Abnormal Uterine Bleeding and Fibroids MCQs

Explanation: This young woman has HMB caused by a submucosal fibroid (which significantly distorts the uterine cavity) and is actively trying to conceive. Submucosal fibroids are known to impair implantation and increase miscarriage rates, in addition to causing HMB. Therefore, removal is indicated for both symptom control and fertility.

• A (Correct): Hysteroscopic excision (transcervical resection of fibroid - TCRF) is the standard minimally invasive surgical approach for removing submucosal fibroids, preserving the uterus and potentially improving fertility outcomes.
• B, C (Incorrect): Laparoscopic or open myomectomy are approaches for intramural or subserosal fibroids, not typically for purely submucosal ones accessible via hysteroscope.
• D (Incorrect): Medical management with tranexamic/mefenamic acid only addresses symptoms and does not remove the fibroid or address the fertility impact.
• E (Incorrect): Ulipristal acetate is generally not used first-line in women actively trying to conceive, and hysteroscopic removal is preferred for submucosal fibroids affecting fertility.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Discusses hysteroscopic removal for submucosal fibroids)
• RCOG/BSGE Green-top Guideline No. 51: Management of Submucous Fibroids (Although older, principles remain)

Explanation: This adolescent has irregular HMB, likely dysfunctional bleeding common after menarche. Treatment aims to regulate cycles and reduce bleeding. Assuming underlying pathology is excluded.

• A (Correct): Combined oral contraceptive pills (COCPs) are considered a first-line option (NICE NG88). They regulate the cycle, reduce bleeding, and often help with associated dysmenorrhea. They are effective for irregular HMB in adolescents.
• B (Incorrect): Cyclical Norethisterone can regulate cycles but is generally less effective at reducing blood loss than COCPs or LNG-IUS.
• C (Incorrect): NSAIDs (like mefenamic acid) help with pain and reduce bleeding somewhat, but don't regulate irregular cycles.
• D (Incorrect): Oral iron is needed if she is anaemic but doesn't treat the bleeding.
• E (Incorrect): Tranexamic acid reduces bleeding effectively but doesn't regulate the cycle. COCPs address both irregularity and heavy flow.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This woman has persistent HMB despite medical treatment, caused by a submucosal fibroid. Since she has completed her family, fertility preservation is not a concern. Definitive treatment is an option.

• A (Incorrect): TAH (Total Abdominal Hysterectomy) is definitive but highly invasive. Less invasive options exist for a small (3x3cm) submucosal fibroid.
• B (Incorrect): Laparoscopic removal (myomectomy) is for intramural/subserosal fibroids, not typically submucosal ones accessible hysteroscopically.
• C (Correct): Hysteroscopic removal of the fibroid (transcervical resection of fibroid - TCRF) is the standard, minimally invasive surgical treatment for symptomatic submucosal fibroids. It directly removes the cause of the bleeding while preserving the uterus (though not required for fertility here, it's less invasive than hysterectomy).
• D (Incorrect): LHRH (GnRH) agonists are temporary medical treatments, not definitive management.
• E (Incorrect): Tranexamic acid is a medical treatment, which has already failed according to the stem ('despite medical treatments').

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This woman desires pregnancy, has severe anaemia (Hb 8.1) due to HMB, and a very large (9x10 cm) intramural (interstitial) fibroid. Given the size and symptomatic nature (HMB, anaemia), and desire for pregnancy, treatment targeting the fibroid while preserving the uterus is necessary.

• A (Incorrect): Uterine artery embolization is generally avoided in women planning pregnancy.
• B (Incorrect): Endometrial ablation destroys the endometrium, causing infertility, and is contraindicated.
• C (Incorrect): TAH + BSO (Total Abdominal Hysterectomy + Bilateral Salpingo-oophorectomy) removes the uterus and ovaries, causing infertility.
• D (Correct): Myomectomy (surgical removal of the fibroid) is the treatment of choice. It removes the large, symptomatic fibroid, potentially alleviating HMB and improving chances of conception/reducing pregnancy complications, while preserving the uterus for future pregnancy. Given the size, this would likely be via laparotomy (open myomectomy).

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management

Explanation: The patient presents with heavy menstrual bleeding (HMB) causing anaemia (pale, Hb 9.3). The key finding is significant lateral fornix tenderness on examination, which raises suspicion for pelvic pathology like pelvic inflammatory disease (PID), endometriosis, or possibly an adnexal mass, rather than just dysfunctional uterine bleeding or simple fibroids/polyps. NICE guideline NG88 recommends examination and considering ultrasound first-line for HMB.

