Independent learning program for GPs

Unit 464
UnitNovember
471 June 2011
2010

Menstrual
Bipolar
disorders
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www.racgp.org.au/check

Independent learning program for GPs

Medical Editor
Catherine Dodgshun

Bipolar disorders
Menstrual
disorders

Editor
Nicole Kouros

Unit 471
464 June
November
2011 2010

Production Coordinator
Morgan Liotta

From the editor

2 2

Case 1
1 Jane presents
Chris concern
with painful periods

3 3

Case 2
2 
Lucia feels
Dorothy
irritable
is experiencing
and bloated pain
everyin month
her groin

6 6

Case 3
3 Sophies
Jills
dysfunctional
knee pain uterine bleeding

910

Case 4
4 Casey Angela
has spotting
presents
between
with painful
her periods
and stiff joints

1214

Case 5
5 Tamaras
Janpostcoital
has ongoing
bleeding
knee pain

1616

References
References

2117

Resources
Resources

2218

Category 2 QI&CPD activity

2419

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Jason Farrugia
Graphic Designer
Beverly Jongue
Authors
Danielle Mazza
Ann Drillich
Reviewer
Louise Stone
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from the editor

This unit of check focuses on menstrual disorders with clinical scenarios involving painful menses in a
young adolescent, heavy menstrual bleeding in a middle aged woman, breakthrough bleeding (bleeding
at a time other than the withdrawal bleed while taking the combined oral contraceptive pill), postcoital
bleeding, and symptoms that suggest premenstrual syndrome. The authors of this unit bring a wealth of
clinical, research and teaching experience to the topic.
The authors are:
Danielle Mazza MD, MBBS, FRACGP, DRANZCOG, GradDipWomHealth, Professor and Head, Department
of General Practice, Monash University, and author of Womens health in general practice, recently
published in its second edition. She was previously the medical director of Family Planning Victoria
Ann Drillich MBBS, BSc, Lecturer, Department of General Practice, Monash University, and general
practitioner with a special interest in womens and preventive health. She is engaged in medical student
teaching and previously worked in theWomens Health Program at Monash University. She is currently
writing a nonmedical book.
The learning objectives of this unit are to:
display increased confidence in the assessment and management of primary dysmenorrhoea
display increased confidence in the assessment and management of heavy menstrual bleeding in middle
aged women, including appropriate use of hormonal treatment options
display increased confidence in the assessment and management of breakthrough bleeding and
postcoital bleeding
understand the role of various pharmacological and nonpharmacological treatments in premenstrual
syndrome
consider the possibility of endometrial carcinoma and cervical carcinoma in patients who present with
abnormal vaginal bleeding, and appropriately refer to a gynaecologist in a timely manner.
We hope that this unit of check will assist you to manage menstrual disorders in general practice.
This unit of check will be the last to be printed monthly. From this issue onward check will be printed as
three issues every quarter as a 'three-in-one' publication. Each issue of check will continue to be available
every month through gplearning as it is now.
Kind regards

Catherine Dodgshun
Medical Editor

check Menstrual disorders

Case 1

check Menstrual disorders

Case 1
Jane presents with painful periods
Jane, 14 years of age, presents alone while her
mother is in the waiting room. You are her local GP
and have known her for 6 years. She complains
of severe, central lower abdominal pain with her
periods for the past few menstrual cycles. The
pain begins gradually on day 1 of her menses
and becomes very severe within a few hours. She
often gets nauseated and sometimes vomits, and
sometimes she feels a nagging ache at the top of her
thighs when she gets the abdominal pain.
Paracetamol does not relieve the pain. Yesterday
her mother gave her a strong analgesic with 30 mg
codeine, and the pain resolved but she slept for the
remainder of the day.
Jane went through menarche at 13 years of age. Her
cycles were irregular for the first 6 months but now
are regular every 28 days, lasting approximately
7 days. She has never been sexually active and does
not have a boyfriend.

Question 2
What clinical features distinguish primary dysmenorrhoea from
secondary dysmenorrhoea? What are the underlying conditions that
can cause secondary dysmenorrhoea?

Question 3
What approach is especially important when dealing with adolescent
patients? Are you obliged to discuss Janes treatment with her
mother?

She is otherwise well.

Her mother suggested Jane see you because she
is concerned that the severity of the pain might
indicate that there is something is wrong with Jane.

Question 1
What are the clinical features of primary dysmenorrhoea? Is this
diagnosis common?

Further history
Further medical history does not reveal anything of note.
You therefore diagnose primary dysmenorrhoea. On further
questioning, Jane says that she has not participated in any
regular exercise since stopping netball last year after a minor
ankle sprain.
Question 4
What is the underlying cause of Janes symptoms?

Case 1

Question 5
Does Jane have any risk factors, including lifestyle factors, that may
respond to intervention?

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CASE 1 ANSWERS
Answer 1
Primary dysmenorrhoea is the usual cause of dysmenorrhoea in
adolescence. Primary dysmenorrhoea is a diagnosis of exclusion
based on key features in the history and a normal examination.
Key features in the history include the onset of pain with the onset of
ovulatory cycles, usually 612 months after the onset of menarche.1
Pain usually begins with the onset of the menses and occurs only in
the first 13 days of the menses. The pain consists of a dull ache in
the suprapubic region with sharp, spasmodic exacerbations, and it
may radiate to the lower back and upper thighs. Nausea and vomiting
may be prominent, due to a prostaglandin effect or as a result of
severe pain.

Question 6
How should Janes primary dysmenorrhoea be managed?

Primary dysmenorrhoea is common. Prevalence of pain in a recent

Australian study2 of girls aged 1519 was 93%. Twenty one percent
experienced severe pain, 26% reported school absence, and 24%
reported moderate to high interference with 4 out of 9 life activities.
Approximately 33% of girls surveyed had seen a GP. The prevalence
of painful periods in women aged 1845 attending primary care
practices has been shown at 90%.3
Answer 2
Primary dysmenorrhoea is characterised by the features described
in Answer 1, these are distinguished from secondary dysmenorrhoea
by the following features: onset at age of mid to late 20s, pain
that persists beyond the first 23 days of the period, presence of
abdominal/pelvic pain at other times of the menstrual cycle, and
presence of other types of pain such as dyspareunia (pain with
intercourse). Nonresponsiveness to an appropriate regimen of first
line therapies for presumed primary dysmenorrhoea also suggests
a diagnosis of secondary dysmenorrhoea. Table 1 lists the clinical
features that distinguish primary and secondary dysmenorrhoea.

Question 7
Are there other treatment options?

Secondary dysmenorrhoea can be uterine in origin (as a result

of adenomyosis, fibroids, an intrauterine device, cervical stenosis
or polyps) or extrauterine (endometriosis, pelvic inflammatory
disease, functional ovarian cysts, tumours malignant or benign, or
inflammatory bowel disease).

