🤔 MEDIUM

Test yourself with this set of MCQs on a wide range of causes of abnormal mnenstrual bleeding. Remember anyone with a uterus can have abnormal menstrual bleeding, not just women! 

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Approach to Patient with abnormal menstrual bleeding

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Question 1

Stem 1, question 1 of 5

Amina, a 16 year old female, presents to her GP worried that she has not started having periods.
What is primary amenorrhoea?
A
A lack of menses in a non-pregnancy person with a uterus for at least 3 cycles of their previous interval
B
A lack of menses for 6 months in a patient who was previously menstruating
C
Any variance of the normal menstrual cycle defined on the basis of frequency, regularity, duration and volume
D
Uterine bleeding at irregular intervals, particularly between expected menstrual periods
E
A lack of menses at age 15 in a patient with appropriate development of secondary sexual characteristics or absent menses by age 13 years and no other pubertal maturation
Question 1 Explanation: 
When discussing abnormal menstrual bleeding there are a large number of definitions that are key to understand. Amenorrhoea is the transient or permanent absence of menstrual flow, which can be primary (rare) or secondary (more common) in nature. Primary amenorrhoea is a lack of menses at age 15 in patient with appropriate development off secondary sexual characteristics or absent menses by age 13 years and no other pubertal maturation. The other answer options refer to the following definitions respectively: Secondary amenorrhoea, secondary amenorrhoea, abnormal uterine bleeding, metrorrhagia.
Question 2

Stem 1, question 2 of 5

Which of the following can present with amenorrhoea? Select all that apply 
A
Polycystic ovary syndrome
B
Leiomyomata
C
Premature ovarian failure
D
Hyperprolactinaemia
E
Endometritis
Question 2 Explanation: 
Amenorrhoea has a number of different causes including causes extrinsic to the reproductive system. Polycystic ovary syndrome (PCOS), premature ovarian failure and hyperprolactinaemia can all result in amenorrhoea. Whereas leiomyomata and endometritis can result in menorrhagia, aka heavy menstrual bleeding.
Question 3

Stem 1, question 3 of 5

The GP performs some blood tests to investigate the cause of Amina's amenorrhoea. The results are: High serum LH High serum testosterone Elevated total cholesterol and LDL-cholesterol Low HDL-cholesterol Normal prolactin
What is the most likely diagnosis based on these blood results?
A
Hyperprolactinaemia
B
Polycystic ovary syndrome
C
Female athlete triad
D
Hyperthyroidism
E
Turner's syndrome
Question 3 Explanation: 
These bloods reflect polycystic ovary syndrome best out of the answer choices. High LH, testosterone and elevated lipid profile with a normal prolactin are commonly seen in PCOS. A normal prolactin rules out hyerprolactinaemia. Female athlete triad refers to low energy available (with or without disordered eating), menstrual dysfunction and low bone density. Turner's syndrome is diagnosed through karyotyping. Thyroid function has not been tested with these results.
Question 4

Stem 1, question 4 of 5

Amina is diagnosed with polycystic ovary syndrome. The GP calculates her BMI 32.
What would be appropriate management for Amina?
A
Combined oral contractive pill
B
Metformin
C
Cyclic progestin
D
Tranexamic acid
E
Supported weight loss
Question 4 Explanation: 
BMJ Best Practice (Feb 2021) states that weight loss alone can restore ovulation in up to 80% of patients who are obese or overweight. This occur by reducing hyperinsulinaemia and thus hyper-androgenism. Combined oral contraceptive pill, metformin and cyclic progestin are 2nd and 3rd line treatments for PCOS with amenorrhoea alone. Tranexamic acid is an antifibrinolytic used to treat heavy menstrual bleeding.
Question 5