• A (Incorrect): CT scan is not a first-line investigation for HMB or pelvic tenderness.
• B (Incorrect): Diagnostic laparotomy is highly invasive and not a first-line investigation.
• C (Incorrect): Endometrial biopsy is considered if structural abnormalities are suspected or risk factors for endometrial cancer exist, but imaging is usually performed first, especially with pelvic tenderness suggesting other pathology.
• D (Incorrect): High vaginal swab is relevant if PID is strongly suspected (requires more history/exam findings like discharge), but pelvic ultrasound provides broader anatomical information first.
• E (Correct): Pelvic Ultrasound (transvaginal scan preferred if acceptable) is the recommended first-line investigation according to NICE NG88 to assess uterine structure (fibroids, adenomyosis), endometrium, and adnexa (ovaries, tubes) to look for the cause of HMB and potential reasons for the fornix tenderness (e.g., endometrioma, hydrosalpinx).

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This adolescent has significant menstrual disturbance (irregular bleeding and dysmenorrhea) impacting her life, with normal investigations ruling out structural pathology. This is likely dysfunctional uterine bleeding, possibly related to anovulatory cycles common in the years after menarche. Hormonal regulation is often the most effective treatment.

• A (Correct): Combined oral contraceptive pills (COCPs) are a first-line management option according to NICE NG88 for HMB when contraception is also required or acceptable. They regulate the cycle, reduce bleeding amount, and often improve dysmenorrhea. Given the irregularity and dysmenorrhea, COCPs are highly appropriate.
• B (Incorrect): Cyclical progesterone can regulate cycles but is less effective for heavy bleeding and dysmenorrhea compared to COCPs.
• C (Incorrect): Medroxyprogesterone acetate (injectable or high-dose oral) is generally second-line due to side effects and impact on future fertility return.
• D (Incorrect): Mefenamic acid (NSAID) helps with dysmenorrhea and can reduce bleeding volume but may not be sufficient for irregular, heavy bleeding and doesn't regulate the cycle.
• E (Incorrect): Tranexamic acid is effective for reducing bleeding volume but doesn't regulate the cycle or significantly treat dysmenorrhea.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Fibroleiomata = Leiomyomata = Fibroids.

• A (Incorrect): COCPs do not treat fibroids; they may manage bleeding symptoms but contain estrogen which could potentially stimulate growth.
• B (Correct): Asymptomatic fibroids, especially small ones (<3cm is often used as a general guide, though size alone isn't the only factor), generally do not require treatment and can be managed expectantly.
• C (Incorrect): Myomectomy is the surgical removal of fibroids, typically performed electively for symptoms or fertility reasons. Red degeneration is usually managed conservatively with analgesia; surgery during an episode of red degeneration is risky due to inflammation and bleeding and generally avoided unless absolutely necessary.
• D (Incorrect): Interstitial (intramural) tumours are within the uterine wall. UAE is an option for treating symptomatic interstitial fibroids, but it's not the only or definitive treatment, and myomectomy is often preferred, especially if fertility is desired.
• E (Incorrect): Subserosal fibroids (on the outer surface) are generally considered the least likely type to cause subfertility unless very large and distorting anatomy. Submucosal fibroids are most strongly linked to subfertility.

Explanation: Subserosal fibroids grow on the outer surface of the uterus. Their complications depend largely on size and location.

• A (Incorrect): Subserosal fibroids generally do not impact fertility unless they are very large and distort the uterine cavity indirectly or obstruct the fallopian tubes. Intramural (distorting cavity) and submucosal fibroids are more strongly linked to infertility.
• B (Incorrect): Subserosal fibroids are the least likely type to cause significant heavy menstrual bleeding leading to anaemia, as they don't directly affect the endometrial lining.
• C (Correct): A large subserosal fibroid, particularly if located anteriorly, can press on the bladder, causing urinary symptoms like frequency or urgency.
• D (Incorrect): Dyspareunia (painful intercourse) is more commonly associated with endometriosis, PID, or sometimes large posterior fibroids or adenomyosis, less typically with an isolated subserosal fibroid unless it's pedunculated and mobile in the pelvis or very large.
• E (Correct): Pedunculated subserosal fibroids (attached to the uterus by a stalk) are at risk of torsion (twisting on their stalk), cutting off their blood supply and causing acute, severe pelvic pain.

Explanation: An asymptomatic intramural fibroid, even one of 5cm, generally does not require active treatment. Management depends on symptoms, size, location, growth rate, and fertility desires.