Table 1. Distinguishing between primary and

secondary dysmenorrhoea on history4
Feature

Primary
dysmenorrhoea

Secondary
dysmenorrhoea

Age at symptom onset Adolescence

Mid to late 20s

Duration

First 23 days of
period

Persists beyond first

23 days of period

Pain at other times of

menstrual cycle

No

Yes

Other types of pain

No

Dyspareunia

check Menstrual disorders

Answer 3
The following are important aspects in your approach to dealing with
adolescent patients.
Adequate time and a nonjudgmental manner it is important
to have a relaxed and unhurried approach (even though you
may have a full waiting room). While maintaining a professional
manner it is important to be open and nonjudgmental, which may
allay the patients anxiety and improve trust and communication
Confidentiality adolescent patients have the legal right to
confidentiality unless they cannot be considered a mature minor
or are themselves at risk, or pose a risk to others.5 However,
consent issues involving adolescents are complex,and ifyou
have uncertainty about your legal obligation, specific cases may
warrant consultation with acolleague or a medical defence
organisation. At the start of the consultation with Jane you should
explain to her that the consultation is confidential, providing you
have no significant concern of there being any risk (eg. sexual or
physical abuse, harm to herself or others)
Performing a psychosocial screen aspects of this can
be summarised by the acronym HEADSSS.6 Taking a full
psychosocial history from Jane could involve questioning
her about:
Home
Education/employment/eating/exercise
Activities/peers
Drugs/cigarettes/alcohol
Sex/sexuality (abuse)
Suicide/depression screen/other symptoms
Safety/spirituality.
Answer 4
Myometrial contractions are stimulated by prostaglandins, in
particular PGF2. Uterine tone and muscular activity is increased
in women who suffer from period pain. Compared to controls, this
group of women has been found to have elevated levels of PGF2
and PGE2.7
Answer 5
Risk factors for primary dysmenorrhoea are younger age at
menarche, long duration of menstrual flow, smoking, obesity, alcohol
consumption, high levels of stress, anxiety, depression and disruption
of social networks.8,9
Jane has no risk factors for dysmenorrhoea but she does have a
lifestyle factor that may respond to intervention increasing her
levels of exercise may improve her stress levels, provide social
benefits and may reduce her dysmenorrhoea.

Case 1

Answer 6
Jane should be educated about the prevalent and benign nature of
the condition. In addition, she should be reassured that in the vast
majority of cases symptoms can be prevented and controlled.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral
contraceptive pill (COCP) are very effective first line agents for the
treatment of primary dysmenorrhoea. Nonsteroidal anti-inflammatory
drugs work by inhibiting the production of the prostaglandins that
are the cause of the pain, and should be used in sufferers when
contraception is not required. The different formulations of NSAIDs all
have similar efficacy for dysmenorrhoea, and pain relief is achieved in
approximately 70% of women.10 Compared with placebo treatment,
the number needed to treat is 2.1 for at least moderate pain relief
over 35 days.10
It is therefore important to explain to adolescents that NSAIDs act to
prevent pain rather than as an analgesic to treat pain. For this reason
the following advice needs to be given to young women who require
them:
start taking the NSAIDs as soon as you know that your period is
imminent, or as soon as the bleeding starts
because these tablets prevent pain you need to take them at
the correct dose on a regular basis for the first 13 days of your
period.
While dosing may be a factor in choosing which NSAID to
recommend (as it varies between NSAIDs) the choice of which NSAID
to take is less important than using the NSAID in the correct way.
Fortunately the incidence of side effects is low, probably because of
the intermittent and short term nature of use.
If there is significant residual pain with the appropriate dosage and
regimen of NSAIDs, the COCP may also be used in conjunction with
the NSAIDs to treat residual pain.
The COCP (which works by reducing menstrual flow and suppressing
ovulation) is also highly effective for first line treatment of primary
dysmenorrhoea where contraception is required, or as an alternative
to NSAIDs. However, about 30% of users report no relief with use of
the COCP.11
Approximately 1020% of women will be refractory to first line
treatment. If either NSAIDS, or the COCP, or both do not control
primary dysmenorrhoea, then the diagnosis should be questioned,
and referral to a specialist considered. It is important to remember
that endometriosis can occur in adolescence.
Answer 7
There are a variety of alternative and nonpharmaceutical therapies
with variable levels of evidence supporting their efficacy. Treatments
include thiamine, pyridoxine, magnesium, fish oil and vitamin E.12
Nonpharmacological approaches with some support include exercise,13
acupuncture,14 heat therapy15 and a low fat vegetarian diet.16

Case 2

Case 2
Lucia feels irritable and bloated every month
Lucia is 34 years of age, and is a kindergarten
teacher who lives with her husband and two
children, aged 5 and 7 years. After requesting a
doctors certificate for an upper respiratory tract
infection she mentions to you that she frequently
feels tearful, irritable and bloated before her period
each month, and that this has been happening for
several years. Her menses last about 1 week and
the symptoms go away completely within 12 days
after onset. Her menses occur every month and she
considers that they are not painful and are not heavy.
She has no bleeding in between her menses or after
intercourse. Her husband had a vasectomy 2 years
ago. Lucia attended for a Pap test 1 month ago,
which was normal.

check Menstrual disorders

Question 3
What other conditions should you consider as differential diagnoses
of Lucias presentation?

Question 4
What is the aetiology of PMS?

Question 1
What is the likely diagnosis for Lucias symptoms? Is this condition
common?

Further history
You take a thorough history, including a psychosocial history.
Lucia has no symptoms of depression or an anxiety disorder but
feels tired at times. She tells you she and her husband rarely
go out since having had the children. Lucia has tried vitamin B6
but is not sure whether it helps her symptoms. She wants to
know if she should continue taking it.
Question 5
Question 2
How does premenstrual syndrome (PMS) present?

What is the next step in your management? What investigations will

you perform?

Case 2

check Menstrual disorders

Question 6
What nonpharmacological and pharmacological treatments are
effective for PMS?

Answer 3
Women presenting with premenstrual complaints may have
psychiatric, medical and/or gynaecological comorbidity and these may
be erroneously labelled by the patient as PMS. General practitioners
should exclude psychiatric illness, including major depression or
anxiety disorder, and consider gynaecological conditions such as
polycystic ovarian sydrome in patients presenting with PMS.
The constellation of Lucias symptoms, the intermittent nature of her
bloating and the absence of certain specific symptoms attributable to
the conditions above make PMS the most likely diagnosis.
Answer 4
Some of the symptoms such as breast fullness and tenderness
may be considered physiological. The exact aetiology of PMS is
still unknown but is currently thought to be related to sensitivity to
progesterone in women with an underlying serotonin deficiency.
In addition, deregulation of the allopregnanolone (a progesterone
metabolite) and gamma-aminobutyric acid (commonly known as
GABA) system may be involved. Genetic factors and endogenous
factors may also play a role.22

CASE 2 ANSWERS
Answer 1
It is likely that Lucia has PMS as she has a history of at least one
or more mood and/or physical symptom/s occurring on a cyclical
basis, relieved by the onset of menstruation.17 Up to 90% of women
experience some kind of cyclical symptoms, of these 510%
are severely affected.18 Figure 119 displays the prevalence of
premenstrual symptoms in women.
The extreme form of PMS, premenstrual dysphoric disorder (PMDD)
occurs in 35% of affected women, and has specific diagnostic
criteria (Table 2).20
Answer 2
Women with PMS tend to have the same symptoms each cycle.21
These can be divided into symptoms or symptom clusters, including
those related to affect; cognition and performance; fluid retention; or
symptoms of a general somatic nature. These are shown in Table 3.

