Download Answers to Learning Issues

Answers to Learning Issues
1 a) For practical purposes an episode of bleeding 12 months or more after the last period is
accepted as post menopausal bleeding
2 a) Delayed return of ovarian follicular function in the perimenopausal woman causing a late
period
b) Atrophic vaginitis from hormone lack usually in the older post menopausal woman
3 a) Hormone replacement treatment – oestrogen and progestogen given sequentially cause regular
scheduled withdrawal bleeds and breakthough bleeding if drug absorption or excretion are
interfered with. Given as a continuous combination, so called “period free HRT”, they may cause
irregular bleeding in the first several months of use
b) Tamoxifen therapy for breast cancer can cause endometrial hyperplasia, carcinoma and
sarcoma
c) Vaginal pessaries for prolapse
4 a) Cancer. In the UK this is most likely to be endometrial in origin. Ovarian cancer rarely
presents with PMB. Primary vaginal cancer is very rare. In developing countries without
screening, cervical cancer remains a common cause.
5 a) The pathophysiological and iatrogenic causes given above
b) Trauma from foreign bodies, vigorous intercourse after a period of abstinence
c) Cervical polyps
d) Endometrial hyperplasia with or without premalignant atypical changes (consider intrinsic
oestrogen source e.g. oestrogen secreting ovarian tumour, obesity)
6 a) In virtually all cases unless there is a ready explanation e.g. recent commencement of
continuous combined HRT, obvious trauma to vagina. N.B. A coincidental benign cervical polyp of long
standing may be present and mistaken for the cause of PMB due to an underlying endometrial cancer.
b) When endometrial biopsy precedes a scanning opportunity and has already revealed
endometrial cancer as the cause
7 a) When the endometrial thickness is 3mm or less in a non-HRT user
b) When the endometrial thickness is 5mm or less in a woman using sequential combined HRT
(or having used it within the past year) with unscheduled bleeding
8 a) When clinical examination and/or ultrasound and/or endometrial biopsy have already revealed
the diagnosis. N.B. Hysteroscopy with biopsy is preferable as the first line of investigation in women taking
Tamoxifen who experience PMB as ultrasound is poor at differentiating potential cancer from other tamoxifeninduced thickening because of the distorted endometrial architecture associated with long term use of this drug