• A (Correct): Conservative management (also known as expectant management or watchful waiting) with regular follow-up (e.g., clinical assessment, possibly periodic ultrasound) is the standard approach for asymptomatic fibroids. Treatment is typically initiated only if symptoms develop, the fibroid grows rapidly, or it is thought to be impacting fertility (if desired).
• B, D, E (Incorrect): Medical treatments like GnRH analogues or Ulipristal acetate, or procedures like UAE, are used for symptomatic fibroids and are not indicated here.
• C (Incorrect): Myomectomy (surgical removal) is reserved for symptomatic fibroids or potentially those impacting fertility; it is not necessary for an asymptomatic 5cm fibroid.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Context for fibroid treatment indications)

Explanation:

• A (Incorrect): The risk of sarcomatous change is very low (<0.1%), not 5%.
• B (Correct): A small (2x2cm) submucosal fibroid causing symptoms (like HMB or subfertility) is ideally treated by hysteroscopic resection (TCRF), a minimally invasive approach.
• C (Incorrect): Uterine artery embolization (UAE) is generally relatively contraindicated or considered second-line in women desiring future fertility due to potential adverse effects on ovarian function and pregnancy outcomes.
• D (Correct): Leiomyomas (fibroids) are the most common benign tumours of the uterus and the female pelvis.
• E (Incorrect): COCPs do not cause fibroids to regress; they contain estrogen which can potentially stimulate growth, although modern low-dose pills may have minimal effect. They can, however, manage bleeding symptoms. Regression occurs with estrogen deprivation (menopause, GnRH analogues).

Explanation: Fibromata = Fibroids (Leiomyomata).

• A (Incorrect): Fibroids are associated with estrogen and typically regress after menopause; they do not cause premature menopause. Premature menopause is due to premature ovarian insufficiency.
• B (Correct): Uterine bleeding, particularly heavy menstrual bleeding (HMB), is the most common symptom of uterine fibroids, especially submucosal and intramural types.
• C (Correct): Fibroids, particularly submucosal or large intramural ones that distort the uterine cavity, can interfere with implantation or distort uterine anatomy, contributing to subfertility or recurrent miscarriage in some women.
• D (Incorrect): Polycythaemia is a rare association; anaemia due to HMB is much more common.

Explanation: Causes of Heavy Menstrual Bleeding (HMB).

• A (Incorrect): Cervical cancer typically presents with post-coital bleeding, intermenstrual bleeding, or persistent vaginal discharge. HMB is not a classic presenting symptom, although advanced disease could potentially cause it.
• B (Incorrect): Chronic cervicitis (inflammation of the cervix) usually causes discharge or post-coital bleeding, not typically HMB.
• C (Correct): Endometrial polyps are benign growths of the uterine lining that commonly cause HMB or intermenstrual bleeding.
• D (Incorrect): Pelvic Inflammatory Disease (PID) is an infection causing pelvic pain, discharge, fever, and sometimes intermenstrual or post-coital bleeding, but not typically cyclical HMB.
• E (Correct): Submucosal fibroids, which protrude into the uterine cavity, significantly increase the surface area of the endometrium and interfere with uterine contractility, commonly causing HMB.

Other common causes: adenomyosis, dysfunctional uterine bleeding, coagulation disorders, thyroid dysfunction.

Explanation: This young woman has HMB with regular cycles. Management should follow NICE NG88. Assuming no contraindications and structural pathology excluded.

• A (Correct): For women who do not want/need contraception, or as an initial trial, non-hormonal treatments taken during menstruation are first-line options. Tranexamic acid (antifibrinolytic) and/or Mefenamic acid (NSAID) effectively reduce blood loss. Using both together might offer additive benefit.
• B (Incorrect): COCPs are an option (especially if contraception desired), but non-hormonal treatment first is reasonable if contraception isn't a priority.
• C (Incorrect): Norethisterone (cyclical progestogen) is generally second/third line.
• D (Incorrect): Depo Provera (injectable progestogen) is not first-line for HMB due to side effect profile and delayed return to fertility.
• E (Incorrect): Levonorgestrel IUS (LNG-IUS) is highly effective but maybe less acceptable initially to a young, unmarried woman compared to oral medication taken only during periods, although it is a NICE first-line recommendation if hormonal treatment is considered. Given the options, A is the most suitable initial *non-hormonal* approach.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Characteristics and associations of uterine leiomyomas (fibroids).

• A (Incorrect): The risk of malignant change (leiomyosarcoma) is very low, estimated at <0.1%, not 10%.
• B (Incorrect): Polycythaemia (increased red blood cell count) is a rare paraneoplastic syndrome associated with some tumours, including occasionally large fibroids producing erythropoietin, but it's not a typical feature. Fibroids usually cause anaemia due to HMB.
• C (Correct): Large fibroids, particularly those located anteriorly or in the lower uterine segment, can press on the bladder or urethra, causing urinary retention or frequency/urgency.
• D (Correct): Uterine artery embolization (UAE) is a recognized treatment option for symptomatic fibroids, involving blocking the arteries supplying the fibroids.
• E (Incorrect): Red degeneration (infarction) is more common during pregnancy or reproductive years due to rapid growth; fibroids typically regress (shrink) after menopause due to estrogen withdrawal.