Answer 5
The next step in management is to confirm the diagnosis. In Lucias
case, a prospective 3 month symptom chart with a menstrual calendar
is appropriate to confirm the cyclical nature of her symptoms in the

Table 2. Criteria for premenstrual dysphoric disorder20

The presence of at least five luteal phase symptoms, at least
one of which must be a mood symptom:
depressed mood or dysphoria
anxiety or tension
affect lability
irritability
decreased interest in usual activities
concentration difficulties
marked lack of energy

35% PMDD
510% PMS (severe)

marked change in appetite, overeating or food cravings

hypersomnia or insomnia
feeling overwhelmed

616% seek help

3050% claim to
have PMS when
surveyed
Increasing
dysphoria

7595% have
premenstrual
changes

Figure 1. Prevalence of premenstrual symptoms in women19

other physical symptoms (eg. breast tenderness, bloating)

Three prospective cycles of daily charting to confirm the timing
of symptoms: symptoms should have been present for most of
the last week of the luteal phase, remitted within a few days after
onset of menses, and remained absent in the week after menses
Symptoms markedly interfere with work, school, social activities
or relationships
Symptoms must not be the exacerbation of another psychiatric
condition

Case 2

check Menstrual disorders

Table 3. Premenstrual syndrome symptom clusters

Affective

Cognitive or performance

Fluid retention

General somatic

Depression or sadness
Mood instability or mood swings
Irritability
Tension
Anxiety
Tearfulness
Restlessness
Anger
Loneliness
Appetite change
Food cravings
Changes in sexual interest
Pain
Headache or migraine
Back pain
Breast pain
Abdominal cramps
General or muscular pain

Difficulty concentrating
Decreased efficiency
Confusion
Forgetfulness
Accident prone
Social avoidance
Temper outbursts
Energetic

Breast tenderness or swelling

Weight gain
Abdominal bloating or swelling
Swelling of extremities

Fatigue or tiredness
Dizziness or vertigo
Nausea
Insomnia

Reproduced with permission from Elsevier Australia

luteal phase, which resolve with her menses. This is necessary before
a diagnosis of PMS is confirmed and other comorbidities which might
account for the symptoms are excluded. You request that she return
in 3 months with a symptom chart to confirm the diagnosis. Figure 2
provides an example of a symptom chart for prospective recording of
symptoms thought to be related to PMS.
Investigations are required only to exclude other diagnoses
suggested by history and examination, and Lucia requires no
investigation at this stage.

Daily symptom calendar

In the chart below write down what you feel each
day over 3 months
A = no symptoms
B = some symptoms
C = severe symptoms
Also be sure to shade the days you menstruate

Your management will also involve explaining to Lucia the most likely
cause of her symptoms. Empathy is important. You should explain to
Lucia about the prevalence of PMS and reassure her of its benign,
albeit troublesome, nature.
You should explain to Lucia that at present there is no conclusive
evidence that vitamin B6 is effective in treating PMS. However, even
though there is only limited evidence of its usefulness in treating
the symptoms of PMS, Lucia could continue with her current dose
of 100 mg of vitamin B6 per day if she wishes. You inform her that
higher doses of vitamin B6 have been found to have neurological
side effects but there is no conclusive evidence of these effects at
this dose.
Figure 2. A symptom chart for prospective recording of symptoms
thought to be related to PMS.
Reproduced with permission from Elsevier Australia

Case 2

check Menstrual disorders

Answer 6
You should discuss with Lucia the possibility of her engaging in
moderate exercise and explain its well documented positive effects
on mood and general health.23 Women who engage in moderate
aerobic exercise at least 3 times per week have significantly fewer
premenstrual symptoms than sedentary women.24,25 There is
evidence of benefit with relaxation techniques such as yoga and
meditation.26
Providing general advice about maintaining a healthy, low fat, high
fibre diet with reduced salt, sugar and caffeine, and restricting
alcohol intake, as well as addressing Lucias stressors and issues
regarding emotional and social support could form part of your overall
treatment.
A pharmacological treatment for which there is proven benefit in PMS
is with selective serotonin uptake inhibitors (SSRIs). These are highly
effective in treating physical, functional and behavioural symptoms
of PMS, confirmed by a recent Cochrane Review,27 with all SSRIs
studied being effective. Because of their rapid onset of action in
treating PMS symptoms (in comparison to their slow onset for the
treatment of depression) SSRIs can be taken in the luteal phase only
(ie. midcycle to menses) orthey can be used continuously throughout
the menstrual cycle. Continuous use of SSRIs is more effective for
somatic symptoms, while intermittent use is more effective for mood
symptoms.

Table 4 .Therapies of no proven benefit for the

treatment of PMS30
Herbal medicines:
chaste tree (Vitex agnus-castus)
gingko biloba
evening primrose oil
Homeopathy
Dietary supplements:
calcium supplementation
magnesium supplementation
vitamin E
multinutrient supplement
carbohydrate drink
Relaxation
Massage
Reflexology
Chiropractic
Biofeedback

Nausea is a common side effect of SSRIs but usually disappears

within a few days and does not reappear, even with intermittent
therapy.28 Reduced libido and anorgasmia are other common
side effects that persist during active treatment, but resolve in the
treatment free interval.
With intermittent use of SSRIs, discontinuation symptoms are seldom
a problem, suggesting that 2 weeks (the luteal phase of the cycle) is
too short an exposure period to elicit withdrawal symptoms.
Although SSRIs are not addictive, care should be taken to wean
the patient off continuous treatment rather than ceasing it abruptly,
because the latter may elicit withdrawal symptoms.
Feedback
The COCP has so far not been proven to improve PMS
symptoms. A low dose (20 g) ethinyloestradiol pill with
drospirenone appears to help symptoms, however, more
research is required to determine whether this combination is
more effective than other COCPs.29
There are several therapies which are of no proven benefit
for the treatment of PMS (Table 4). There is a large placebo
response irrespective of which oral therapy is used (70%).
Randomised controlled trials show no difference between
placebo and progesterone, vitamin B6, evening primrose oil and
the complementary therapies listed in Table 4. Therapy should
target individual symptoms and be tailored to an individuals
response.

Case 3

Case 3
Sophies dysfunctional uterine bleeding

check Menstrual disorders

Question 3
What investigations will you do? What might they show?

