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B. Local silver nitrate application
C. Change dose of pill
D. Insert Mirena
E. Endometrial biopsy
G. Tranexamic acid
H. Novasure endometrial ablation
I. Add to waiting list of lap hysterectomy
J. Insert mirena and follow up in 6months
K. Perform Endometrial sampling with Hysteroscopy
L. Reinsert Mirena coil
M. Tranexamic acid with mirena
N. Total abdominal hysterectomy with bilateral salpingo-oophrectomy.
Each of the above options describes various woman presenting with abnormal uterine bleeding.
For each patient select the single most appropriate management option from the list
1. Ms Lucy, 27-year-old nulliparous, presents with a history of post-coital bleeding for 6 months. Bleeding is often unpredictable and is affecting her relationship. She is otherwise fit and well. She is using a COCP over the last year for contraception. BMI is 21kg/m2.Gynaecological examination is within normal limits with the exception of a cervical ectropion. Swabs for Chlamydia and an HVS are negative. Pelvic USS shows an endometrial thickness of 10 mm with a normal uterus, rest of the pelvic anatomy being normal. What treatment is most suited to her?
2. Mrs, Brown 46-year-old mutiparous , who has completed her family presents with a history of painful heavy menstrual bleeding with infrequent cycles (every 2–3 months) for 1 year. Her BMI is 44. She is currently on iron supplements for anaemia and is prescribed proton pump inhibitors for GORD. She is otherwise fit and well. Abdominopelvic examination is unremarkable. Pelvic ultrasound shows an endometrial thickness of 12 mm with a bulky uterus and normal ovaries with no pelvic pathology. A pipelle biopsy suggests a proliferative endometrium.
3. You review a 48-year-old woman in the menstrual disorders clinic who complains of a 3-year history of heavy menstrual bleeding. She is a mother of four children, all born by normal vaginal deliveries. Her menstrual cycle is every 30 days and the bleeding lasts for 6 days. However, recently it has become associated with clots.
Cervical smears are up-to-date and her BMI is 39. You perform atransvaginal scan which reveals a bulky uterus of 8 mm endometrial thicknessand three intramural fibroids of 1, 3and 5 cm size respectively. On vaginal examination you find stage I cystocele, stage I rectocele and stage II uterine descent.The current waiting list for benign gynaecological surgery in your hospital is 4 months.
4. Mrs. Leslie , 50-year-old woman had a Mirena IUS inserted 2 years ago for heavy menstrual periods. She was initially amenorrhoeic but has now developed heavy menstrual bleeding again. Endometrial biopsy shows complex endometrial hyperplasia with atypia.
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