Explanation: Endometrial hyperplasia with atypia (atypical hyperplasia) carries a significant risk of underlying concurrent endometrial cancer (up to 40%) and a high risk of progression to cancer if left untreated. The standard recommended management, especially in a perimenopausal woman (age 45) who has likely completed her family (uterus size might relate to fibroids/adenomyosis or parity, not specified), is hysterectomy.

• A (Incorrect): Endometrial ablation is contraindicated in atypical hyperplasia due to the risk of underlying/developing cancer.
• B (Incorrect): Levonorgestrel IUS (LNG-IUS) can be considered as a fertility-sparing option for atypical hyperplasia in younger women desiring fertility or those unfit for surgery, but requires close monitoring and biopsy follow-up. Total hysterectomy remains the gold standard due to the cancer risk (RCOG GTG 67).
• C (Incorrect): D&C is diagnostic, not definitive treatment for atypical hyperplasia.
• D (Correct): Total Abdominal Hysterectomy (TAH) with Bilateral Salpingo-oophorectomy (BSO) is the recommended treatment for atypical endometrial hyperplasia in women who do not wish to preserve fertility, due to the high risk of associated or future malignancy. The approach (abdominal, vaginal, laparoscopic) may vary, but hysterectomy is the principle. BSO is usually included due to age and risk reduction.
• E (Incorrect): Systemic progestogens like Norethisterone are less effective than LNG-IUS for reversing hyperplasia and not the standard for atypical hyperplasia when hysterectomy is feasible.

References:

• RCOG Green-top Guideline No. 67: Management of Endometrial Hyperplasia (Published Feb 2016)

Explanation: Characteristics and associations of Abnormal Uterine Bleeding (AUB).

• A (Correct): Adenomyosis (endometrial tissue in the myometrium) is a common cause of heavy menstrual bleeding (HMB) and dysmenorrhea, components of AUB.
• B (Incorrect): Hormonal assessment (FSH, LH, Prolactin, TSH) is not performed routinely for all AUB cases according to NICE NG88. It's indicated if endocrine disorders (e.g., PCOS, thyroid disease, hyperprolactinemia) are suspected based on history (e.g., irregular cycles, galactorrhea). Thyroid disease should be excluded in HMB.
• C (Incorrect): The Levonorgestrel Intrauterine System (LNG-IUS) is recommended as a first-line, long-term (licensed for up to 5-8 years depending on type/indication) treatment for HMB (NICE NG88).
• D (Correct): Intermenstrual bleeding (IMB) is frequently associated with structural pathologies like endometrial polyps or submucosal fibroids, as well as cervical pathology or endometrial hyperplasia/cancer.
• E (Incorrect): High-dose progestogens (like Norethisterone) are sometimes used off-label in acute, severe HMB to try and stabilize the endometrium and stop bleeding, although evidence is limited compared to tranexamic acid or other measures. NICE NG88 doesn't specifically recommend it for acute HMB management in primary care setting. Tranexamic acid is often used.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Several treatments aim to reduce the size of uterine fibroids, primarily by modulating hormone levels.

• A (Incorrect): Depot medroxyprogesterone acetate (DMPA) is a progestogen-only contraceptive. While it can help control fibroid-related bleeding, it does not reliably shrink fibroids.
• B (Correct): Gonadotropin-releasing hormone (GnRH) analogues create a hypoestrogenic state, similar to menopause, which effectively shrinks fibroids. However, their use is typically limited to short-term (3-6 months), often pre-operatively, due to side effects (NICE NG88).
• C (Incorrect): Tranexamic acid is an antifibrinolytic agent that reduces heavy menstrual bleeding but has no effect on fibroid size.
• D (Correct): Ulipristal acetate is a selective progesterone receptor modulator (SPRM) that effectively reduces both fibroid size and bleeding. Its use requires specific monitoring conditions in the UK/EU due to rare liver injury concerns (NICE NG88).
• E (Correct): Uterine artery embolization (UAE) is an interventional radiology procedure that blocks the blood supply to the fibroids, causing them to shrink and alleviating symptoms. It is a recognised treatment option (NICE NG88).

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Acute urinary retention caused by a large posterior wall fibroid compressing the bladder neck or urethra requires definitive treatment of the fibroid to resolve the pressure symptoms. The fibroid is large (8cm) and causing significant impact.