Sophie, 46 years of age, is new to your general

practice. She has three children, the youngest of
which is 10 years of age. Following her last delivery
her husband had a vasectomy. She tells you she
is very tired all the time and that her periods are a
nightmare. They have become exceedingly heavy
over the last year or so, and she has to put herself to
bed for 1 day each month.

Question 1
How can you tell whether or not Sophie has menorrhagia (heavy
menstrual bleeding)? What features in the history of a woman
presenting with menorrhagia might suggest an underlying pathology?

Further information
Sophie returns for her results 4 days later. Her transvaginal
ultrasound (TVS) shows an anteverted uterus with no evidence
of fibroids, and an endometrial thickness of 3 mm. Her full
blood examination (FBE) reveals changes consistent with mild
anaemia and iron deficiency.
Question 4
What is the significance of the endometrial thickness found on TVS?

Question 2
What examination should be performed on Sophie?

Question 5
What is dysfunctional uterine bleeding (DUB)?

10

Case 3

check Menstrual disorders

Question 6
Given Sophies history and the fact that Sophies TVS showed no
abnormalities, you ascertain that Sophie has DUB. What first line
therapy would you suggest to Sophie?

the patient is to be referred for further investigations such as

ultrasound or biopsy.
You should perform a pelvic examination on Sophie before requesting
a TVS, which is indicated for the reasons given below in Answer 3.
Answer 3
Sophie requires an FBE, which may show anaemia consistent with iron
deficiency. An FBE should be done in all women with heavy menstrual
loss. A serum ferritin is not routinely required as the indices in an FBE
will give an indication of iron stores.32 Table 5 lists recommendations
for commonly performed investigations for menorrhagia and the level
of evidence for each of these investigations.
In addition, Sophie requires a TVS because she has a history of heavy
menstrual loss and is over 45 years of age. New Zealand guidelines33
recommend a TVS of the endometrium in all women:

CASE 3 ANSWERS
Answer 1
Sophie complains of regular heavy menstrual bleeding. Clots, flooding
and the need for simultaneous use of pads and tampons are good
indicators of menorrhagia, as is the need to change pads and/or
tampons every 12 hours. Sophies menses are also interfering with
her daily life and this is another indication of heavy bleeding. Sophies
tiredness raises the possibility that she may have developed iron
deficiency anaemia as a result of her bleeding.
Excessive menstrual loss in women in their late 30s and early 40s
is usually ovulatory (associated with regular cycles) and a result of
fibroids, in particular submucous fibroids.
Irregular bleeding and/or intermenstrual bleeding is associated with
an increased incidence of underlying pathology. General practitioners
need to be alert to features in the history that suggest underlying
pathology, such as malignancy in women in their 40s, as the risk of
endometrial carcinoma starts to rise at this age.
Risk factors for endometrial hyperplasia or carcinoma in
premenopausal women include:
infertility and nulliparity
exposure to unopposed endogenous or exogenous
oestrogen/tamoxifen
polycystic ovarian syndrome
obesity
family history of endometrial or colonic carcinoma.31
Answer 2
Recent guidelines32 suggest that GPs should undertake a pelvic
examination if:

whose age is older than 45 years (United Kingdom guidelines,34

however, recommend further assessment in women older
than 40 years)
whose weight is more than 90 kg
who have other risk factors for endometrial hyperplasia or
carcinoma (eg. infertility, nulliparity, exposure to unopposed
oestrogens, polycystic ovarian syndrome or a family history of
endometrial or colonic carcinoma).
A TVS should also be performed when:
the uterus is palpable abdominally
vaginal examination reveals a pelvic mass of uncertain origin
pharmacological treatment fails.32
A TVS will assess the endometrium for its thickness, the uterus
for structural abnormalities such as fibroids or a focal mass, the
ovaries for cysts, and the rectouterine pouch for fluid. An abdominally

Table 5. Recommendations and level of evidence for

commonly performed investigations for menorrhagia32
A full blood count test should be carried out on all women with
heavy menstrual bleeding. This should be done in parallel with
any heavy menstrual bleeding treatment offered [Level C]
Testing for coagulation disorders (eg. von Willebrand disease)
should be considered in women who have had heavy menstrual
bleeding since menarche and have personal or family history
suggesting a coagulation disorder [Level C]
A serum ferritin test should not routinely be carried out on
women with heavy menstrual bleeding [Level B]
Female hormone testing should not be carried out on women
with heavy menstrual bleeding [Level C]

there are features in the history suggesting underlying pathology

(eg. risk factors for endometrial hyperplasia or carcinoma)

Thyroid testing should only be carried out when other signs and
symptoms of thyroid disease are present [Level C]

the patient has decided to go ahead with a levonorgestrel

intrauterine device a pelvic examination is performed to assess
the uterus for suitability for the device

Note: Level A evidence denotes randomised controlled trial or

meta-analysis; Level B denotes other evidence; Level C denotes
consensus or expert opinion

11

Case 3

palpable uterus confirmed as fibroids on ultrasound, intracavity

fibroids and/or uterine length of more than 12 cm measured by
ultrasound should be referred promptly to a gynaecologist.32
Answer 4
Sophies endometrial thickness of less than 4 mm indicates that
endometrial hyperplasia or carcinoma is unlikely, and further
investigation is unnecessary at this stage.
An endometrial thickness of:
less than 4 mm indicates that hyperplasia or carcinoma is unlikely
and a biopsy is considered unnecessary before treatment
512 mm indicates that biopsy may be required depending on
whether the patient has risk factors for endometrial carcinoma
more than 12 mm indicates that hyperplasia or carcinoma is
possible so a biopsy should be done.
Feedback
Hysteroscopy is a procedure performed by a gynaecologist
which allows visualisation of the endometrium, enabling
targeted biopsy. Hysteroscopy and biopsy are indicated for a
patient with a TVS that suggests submucous fibroids or polyps,
a patient in whom medical therapy has failed, or in a patient
with more than one episode of intermenstrual bleeding.
Endometrial sampling and biopsy may be done blind by a
gynaecologist, but hysteroscopy remains the definitive investigative
procedure for diagnosis of intrauterine lesions detected by less
invasive methods such as TVS.
Answer 5
Dysfunctional uterine bleeding is excessively heavy, prolonged or
frequent bleeding of uterine origin which is not due to pelvic or
systemic disease, or pregnancy.35 It can only be diagnosed after
other uterine and systemic causes have been excluded by history,
examination and investigations.
Dysfunctional uterine bleeding is common in women aged 3050
years of age.
Ovulatory dysfunctional bleeding, where cycles are regular, accounts
for about 80% of cases and is most common in women who are in
their 30s.36
Anovulatory DUB occurs at the extremes of the reproductive period
around menarche and perimenopausally, and can also occur in
women with polycystic ovarian syndrome. In cases of anovulatory
DUB, unopposed oestrogen and the lack of progesterone, which is
normally produced by the corpus luteum at ovulation, and stabilises
the endometrium, produces a proliferative endometrium. Bleeding
becomes irregular and menorrhagia is common.
In the adolescent, coagulopathies should be excluded before
diagnosing DUB.