Stem 1, question 5 of 5

What is the mechanism of the oral combined contraceptive?
A
Mimics ovulation, reduces LH and FSH
B
Mimics ovulation, reduces LH and FSH, endometrial changes
C
Suppresses ovulation, increases LH and FSH
D
Suppresses ovulation, reduced LH and FSH
E
Suppreses ovulation, no effect on LH and FSH
Question 5 Explanation: 
The combined oral contraceptive pill uses both oestrogen and progesterone to mimic ovulation and reduces LH and FSH. The progesterone only pill mimics ovulation, reduces LH and FSH plus causes endometrial changes. The other three answers are made up and false.
Question 6

Stem 2, question 1 of 3

Priyanka, a 56 year old female, presents to GP with post menopausal bleeding. She went through menopause at 49, has had 3 pregnancies and takes HRT patches.
What is post-menopausal bleeding?
A
Vaginal bleeding that occurs within 2 years of menopause establishment
B
Vaginal bleeding that occurs >6 months after menopause has been established
C
Vaginal bleeding that occurs >18 months after menopause has been established
D
Vaginal bleeding that occurs >12 months after menopause has been established
E
Vaginal bleeding that occurs 5 years after menopause has been established
Question 6 Explanation: 
Post-menopausal bleeding occurs >12 months after menopause has been established. Remember that a diagnosis of menopause is made in retrospect. Post-menopausal bleeding is always abnormal and must be investigated to exclude sinister diagnoses.
Question 7

Stem 2, question 2 of 3

Uterine malignancy is associated with an inherited genetic predisposition to uterine cancer
Which of the following inherited syndromes predisposes to uterine cancer?
A
Hereditary non-polyposis colon cancer
B
BRCA1 mutation
C
Familial adenomatous polyposis
D
Xeroderma pigmentosum
E
Li-Fraumeni syndrome
Question 7 Explanation: 
Hereditary non-polyposis (also known as Lynch Syndrome) colon cancer predisposes an individual to uterine malignancy, via autosomal dominant inheritance. BRCA1 mutations predispose to breast and ovarian cancers. Familial adenomatous polyposis will result in colon cancer within the first two decades of life. Xeroderma pigmentosum is caused by an inability to repair UV light induced damage, resulting in skin cancers. Li-Fraumeni syndrome results in TP53 mutations which greatly increases the risk of many cancers.
Question 8

Stem 2, question 3 of 3

The GP examines Priyanka
What is the most likely examination finding of uterine malignancy?
A
Uterine tenderness on examination
B
Uterine enlargement and irregularity on bimanual examination
C
Uterine, cervical motion and adnexal tenderness
D
Unremarkable
E
Excessive body hair, acne and obesity
Question 8 Explanation: 
Uterine malignancy commonly presents with uterine enlargement and irregularity on bimanual examination. Uterine tenderness is often found in endometritis, whereas the triad of uterine, adnexal and cervical motion tenderness is seen in pelvic inflammatory disease. Examination may be unremarkable in cervical cancer. Excessive body hair, acne and obesity may be seen in PCOS
Question 9
What are uterine fibroids primarily composed of?
A
Smooth muscle only
B
Fibrous connective tissue only
C
Collagen
D
Smooth muscle and fibrous connective tissue
E
Skeletal muscle
Question 9 Explanation: 
Uterine fibroids are the most common benign uterine tumours and can present with excessive uterine bleeding. These can distort the uterine cavity leading to miscarriage or infertility. They are primarily composed of smooth muscle and fibrous connective tissue.
Question 10
Cora, an 8 year old female, presents to GP with her worried parents. Cora has noticed blood in her underwear  for 3 days and her parents have noticed she has started to develop breasts.
What differential should the GP suspect?
A
Infection of the vagina
B
Endometrial cancer
C
Hyperthyroidism
D
Precocious puberty
E
Leiomyomata
Question 10 Explanation: 
This is a challenging question so well done if you managed to work it out. Premenarchal bleeding is vaginal bleeding that occurs before a person with a uterus is 9 years old and is always abnormal. Precocious puberty should be suspected if bleeding is assoicated with early development of secondary sexual characteristics, particularly breast development. Infection of the vagina can result in isolated abnormal bleeding but given the secondary sexual characteristics this is unlikely. Endometrial cancer, leiomyomata and hyperthyroidism do not fit the presentation.
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