• A (Incorrect): GnRH analogues shrink fibroids but are a temporary measure (usually pre-op) and have side effects; they are not a long-term solution for a large, symptomatic fibroid causing retention.
• B (Incorrect): COCPs do not treat fibroids or urinary retention.
• C (Correct): Hysterectomy (removal of the uterus containing the fibroid) provides a definitive cure for the fibroid and its associated symptoms, including the urinary retention. Given her age (47, likely perimenopausal) and the severity of the symptom (acute retention), hysterectomy is often considered the most effective long-term solution if fertility is not desired and less invasive options are unsuitable or ineffective. Myomectomy could be an alternative if uterus preservation is desired, but hysterectomy is a very reasonable option here.
• D (Incorrect): Progesterone injectables do not shrink fibroids or relieve pressure symptoms.
• E (Incorrect): Self-intermittent catheterization manages the retention symptomatically but does not address the underlying cause (the fibroid).

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Discusses fibroid treatments in HMB context)

Explanation: This young woman has HMB causing significant anaemia (Hb 8.5). An intramural fibroid (3cm) is present, but may or may not be the sole cause of HMB (especially if not cavity-distorting). She is recently married, implying fertility may be desired soon. Treatment should address the anaemia and HMB, considering fertility.

• A (Incorrect): Cyclical oral Norethisterone can help HMB but may have side effects and isn't ideal long-term.
• B (Incorrect): GnRH Agonists are temporary, suppress fertility, and have side effects.
• C, D (Incorrect): Myomectomy (laparoscopic or open) is surgery to remove the fibroid. For a 3cm intramural fibroid, it might be considered if medical options fail or if it's thought to significantly contribute to HMB/subfertility, but it's not usually the *first* step. Medical management is typically tried first.
• E (Correct): Treating with Tranexamic acid and/or Mefenamic acid during menstruation is a first-line medical approach according to NICE NG88. It directly reduces blood loss, helping manage the HMB and allowing the anaemia to be corrected with iron supplementation (which should also be given). This approach avoids hormones and surgery initially and preserves fertility options. If this fails, other options (LNG-IUS - though may affect fertility planning timing, or myomectomy) can be considered.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This perimenopausal woman (age 48) has HMB with normal pelvic structures on ultrasound. This is likely dysfunctional uterine bleeding. Management should follow NICE NG88 guidance.

• A (Incorrect): Ignoring symptoms for six months is inappropriate, especially if bleeding is heavy.
• B (Incorrect): Endometrial biopsy is considered if risk factors for cancer exist, bleeding persists despite treatment, or before ablation, but not usually first-line with normal USS in the absence of specific risk factors (though age 48 is borderline, biopsy might be considered if initial medical treatment fails).
• C (Correct): First-line medical management according to NICE NG88 (if LNG-IUS is not chosen/suitable) includes tranexamic acid and/or mefenamic acid (NSAID). These are non-hormonal options taken during menstruation to reduce blood loss and pain.
• D (Incorrect): Norethisterone (cyclical progestogen) is a second or third-line medical option.
• E (Incorrect): Oral iron is only needed if she is found to be anaemic on FBC (which should be checked). It doesn't treat the bleeding itself.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation:

• A (Correct): There is evidence for a genetic predisposition to uterine fibroids, with familial clustering and higher incidence in certain ethnic groups (e.g., women of African descent).
• B (Correct): Ulipristal acetate (a selective progesterone receptor modulator) is a medical treatment licensed for moderate to severe symptoms of uterine fibroids, effectively shrinking them and reducing bleeding (use requires specific monitoring).
• C (Correct): Red degeneration is a type of infarction within a fibroid, often occurring during pregnancy due to rapid growth outstripping blood supply. It causes acute pain.
• D (Incorrect): Sarcomatous change (leiomyosarcoma) in a presumed fibroid is rare, estimated at less than 0.1% (<<1 in 1000), not 10%.
• E (Correct): On gross pathology (cut section), uterine fibroids classically exhibit a firm, white, whorled appearance due to the arrangement of smooth muscle bundles.

Explanation: This adolescent has HMB (heavy flow for 8 days) and dysmenorrhea causing anaemia (Hb 9), with regular cycles and normal USS. Initial management should target both symptoms effectively.

• A (Incorrect): COCPs are an option, but starting with non-hormonal treatments is also appropriate first-line (NICE NG88).
• B (Incorrect): Depot injection is not first-line.
• C (Correct): Combining Mefenamic acid (an NSAID targeting pain and reducing flow) with Tranexamic acid (an antifibrinolytic strongly reducing flow) taken during menstruation is a highly effective initial non-hormonal approach according to NICE NG88. It addresses both the heavy bleeding (likely cause of anaemia) and the dysmenorrhea. Iron supplementation should also be started.
• D (Incorrect): Norethisterone is not first-line.
• E (Incorrect): Tranexamic acid alone is effective for bleeding but mefenamic acid adds benefit for the significant dysmenorrhea mentioned.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This young woman desires fertility and has HMB caused by a significant (5cm) fibroid that is distorting the uterine cavity (submucosal component - 'slightly bulging'). Such fibroids can impair fertility and cause HMB. Treatment should aim to resolve symptoms and preserve/enhance fertility.