12

check Menstrual disorders

Feedback
A new classification system has been suggested to replace the
term dysfunctional uterine bleeding with the term abnormal
uterine bleeding. The classification system includes information
on the cause of the bleeding. Full details are available in
Fraser et al.35 As this term is not yet in common clinical use in
Australia, we used the term dysfunctional uterine bleeding here,
but over time there may be a change to the term abnormal
uterine bleeding.
Answer 6
Medical management is important to control or lessen Sophies
bleeding. In addition, a daily dose of 60180 mg of elemental iron
should be used to treat her iron deficiency anaemia.
Choice of therapy depends on the need for contraception or a desire
for fertility, contraindications to treatment, and treatment preference
of the patient.
Sophies best option is likely to be the intrauterine levonorgestrel
releasing device. The low level (20 g per day) progestogen
(levonorgestrel) prevents endometrial proliferation and consequently
reduces duration and amount of menstrual bleeding by approximately
90%. Women using the intrauterine levonorgestrel releasing device
may experience irregular bleeding or spotting for the first 6
(and especially the first 3) months, but by 12 months the majority
of women will be amenorrhoeic. Counselling patients on what to
expect is therefore vital. This treatment is also very cost effective in
the long term.
Another option is tranexamic acid, which inhibits plasminogen
activation in peripheral blood, depressing fibrinolytic activity.
It is contraindicated in patients with a past history of venous
thromboembolism, stroke, and acquired colour vision disturbance.
It reduces menstrual loss by about half. Tranexamic acid has no
contraceptive effect and does not affect dysmenorrhoea, so it must
be used with appropriate additional treatment if contraception or pain
relief is required. Appropriate dosing is two tablets 3 times per day,
to a maximum total dose of 4 g per day (8 tablets) for the first 4 days
of the menses. Side effects may include nausea, vomiting, diarrhoea
and dyspepsia.
If there are no contraindications, NSAIDs or the COCP can be given.
The COCP is useful in treating symptoms as well as in providing
contraception. If a levonorgestrel pill does not control bleeding, the
pill can be swapped to a norethisterone pill and the new COCP
(estradiol valerate/dienogest) may be especially helpful in women
with heavy bleeding. The COCP can be tricycled, with the sugar
pills omitted for 2 cycles, so that the woman has a break from her
menses.
The COCP can generally be prescribed until around the time of
menopause unless there are contraindications. Contraindications to

Case 3

check Menstrual disorders

the COCP can be divided into four different categories according to

their classification by the World Health Organization37 and prescription
of the COCP in this age group merits a discussion of the benefits and
risks with the patient.
Oral progestogens such as norethisterone (15 mg per day) from days
526, where day 1 is the first day of the menses, are also useful.
However, progestogens are required for 21 days in each cycle to be
effective (compared to the 1214 days per month required to prevent
endometrial carcinoma when the patient has unopposed oestrogen),
and side effects limit patient tolerance. Table 6 provides a summary
of the medical therapies for the treatment of heavy menstrual
bleeding.

Table 6. A comparison of medical therapies for the

treatment of heavy menstrual bleeding33
Drug

Mean
reduction in
mean blood
loss (%)

Women
benefiting (%)

Levonorgestrel intrauterine device

94

100

Oral progesterone (days 525)

87

86

Tranexamic acid

47

56

Nonsteroidal anti-inflammatory drugs

29

51

Combined oral contraceptive pill

43

50

Danazol

50

76

Oral progesterone
(luteal phase, days 1226)

24

18

Note: In the small number of women where treatment is not successful

then referral for surgical management will be required

Feedback
In women with heavy menstrual bleeding alone, with a uterus
no bigger than a 10 week pregnancy where pharmaceutical
options have failed or are unsuitable, endometrial ablation
should be considered preferable to hysterectomy.32
Hysterectomy is usually considered to be a second line option
in the treatment of menorrhagia due to a benign cause. It is
indicated as a first line option where there is concern about
serious pathology such as carcinoma of the uterus or ovaries.

13

Case 4

Case 4
Casey has spotting between her periods

check Menstrual disorders

Question 3
Is an examination required before advising on management?

Casey, 23 years of age, is a patient of your practice

who presents with spotting between her periods.
She has been in a relationship with Matt for
the past 6 months and has been on the COCP,
composed of 30 g of ethinyloestradiol and 150 g
of levonorgestrel, for the past 5 months. She takes
21 active pills followed by 7 sugar pills. She has
no significant past medical history.

Question 1
What further history related to Caseys spotting do you need to know?

Question 4
What are the expected bleeding patterns when a woman is using
hormonal contraception?

Further information
Caseys breakthrough bleeding (bleeding at a time other
than the withdrawal bleed when taking the COCP) has been
happening since she started the COCP 5 months ago. The
spotting tends to occur late in the cycle and persist throughout
the cycle until her withdrawal bleed. Her withdrawal bleeds are
a little lighter but otherwise are unchanged. She has had no
postcoital bleeding or abnormal vaginal discharge. She had a
normal withdrawal bleed which began 4 days ago and has no
symptoms of pregnancy. She takes the pill every morning and
has not missed a dose. She has been otherwise well.

Further information
You examine Casey. Abdominal examination is normal. You take
an endocervical swab for chlamydial polymerase chain reaction
(PCR), an endocervical swab for gonococcal PCR, a high vaginal
swab for microscopy and culture, and a Pap test.
Question 5
If Caseys results are all normal, what are her management options?

Question 2
What further history do you need to obtain from Casey as part of a full
sexual health assessment?

Further information
Caseys results are all normal. She opts to try the triphasic pill and
her irregular bleeding settles. No cause is found for the bleeding.

14

Case 4

check Menstrual disorders

oral progestogen only pill

CASE 4 ANSWERS

injectable depot medroxyprogesterone acetate

implant etonogestrel implant

Answer 1
You need more information about the duration, nature and pattern of the
bleeding, whether there are other symptoms to suggest an underlying
cause of the bleeding such as dyspareunia or pelvic pain, and whether
there are symptoms of pregnancy.
You also need to know whether Casey is taking the pills of her COCP
regularly, whether she has missed any pills or been late in taking the
pills, whether she has had any recent episodes of illness such as
diarrhoea and vomiting, whether she has symptoms of malabsorption
oruses medications that may interfere with the efficacy of the COCP, or
cause breakthrough bleeding.
Answer 2
Before taking further history, it is important to clarify that the questions
you are asking are personal but part of a thorough health check, and
to seek consent before proceeding. The issue of safe sex needs to
be sensitively explored and discussed in an open and nonjudgmental
manner, including her knowledge about the correct use of condoms.
Questions about unwanted sexual contact should be raised with
sensitivity. In addition, this is an opportune moment to check Caseys
hepatitis B immunity, human papilloma virus vaccination status and her
knowledge of emergency contraception and management of missed
pills, as well as her use of drugs and alcohol.
Answer 3
In Caseys case, an examination is necessary as she has had spotting
persisting beyond 3 months after starting the COCP.
Feedback
In general, in women attending with unscheduled bleeding within
the first 3 months of commencing hormonal contraception,
examination may not be required if, after taking a clinical history,
there are:
no risk factors for sexually transmissible infection
no concurrent symptoms suggesting underlying causes

intrauterine device levonorgestrel releasing intrauterine device.

