading to side effects like bone density loss and menopausal symptoms, making them unsuitable for chronic use.
Question 117: A 23-year-old woman presents to the emergency department with sudden onset severe left-sided abdominal pain. She has a 4-week history of amenorrhoea. Urine pregnancy test is positive. Transvaginal ultrasound shows an empty uterus, a 3 cm left adnexal mass, and a moderate amount of free fluid in the pouch of Douglas. Her serum beta-hCG is 4500 IU/L. Observations: blood pressure 100/65 mmHg, heart rate 105 bpm. She reports the pain is severe but stable. What is the most appropriate management?
A. Immediate laparotomy
B. Laparoscopic salpingectomy (Correct Answer)
C. Intramuscular methotrexate
D. Expectant management with close monitoring
E. Laparoscopic salpingotomy
Explanation: ***Laparoscopic salpingectomy***
- **Surgical intervention** is the definitive treatment for ectopic pregnancies with signs of rupture (moderate free fluid in the pouch of Douglas) and a high **beta-hCG level** (4500 IU/L), even if haemodynamically borderline stable.
- **Salpingectomy** (removal of the fallopian tube) is preferred over salpingotomy when the tube is significantly damaged or there is a higher risk of **persistent trophoblastic disease**, which is more likely with higher hCG levels and free fluid.
*Immediate laparotomy*
- This open surgical approach is typically reserved for patients who are **haemodynamically unstable** (e.g., severe hypotension, shock) or where laparoscopic surgery is contraindicated or not feasible.
- Although the patient's vitals are borderline, she is not in overt shock, allowing for a less invasive **laparoscopic** approach which offers faster recovery.
*Intramuscular methotrexate*
- Medical management with methotrexate is contraindicated in this patient due to her high **beta-hCG level** (4500 IU/L, typically >3000-5000 IU/L is a contraindication) and evidence of significant intra-abdominal bleeding (moderate free fluid).
- It also requires the patient to be clinically stable and typically have an unruptured ectopic pregnancy, which is not the case here given the severe pain and free fluid.
*Expectant management with close monitoring*
- Expectant management is appropriate only for very carefully selected, asymptomatic patients with small ectopic pregnancies, no free fluid, and a low and **decreasing beta-hCG level** (typically <1000 IU/L).
- This patient has severe pain, a 3 cm mass, moderate free fluid, and a high beta-hCG, indicating a high risk of imminent or ongoing **tubal rupture** and internal haemorrhage.
*Laparoscopic salpingotomy*
- While a laparoscopic approach is suitable, **salpingotomy** involves incising the tube to remove the pregnancy, aiming to preserve fertility. However, it carries a higher risk of **persistent ectopic pregnancy**.
- Given the high hCG level and signs of significant bleeding (free fluid), there's an increased risk of complications with tube preservation, making **salpingectomy** a safer and more definitive option.
Question 118: A 39-year-old woman with heavy menstrual bleeding has been using a levonorgestrel-releasing intrauterine system for 18 months with good symptom control. She now presents with a 6-week history of persistent irregular vaginal bleeding and lower abdominal discomfort. Clinical examination reveals a 12-week size uterus. Transvaginal ultrasound shows the intrauterine system in situ with appropriate positioning, an endometrial thickness of 15 mm, and increased vascularity on Doppler. What is the most appropriate next step?
A. Remove and reinsert a new levonorgestrel-releasing intrauterine system
B. Commence oral progestogens
C. Perform endometrial biopsy (Correct Answer)
D. Prescribe additional tranexamic acid
E. Reassure and review in 3 months
Explanation: ***Perform endometrial biopsy***
- The presence of an **endometrial thickness of 15 mm** while using a **levonorgestrel-releasing intrauterine system (LNG-IUS)** is highly abnormal, as the device typically causes **endometrial atrophy**.
- New-onset **persistent irregular bleeding** and increased **vascularity** on Doppler necessitate histopathological evaluation to rule out **endometrial hyperplasia** or **endometrial carcinoma**.
*Remove and reinsert a new levonorgestrel-releasing intrauterine system*
- The current device is **appropriately positioned** and has only been in situ for 18 months, indicating that device failure/expiry is not the issue.
- Replacing the device without investigating the **thickened endometrium** would dangerously delay the diagnosis of potential malignancy.
*Commence oral progestogens*
- Adding systemic progestogens is an appropriate treatment for certain types of bleeding, but it does not serve as a **diagnostic tool** for the suspicious ultrasound findings.
- You must first exclude **atypical hyperplasia** or **carcinoma** through biopsy before determining if hormonal management is safe or sufficient.
*Prescribe additional tranexamic acid*
- Tranexamic acid is used for the symptomatic relief of **heavy menstrual bleeding**, but it does not address the **irregular bleeding pattern** or the physical ultrasound findings.
- Using it here would be **symptomatic management** only, failing to investigate the underlying cause of the thickened, vascular endometrium.
*Reassure and review in 3 months*
- Reassurance is contraindicated when a patient develops a **change in bleeding pattern** alongside suspicious imaging findings (**15 mm endometrial thickness**).