• A (Correct): Myomectomy (surgical removal of the fibroid while preserving the uterus) is the most appropriate management. Given the cavity distortion and desire for fertility, removing the fibroid is necessary. The approach (hysteroscopic, laparoscopic, open) depends on the exact location and extent of the intramural component, but surgical removal is indicated. NICE NG88 supports myomectomy for women with HMB and fibroids >3cm wishing to conceive.
• B (Incorrect): Mefenamic acid and tranexamic acid treat the symptom (HMB) but not the underlying fibroid or potential fertility impact.
• C (Incorrect): GnRH analogues shrink fibroids temporarily but are not a fertility treatment and have side effects.
• D (Incorrect): Ulipristal acetate shrinks fibroids but its role in women desiring immediate fertility is less established/limited.
• E (Incorrect): Uterine artery embolization is effective for HMB but generally not recommended for women desiring future pregnancy due to potential adverse effects on ovarian function and placentation.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Differentiating a large uterine fibroid from an ovarian mass like an endometrioma on clinical examination.

• A (Incorrect): Ascites (fluid in the abdomen) is more commonly associated with ovarian malignancy, but can occasionally occur with benign ovarian cysts or rarely with degenerating fibroids; its absence doesn't strongly differentiate.
• B (Incorrect): Limited vertical movement suggests fixation, which could occur with large fibroids, endometriosis, or malignancy. Fibroids generally move vertically with respiration to some extent unless very large or adherent.
• C (Incorrect): Firm consistency is typical of fibroids. Endometriomas are cystic and feel less firm, often tense or fluctuant, although large or complex ones can feel firmish. Firmness strongly favours fibroid.
• D (Correct): Mobility with the cervix is a key feature distinguishing a uterine mass (like a fibroid) from an ovarian mass. When the cervix is moved side-to-side during bimanual examination, a uterine mass will move with it, whereas an ovarian mass typically moves separately (unless adherent to the uterus).
• E (Incorrect): Both large fibroids and endometriomas often have a relatively smooth surface, although fibroids can sometimes feel nodular or 'bosselated'.

Explanation: This young woman has heavy, irregular bleeding (suggesting possible anovulation or dysfunctional bleeding) with normal examination. Treatment should aim to regulate cycles and reduce bleeding. NICE NG88 applies.

• A (Correct): Combined Oral Contraceptive Pills (COCPs) are a suitable first-line option. They regulate the cycle, reduce bleeding, and provide contraception. Given the irregular bleeding, hormonal regulation is often preferred over non-hormonal methods that only reduce flow.
• B (Incorrect): DMPA (injectable progestogen) is generally second-line.
• C (Incorrect): Levonorgestrel-releasing IUS (LNG-IUS) is highly effective for HMB but may not be the first choice for irregular bleeding unless HMB is the predominant feature and long-term contraception is desired. COCPs offer better cycle control initially for irregular bleeding.
• D (Incorrect): Progesterone-only pills (POPs) can sometimes help with HMB but often cause irregular bleeding patterns themselves, making them less ideal for someone already experiencing irregular bleeding.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation:

• A (Correct): Asymptomatic fibroids discovered incidentally, especially in postmenopausal women (when they typically regress due to low estrogen), can usually be managed conservatively with observation.
• B (Correct): GnRH analogue therapy induces a hypoestrogenic state, leading to a reduction in fibroid size. This effect is temporary, and fibroids usually regrow after stopping treatment.
• C (Correct): Uterine artery embolization (UAE) blocks blood supply to the fibroids. While many successful pregnancies have occurred after UAE, there is evidence suggesting it may increase risks such as miscarriage, preterm birth, and abnormal placentation compared to myomectomy or no intervention. It is therefore generally not recommended as first-line for women desiring future fertility (NICE NG88). So, it 'can' reduce fertility potential or increase pregnancy risks.
• D (Incorrect): Myomectomy (removal of fibroids) during Caesarean section is generally discouraged unless the fibroid obstructs delivery or causes significant bleeding, due to the increased risk of haemorrhage from the highly vascular pregnant uterus.
• E (Incorrect): Intramural fibroids (within the uterine wall) are typically removed via laparotomy or laparoscopy (myomectomy), not transcervically. Transcervical resection is used for submucosal fibroids located within the uterine cavity.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: This perimenopausal woman (age 40, last period 6 months ago) is obese (BMI 32), has risk factors for endometrial hyperplasia/cancer (obesity, irregular cycles potentially indicating chronic anovulation, polycystic ovaries), and an endometrial thickness (ET) of 9mm, which is increased for someone potentially postmenopausal or with prolonged amenorrhea. NICE guidelines recommend investigation for women ≥40 with HMB/irregular bleeding, especially with risk factors. An ET >4-5mm in postmenopausal women or thickened/irregular endometrium in perimenopausal women with risk factors warrants sampling.