A summary of expected bleeding patterns for various forms of hormonal
contraception is given in Table 7. It is important that women are made aware
of what bleeding pattern they may expect in both the short and long term in
order to improve compliance and acceptability of the contraceptive method
in question.
Answer 5
Traditionally the advice in a situation such as Caseys has been to:
try changing from a monophasic pill to a triphasic pill
try changing to a third generation progestogen pill
try increasing the dose of oestrogen in the pill, or
try changing the delivery method to ethinyloestradiol/etonogestrel
vaginal ring.4
Whatever change is made, GPs should advise the patient to persist with the
new change for at least 3 months given that bleeding problems often settle
after this time.
However, very recent guidelines issued by the UK Faculty of Sexual and
Reproductive Health Care38 have stated that there is no evidence that
changing the progestogen dose or type of progestogen improves cycle
control. They do, however, concede that in the absence of evidence it
may help on an individual basis. Their guidance advises using a COCP
with a dose of ethinyloestradiol sufficient to provide the best cycle control
and they advise that the maximum dose that should be used is 35 g.

Table 7. Expected bleeding patterns with hormonal

contraception38
Contraceptive
method

Bleeding pattern in the

longer term

Combined hormonal About one-fifth have

irregular bleeding
contraception
(pill or ring)

Bleeding usually settles,

ovarian activity effectively
suppressed

Progestogen only
pill

One-third have a
change in bleeding with
10% having frequent
bleeding

Ovarian activity usually

incompletely suppressed.
While up to half will have
regular bleeding, 3040%
have irregular bleeding
and up to 15% are
amenorrhoeic

Progestogen only
injectable

Bleeding disturbance
is common but 35%
become amenorrhoeic
by 3 months

70% amenorrhoeic by
1 year

Progestogen only
implant

Bleeding disturbance is 20% become

common
amenorrhoeic, 50% have
infrequent or prolonged
bleeding which does not
settle with time

Levonorgestrel
releasing
intrauterine device

Bleeding disturbance is 90% reduction in blood

loss by 12 months,
common in first
frequent amenorrhoea
6 months

the woman is participating in a National Cervical Screening

Programme.38
Answer 4
It is important to understand the different effects of hormonal
contraception on bleeding. In general, oestrogens build the endometrial
lining and progestogens stabilise the endometrial lining. That is why
combined oral contraception gives one of the most predictable bleeding
patterns. A progestogen on its own has varying effects, depending on
how it is delivered and whether or not the method of delivery and dose
brings about suppression of ovulation. Progestogen only options for
contraception are:

Bleeding pattern in
first 3 months

15

Case 5

Case 5
Tamaras postcoital bleeding

check Menstrual disorders

Question 3
What should you do next?

Tamara, 40 years of age, presents with some vaginal

bleeding between periods. Further questioning
reveals spotting after intercourse. She is married and
uses the diaphragm for contraception.

Question 1
What important diagnosis must you consider?
CASE 5 ANSWERS

Answer 1
Postcoital bleeding is a cardinal symptom of cervical carcinoma.
Genital tract malignancy is rare in young women and an uncommon
cause of bleeding at any age, but must be considered in all
patients.39

Question 2
What examination and investigation should you perform on Tamara?

Further information
You examine Tamara. Examination of her abdomen reveals no
abnormalities, bimanual examination is normal and you note
on speculum examination that she has a normal looking cervix.
You perform a Pap test and take endocervical swabs and a high
vaginal swab.

16

Feedback
A recent systematic review has examined the issue of postcoital
bleeding and genital tract malignancy.40 It was found that
the point prevalence of postcoital bleeding in women in the
community ranged from 0.79%. The prevalence of postcoital
bleeding in women with cervical carcinoma ranged from
0.739%. Calculation of risk that a woman in the community
developing postcoital bleeding has cervical carcinoma ranges
from 1 in 44 000 at age 2024 years, to 1 in 2400 at age 4554
years. There was no information allowing the direct calculation
of risk in women presenting to primary care.
Answer 2
Examination should include an abdominal examination, speculum
examination to visualise the cervix and bimanual examination.
She should also have a Pap test. If Tamara is at risk of sexually
transmissible infections, she should have appropriate investigations
including an endocervical swab for chlamydial PCR, an endocervical
swab for gonococcal PCR, and a high vaginal swab for microscopy
and culture.
Answer 3
It is commonly accepted that a single episode of postcoital bleeding
in a woman with a normal smear does not warrant immediate referral,
but recurrence of this symptom mandates referral for colposcopy.39 It
is important that you explain to Tamara that irrespective of a normal
Pap result, if the symptom of postcoital bleeding recurs, she requires
further investigation to exclude the possibility of carcinoma of the
cervix. All women with persistent or recurrent episodes of postcoital
bleeding must be referred for colposcopy.39