- A 3-month delay risks the **progression of pathology**, as these features are red flags that warrant immediate investigation regardless of the patient's age.
Question 119: A 27-year-old woman with a known ectopic pregnancy is being treated with methotrexate. On day 5 post-administration, she presents to the emergency department with severe abdominal pain and vomiting. Her observations show: blood pressure 110/70 mmHg, heart rate 88 bpm, temperature 37.2°C. Abdominal examination reveals generalised tenderness but no guarding or rebound. Her initial beta-hCG was 1800 IU/L on day 0. What is the most likely diagnosis?
A. Ruptured ectopic pregnancy requiring emergency surgery
B. Methotrexate treatment failure
C. Methotrexate-induced side effects (separation pain) (Correct Answer)
D. Acute gastroenteritis
E. Developing tubo-ovarian abscess
Explanation: ***Methotrexate-induced side effects (separation pain)***
- This occurs in **15-20%** of patients, typically **3-7 days** after methotrexate, due to tubal distension as the pregnancy separates from the tubal wall.
- The patient remains **haemodynamically stable** with no signs of peritonism (no guarding or rebound), distinguishing it from clinical rupture.
*Ruptured ectopic pregnancy requiring emergency surgery*
- While a major concern, it is less likely here given the **normal blood pressure** (110/70 mmHg) and **heart rate** (88 bpm).
- Rupture typically presents with **signs of shock** and surgical abdomen features like **guarding or rebound tenderness**, which are absent in this case.
*Methotrexate treatment failure*
- Failure is defined by an **inadequate fall in beta-hCG** (less than 15% decrease) between **days 4 and 7**, not primarily by clinical pain on day 5.
- Pain alone does not indicate failure, as long as the patient remains **clinically stable** and the biochemical markers follow the expected trend.
*Acute gastroenteritis*
- While vomiting is present, the context of a known ectopic pregnancy and **generalised abdominal tenderness** points more toward a gynecological etiology.
- Gastroenteritis would typically involve **diarrhea** and hyperactive bowel sounds, rather than isolated pain following **methotrexate administration**.
*Developing tubo-ovarian abscess*
- This typically presents with **fever**, purulent vaginal discharge, and persistent pelvic pain rather than acute onset after medical therapy for ectopic pregnancy.
- The patient is **afebrile** (37.2°C), and there is no mention of inflammatory markers or history suggestive of **pelvic inflammatory disease**.
Question 120: A 47-year-old woman presents with a 9-month history of heavy menstrual bleeding. She reports flooding and passing clots, requiring double protection. Her periods occur regularly every 28 days and last 8 days. Pelvic examination is unremarkable. Haemoglobin is 102 g/L. Transvaginal ultrasound shows a normal-sized uterus with homogeneous myometrium and endometrial thickness of 7 mm on day 6 of cycle. She has tried tranexamic acid with minimal benefit. What is the most appropriate next management step?
A. Refer for endometrial ablation
B. Prescribe combined oral contraceptive pill
C. Arrange endometrial biopsy before further treatment (Correct Answer)
D. Insert levonorgestrel-releasing intrauterine system
E. Prescribe mefenamic acid
Explanation: ***Arrange endometrial biopsy before further treatment*** - For women aged **45 and over** presenting with **heavy menstrual bleeding (HMB)**, clinical guidelines recommend performing **endometrial sampling** to exclude **endometrial hyperplasia** or **malignancy**. - Although her **transvaginal ultrasound** is relatively reassuring, her age and persistent symptoms (heavy bleeding, clots, and anemia) necessitate ruling out pathology before starting definitive long-term therapy.*Prescribe combined oral contraceptive pill* - This medication is used for **heavy menstrual bleeding** but should not be the first step in a 47-year-old before excluding serious **endometrial pathology**. - At age 47, the **combined oral contraceptive pill** requires a careful assessment of **cardiovascular risk factors** and may be contraindicated if she smokes or has other comorbidities.*Insert levonorgestrel-releasing intrauterine system* - The **LNG-IUS (Mirena)** is the first-line medical treatment for HMB; however, in a patient over 45, it should only be inserted after **endometrial biopsy** has confirmed the absence of cancer. - Inserting the device before sampling could delay the diagnosis of **endometrial cancer** and complicate later histological evaluation.*Prescribe mefenamic acid* - **Mefenamic acid** is an NSAID that reduces blood loss by inhibiting prostaglandins, but it is generally less effective than **tranexamic acid**, which has already failed for this patient. - This approach treats only the symptoms and fails to address the requirement for **diagnostic sampling** in a woman over the age of 45.*Refer for endometrial ablation* - **Endometrial ablation** is an effective surgical option for HMB, but it is reserved for patients where medical management has failed or is declined, and **endometrial pathology** has been ruled out. - It is crucial that **endometrial sampling** is performed prior to ablation to ensure there is no **pre-malignant** or **malignant** condition that would be masked or missed by the procedure.