• A (Incorrect): COCPs are contraindicated due to migraine with aura.
• B (Correct): Endometrial biopsy (e.g., Pipelle sampling) is the most appropriate next step to exclude endometrial hyperplasia or malignancy given her age, risk factors (obesity, irregular cycles, PCOS morphology), and ET of 9mm after 6 months of amenorrhea. NICE guideline NG88 and RCOG guidelines recommend endometrial sampling in such cases.
• C (Incorrect): Inducing bleeding with progesterone doesn't exclude underlying pathology.
• D (Incorrect): Metformin addresses insulin resistance (PCOS) but doesn't address the potential endometrial pathology.
• E (Incorrect): Reassurance is inappropriate given the ET and risk factors; investigation is needed.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)
• RCOG Green-top Guideline No. 52: Management of Suspected Ovarian Masses in Premenopausal Women (useful context for PCOS morphology but focus here is endometrium)
• RCOG Green-top Guideline No. 67: Management of Endometrial Hyperplasia (Published Feb 2016)

Explanation: Leiomyomas are benign uterine fibroids.

• A (Correct): Large or strategically located fibroids can increase the risk of pregnancy complications, including preterm labour, malpresentation, caesarean section, and postpartum haemorrhage (RCOG Patient Information).
• B (Incorrect): Leiomyomas are benign tumours. The risk of sarcomatous change (leiomyosarcoma) is very low, estimated at <1 in 1000, and it's debated whether sarcomas arise from pre-existing fibroids or de novo. They do not inherently 'increase the risk of malignancy' in the way conditions like endometrial hyperplasia do.
• C (Incorrect): Nulliparity (never having given birth) is considered a risk factor for fibroids, while multiparity may be protective.
• D (Incorrect): Estrogen (like ethinylestradiol in COCPs) generally promotes fibroid growth, although low-dose COCPs may not significantly increase size and can help control bleeding. Fibroids typically regress in hypoestrogenic states (menopause, GnRH analogue use).
• E (Incorrect): Degenerative changes (including hyaline, cystic, calcific, red degeneration) occur more commonly during reproductive years or pregnancy due to rapid growth outstripping blood supply. Fibroids tend to regress (shrink) after menopause due to estrogen deprivation, not undergo cystic degeneration.

References:

• RCOG Patient Information Leaflet: Fibroids
• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management

Explanation: This woman has relatively mild symptoms ('occasional' HMB) and mild anaemia (Hb 10.2) attributed to a subserosal fibroid. Subserosal fibroids (on the outer surface of the uterus) are less likely to cause HMB than submucosal or intramural ones unless very large. Treatment should be tailored to symptom severity.

• A (Incorrect): Oral norethisterone is a hormonal treatment, usually second/third line for HMB and may not be necessary for 'occasional' bleeding.
• B (Incorrect): GnRH analogues are used for significant symptoms or pre-operative shrinkage, not for mild/occasional HMB.
• C, D (Incorrect): Surgical removal (myomectomy) via laparoscopy or laparotomy is generally reserved for more significant symptoms, larger fibroids causing pressure, or fertility issues, not typically for occasional HMB from a 5cm subserosal fibroid.
• E (Correct): Given the occasional nature of the HMB and only mild anaemia, starting with simple medical management taken only during menstruation is appropriate. Tranexamic acid (antifibrinolytic) and/or Mefenamic acid (NSAID, also helps dysmenorrhea if present) are recommended first-line medical treatments by NICE NG88 for HMB when hormonal methods/IUS are not used or suitable. This addresses the symptoms without invasive or systemic hormonal treatment.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)

Explanation: Management of an intramural fibroid in the context of subfertility is controversial, especially if it doesn't distort the uterine cavity. Evidence for removal improving fertility outcomes is debated unless the fibroid is large or significantly impacting the endometrium/cavity.

• A (Correct): Myomectomy (surgical removal) may be considered, particularly if the fibroid is large (>4-5cm) or potentially contributing to subfertility, although evidence is not definitive for purely intramural fibroids not distorting the cavity. It's an 'option'.
• B (Incorrect): GnRH agonists shrink fibroids temporarily but suppress ovulation and are not a fertility treatment. Used pre-operatively sometimes.
• C (Incorrect): LNG-IUS is a contraceptive and treats HMB, not suitable for enhancing fertility or treating the fibroid itself.
• D (Incorrect): Transcervical resection is for submucosal fibroids.
• E (Incorrect): Uterine artery embolization is generally avoided in women desiring future fertility due to potential adverse impacts.