check Menstrual disorders

1. Proctor M, Farquhar C. Diagnosis and management of

dysmenorrhoea. BMJ (Review) 2006;13:11348.
2. Parker MA, Sneddon AE, Arbon P. The menstrual disorder of
teenagers (MDOT) study: determining typical menstrual patterns
and menstrual disturbance in a large population-based study of
Australian teenagers. BJOG: An International Journal of Obstetrics
and Gynaecology 2010;117:18592.
3. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea,
dyspareunia, pelvic pain, and irritable bowel syndrome in primary
care practices. Obstet Gynecol 1996;87:558.
4. Mazza D. Womens health in general practice. 2nd edn. Sydney:
Churchill Livingstone, 2011.
5. Bird S. Consent to medical treatment: the mature minor. Aust Fam
Physician 2011;40:15960.
6. Goldenring JM, Rosen DS. Getting into adolescent heads: an
essential update. Contemp Pediatr 2004;121:6490.
7. Lumsden MA, Kelly RW, Baird DT. Primary dysmenorrhoea: the
importance of both prostaglandins E2 and F2 alpha. Br J Obstet
Gynaecol 1983;90:113540.
8. Sundell G, Milsom I, Andersch B. Factors influencing the prevalence
and severity of dysmenorrhoea in young women. Br J Obstet
Gynaecol 1990;97:58894.
9. Wang L, Wang X, Wang W, et al. Stress and dysmenorrhoea:
a population based prospective study. Occup Environ Med
2004;61:10216.
10. Marjoribanks J, Proctor ML, Farquhar C. Nonsteroidal antiinflammatory drugs for primary dysmenorrhoea. Cochrane Database
Syst Rev (Meta-analysis Review) 2003:CD001751.
11. Robinson JC, Plichta S, Weisman CS, et al. Dysmenorrhea and
use of oral contraceptives in adolescent women attending a family
planning clinic. Am J Obstet Gynecol 1992;166:57883.
12. Proctor ML, Murphy PA. Herbal and dietary therapies for primary
and secondary dysmenorrhoea. Cochrane Database Syst Rev
2001:CD002124.
13. Daley AJ. Exercise and primary dysmenorrhoea: a comprehensive
and critical review of literature. Sports Med 2008;38:65970.
14. Proctor ML, Smith CA, Farquhar CM, et al. Transcutaneous electrical
nerve stimulation and acupuncture for primary dysmenorrhoea.
Cochrane Database Syst Rev 2002:CD002123.
15. Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level
topical heat in the treatment of dysmenorrhea. Obstet Gynecol
2001;97:3439.
16. Barnard ND, Scialli AR, Hurlock D, et al. Diet and sex-hormone
binding globulin, dysmenorrhea, and premenstrual symptoms.
Obstet Gynecol 2000;95:24550.
17. World Health Organization. Mental, behavioural and developmental
disorders. Tenth revision of the International Classification of
Diseases (ICD-10). Geneva: WHO, 1996.
18. Sveindottir H, Backstrom T. Prevalence of menstrual cycle symptom
cyclicity and premenstrual dysphoric disorder in a random sample
of women using and not using oral contraceptives. Acta Obstet
Gynecol Scand 2000;79:40513.
19. Vanselow W. A comprehensive approach to premenstrual
complaints. Aust Fam Physician 1998;27:35461.
20. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders DSM-IV-TR (4th edn, text revision). Washington
DC: American Psychiatric Association, 2000.
21. Bloch M, Schmidt PJ, Rubinow DR. Premenstrual syndrome:
evidence for symptom stability across cycles. Am J Psychiatry
1997;154:17416.

References

22. Henshaw C. PMS: diagnosis, aetiology, assessment and

management: revisiting premenstrual syndrome. Advances in
Psychiatric Treatment 2007;13:13946.
23. Byrne A, Byrne DG. The effect of exercise on depression,
anxiety and other mood states: a review. J Psychosom Res
1993;37:56574.
24. Johnson WG, Carr-Nangle RE, Bergeron KC. Macronutrient
intake, eating habits, and exercise as moderators of menstrual
distress in healthy women. Psychosom Med 1995;57:32430.
25. Prior JC, Vigna Y, Alojada N. Conditioning exercise decreases
premenstrual symptoms. A prospective controlled three month
trial. Eur J Appl Physiol Occup Physiol 1986;55:34955.
26. Goodale IL, Domar AD, Benson H. Alleviation of premenstrual
syndrome symptoms with the relaxation response. Obstet
Gynecol 1990;75:64955.
27. Brown J, OBrien PM, Marjoribanks J, et al. Selective serotonin
reuptake inhibitors for premenstrual syndrome. Cochrane
Database Syst Rev 2009:CD001396.
28. Yonkers KA, OBrien PM, Eriksson E. Premenstrual syndrome.
Lancet 2008;371:120010.
29. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives
containing drospirenone for premenstrual syndrome. Cochrane
Database Syst Rev 2009:CD006586.
30. Stevinson C, Ernst E. Complementary/alternative therapies for
premenstrual syndrome: a systematic review of randomized
controlled trials. Am J Obstet Gynecol 2001;185:22735.
31. Farquhar CM, Lethaby A, Sowter M, et al. An evaluation of risk
factors for endometrial hyperplasia in premenopausal women
with abnormal menstrual bleeding. Am J Obstet Gynecol
1999;181:5259.
32. National Institute of Health and Clinical Excellence. NICE Clinical
Guideline 44. Heavy menstrual bleeding, 2007. Available at
www.nice.org.uk/nicemedia/pdf/CG44NICEGuideline.pdf.
33. National Advisory Committee on Health and Disability. Guidelines
for the management of heavy menstrual bleeding. New Zealand:
NACHD, 1998.
34. Royal College of Obstetricians and Gynaecologists. The initial
management of menorrhagia. Evidence-based clinical guidelines:
No 1. London: RCOG; 1998.
35. Fraser IS, Critchley HO, Munro MG, et al. A process designed to
lead to international agreement on terminologies and definitions
used to describe abnormalities of menstrual bleeding. FertilSteril
2007;87:46676.
36. Farrell E. Dysfunctional uterine bleeding. Aust Fam Physician
2004;33:9068.
37. World Health Organization. Improving access to quality care in
family planning. Medical eligibility criteria for contraceptive use.
Geneva: WHO, 1996.
38. Faculty of Sexual and Reproductive Health Care. Management of
unscheduled bleeding in women using hormonal contraception,
2009. Available at www.ffprhc.org.uk/admin/uploads/
UnscheduledBleedingMay09.pdf.
39. Royal Australian and New Zealand College of Obstetricians and
Gynaecologists. Investigation of intermenstrual and postcoital
bleeding: College Statement: C-Gyn 6. RANZCOG, 2009.
Available at www.ranzcog.edu.au/publications/statements/Cgyn6.pdf.
40. Shapley M, Jordan J, Croft PR. A systematic review of
postcoital bleeding and risk of cervical cancer. Br J Gen Pract
2006;56:45360.

17

resources

Resources for patients

New South Wales
Family Planning New South Wales
www.fpnsw.org.au/index_factsheets.html
Northern Territory
Family Planning Northern Territory
www.fpwnt.com.au
Queensland
Family Planning Queensland
www.fpq.com.au/publications.php
South Australia
Women and Childrens Hospital Adelaide
www.wch.sa.gov.au/healthinfo/index.html
Tasmania
Family Planning Tasmania
www.fpt.asn.au/info-advice/fact-sheets
Victoria
Family Planning Victoria
www.fpv.org.au/women
The Royal Womens Hospital
www.thewomens.org.auGynaecologyAndWomensHealthFactSheets
Women's Health Program, Monash University
www.med.monash.edu.au/medicine/alfred/womenshealth/info-sheets.html
Western Australia
Family Planning Western Australia
www.fpwa.org.au/healthinformation/infosheets/womenshealthinfo

Resources for doctors

Mazza D. Womens health in general practice. 2nd edn. Sydney: Churchill
Livngstone, 2011
Guidelines for womens health
www.thewomens.org.au/WomensHealthClinicalPracticeGuidelines
www.cdc.gov/women/index.htm
www.ffprhc.org.uk/Default2.asp?Section=GoodMedical&SubSection=Clini
calGuidance

18

check Menstrual disorders

check Category 2 QI&CPD activity

check Menstrual disorders

Menstrual disorders

A. advise her to complete a prospective symptom chart for 3 months

to confirm the diagnosis

In order to qualify for 6 Category 2 points for the QI&CPD

activity associated with this unit:

B. request a transvaginal ultrasound (TVS) to rule out other

gynaecological conditions

read and complete the unit of check in hardcopy or

online at the gplearning website at www.gplearning.
com.au, and

C. request progesterone level test in the luteal phase of her

menstrual cycle

log onto the gplearning website at www.gplearning.

com.au and answer the following 10 multiple choice
questions (MCQs) online
complete the online evaluation.
If you are not an RACGP member, please contact the
gplearning helpdesk on 1800 284 789 to register in the
first instance. You will be provided with a username and
password that will allow you access to the test.
The expected time to complete this activity is 3 hours.
Please note:
from January 2011, there will no longer be a Category 1
activity (ALM) associated with check units. This decision
was made due to a lack of interest in this activity. The
RACGP apologises for any inconvenience caused by this
change
do not send answers to the MCQs into the check office.
This activity can only be completed online at www.
gplearning.com.au.
If you have any queries or technical issues accessing the
test online, please contact the gplearning helpdesk on
1800 284 789.
Question 1
Stacey is 26 years of age and presents to you with a 12 month
history of increasingly painful menses, which after some history
taking you believe to be secondary dysmenorrhoea. All of the
following features are consistent with a diagnosis of secondary
dysmenorrhoea except:

D. reassure her that her symptoms are common and do not need
any treatment
E. start her on the combined oral contraceptive pill (COCP) in order
to help reduce her symptoms.
Question 3
You discuss options for management of PMS with Claire. There is
evidence of benefit for which of the following treatments for PMS?
A. Magnesium supplementation
B. Evening primrose oil
C. Yoga
D. Progesterone
E. Massage.
Question 4
Lara is 42 years of age and is nulliparous after several unsuccessful
attempts at in vitro fertilisation a few years ago. She presents to
you with 3 months of heavy menstrual bleeding with a cycle varying
between 25 and 28 days. She says that she is tired and dizzy due to
her heavy bleeding. You examine her abdominally and note that her
uterus is palpable. The next most appropriate step in management
is to:
A. perform a pelvic examination
B. request a full blood examination
C. arrange a TVS
D. refer her for gynaecological opinion
E. reassure her that this bleeding pattern is common at her age and
usually signals that menopause will occur within the next 2 years.

A. onset of painful menses in age 20s

B. pain also occurring in between the menses
C. pain isolated to the first 23 days of the menses
D. dyspareunia
E. diarrhoea.
Question 2
Claire is 38 years of age and presents to you with a 3 month history
of feelings of anxiety and irritability, increased appetite, breast
tenderness, bloating and fatigue, which occur for 1 week before
her period and resolve within 1 day of onset of her period. You
suspect that she has premenstrual syndrome (PMS). The next most
appropriate step in her management is to:

Question 5
Lara has a TVS which reveals uterine fibroids and an endometrial
thickness of 6 mm. You refer her to a gynaecologist, who performs a
hysteroscopy (which confirms fibroids) and obtains a biopsy (which
is found to be negative for malignancy). You explore with Lara the
hormonal options for control of her bleeding. Which of the following
options is most appropriate for control of Laras bleeding?
A. Progestogen containing injectable
B. Progestogen containing implant
C. Progestogen only oral pill
D. Progestogen releasing intrauterine device
E. Progestogen pessaries.

19

check Category 2 QI&CPD activity

Question 6
Belinda is 19 years of age and for the past 6 months has been
on the COCP (containing 30 g of ethinyloestradiol and 150 g
of levonorgestrel). She presents to you with a few episodes of
breakthrough bleeding that have occurred in the past 2 months.
Which of the following is true regarding breakthrough bleeding?

check Menstrual disorders

Question 9
Which of the following bleeding patterns is an accurate
representation of the effects of the respective forms of hormonal
contraception?
A. With the COCP, one-fifth of women have irregular bleeding in the
first 3 months, which, in most cases, settles with time

A. Possible causes for breakthrough bleeding include a cervical

ectropian, a missed pill, chlamydia and cervical dysplasia

B. Those on the progestogen only pill usually have one of two

patterns of bleeding: regular bleeding or irregular bleeding

B. Examination may not be necessary if she has no risk factors

for sexually transmissible infections, no concurrent symptoms
that suggest underlying causes, and she is having Pap tests at
appropriate intervals

C. Most of the users of the injectable progestogen containing

injectable are amenorrhoeic by 3 months

C. Colposcopy is indicated at this stage to exclude dysplasia as a

cause for her breakthrough bleeding

E. Amenorrhoea is an uncommon bleeding pattern in the long term

when using the levonorgestrel releasing intrauterine device.

D. Increasing the dose of oestrogen to a pill containing 50 g of

ethinyloestradiol is recommended once other diagnoses have
been excluded, according to the UK Faculty of Sexual and
Reproductive Health
E. If she is currently taking a triphasic pill, changing to a
monophasic pill could help settle bleeding which is related to use
of the COCP.
Question 7
Amy is 22 years of age and has been in a sexual relationship with
Samuel for 2 years. Two and a half months ago you started her on
the COCP for contraception. She comes back to you for a repeat
prescription and says that she has been having occasional spotting
for the last 2 months despite taking her pills as directed. The most
likely cause for her spotting is:
A. wart virus
B. cervicitis due to chlamydia
C. cervical dysplasia
D. the contraceptive pill
E. infection with Candida.
Question 8
Sally is 35 years of age and presented to your clinic last month
with an episode of postcoital bleeding. You examine her, visualise
her cervix, which looks normal, and take a cervical and high vaginal
swab, and a Pap test, which all come back normal. She presents
again to your clinic with another episode of postcoital bleeding. Your
next most appropriate step in management is:
A. to re-examine her and take a sample for liquid based cytology
B. to reassure her that a cervical ectropian is the most likely cause
for her symptoms, and should the bleeding recur, she should
re-present to you
C. to request a TVS
D. to refer her for a colposcopy
E. to discuss starting the COCP.

20

D. Prolonged bleeding in the long term when using the progestogen

containing implant is uncommon

Question 10
Angie is 49 years of age and has had heavy menstrual periods
occurring every 30 days for the last 2 years, whereby she needs
to change a tampon or pad every 2 hours and floods at night. She
said that she has always been a bleeder. She has a past history
of two normal vaginal deliveries without complication and has no
relevant family history. Your examination of her is normal. Which of
the following tests should you order for Angie in line with current
recommendations?
A. Full blood examination to check for anaemia and indirectly assess
for iron deficiency
B. Serum ferritin studies to check for iron deficiency as a
complication of her heavy menstrual bleeding
C. Coagulation studies given her history of being a bleeder
D. Serum oestrogen and progesterone to ascertain her menopausal
status
E. Thyroid function tests to exclude thyroid dysfunction as a cause
of her heavy bleeding.