Note: Given the uncertainty in guidelines about removing intramural fibroids for fertility, Myomectomy is the only plausible 'treatment option' aimed at potentially improving fertility by removing the fibroid.

Explanation: This woman has HMB causing significant anaemia (Hb 8.5) with normal investigations. She desires treatment but has migraine with aura, which is a contraindication to estrogen-containing methods (like COCPs). NICE NG88 provides guidance.

• A (Incorrect): COCPs are contraindicated due to migraine with aura (UKMEC Category 4).
• B (Incorrect): Dilatation and curettage is diagnostic and therapeutic for some conditions but not first-line management for HMB with normal USS.
• C (Correct): High-dose cyclical progestogens, like Norethisterone 5mg tds from day 5-26 of the cycle, can reduce heavy bleeding. While the LNG-IUS is often preferred first-line pharmacologically (NICE NG88), oral options are needed if IUS is declined or unsuitable. Norethisterone is a possible medical treatment. Tranexamic acid (E) is also an option. Let's re-evaluate based on NICE. NICE NG88 suggests LNG-IUS first, then tranexamic acid, NSAIDs, COCP (contraindicated), or cyclical progestogens. Given the anaemia, effective reduction is needed. Tranexamic acid is highly effective at reducing flow. Norethisterone can work but side effects can be limiting. *Revisiting*: Both C and E are plausible medical options. Tranexamic acid directly targets blood loss during menstruation. Norethisterone manipulates the cycle. Tranexamic acid is often considered highly effective for HMB itself. Let's choose Tranexamic acid as per NICE algorithm favouring it over cyclical progestogens if LNG-IUS isn't used.
• D (Incorrect): Oral iron supplementation is essential to treat her anaemia but doesn't manage the HMB itself. It should be given alongside treatment for HMB.
• E (Correct - Reconsidering): Tranexamic acid taken only during menstruation is a first-line medical option (after LNG-IUS) according to NICE NG88 and is effective at reducing blood loss without hormonal side effects or contraindications related to migraine. It directly addresses the HMB. This is likely the most appropriate *initial* medical management choice alongside iron therapy.

Revised Decision: E (Tranexamic acid) is the better choice as per NICE guideline sequence for non-hormonal effective treatment, especially given the contraindication to COCPs.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)
• FSRH Guideline: Combined Hormonal Contraception (Jan 2019, updated Dec 2020) - for UKMEC categories.

Explanation: Similar to Q37 (2021 March), an asymptomatic fibroid discovered incidentally usually does not require active intervention, regardless of age (unless postmenopausal growth occurs).

• A, C (Incorrect): Myomectomy (laparoscopic or open) is surgery reserved for symptomatic fibroids or those potentially impacting fertility.
• B (Correct): Expectant management (watchful waiting or conservative management) is the appropriate approach for an asymptomatic fibroid. Follow-up frequency and modality can be individualized.
• D (Incorrect): Ulipristal acetate is for symptomatic fibroids.
• E (Incorrect): TAH (Total Abdominal Hysterectomy) is major surgery and completely inappropriate for an asymptomatic fibroid.

Explanation: Several treatments aim to reduce the size of uterine fibroids, primarily by modulating hormone levels.

• A (Incorrect): Depot medroxyprogesterone acetate (DMPA) is a progestogen-only contraceptive. While it can help control fibroid-related bleeding, it does not reliably shrink fibroids and may even be associated with growth in some cases.
• B (Correct): Gonadotropin-releasing hormone (GnRH) analogues create a hypoestrogenic state, similar to menopause, which effectively shrinks fibroids. However, their use is typically limited to short-term (3-6 months), often pre-operatively, due to side effects (menopaual symptoms, bone density loss) (NICE NG88).
• C (Incorrect): Tranexamic acid is an antifibrinolytic agent that reduces heavy menstrual bleeding but has no effect on fibroid size.
• D (Correct): Ulipristal acetate is a selective progesterone receptor modulator (SPRM) that effectively reduces both fibroid size and bleeding. Its use has been subject to review due to rare concerns about liver injury, but it remains an option under specific monitoring conditions in the UK/EU (NICE NG88).
• E (Correct): Uterine artery embolization (UAE) is an interventional radiology procedure that blocks the blood supply to the fibroids, causing them to shrink and alleviating symptoms. It is a recognised treatment option for symptomatic fibroids (NICE NG88).

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)