If the woman is not breast-feeding, menstruation could return soon after delivery.
After what period of time, 70-90% of women menstruate?
Correct Answer C:
If the woman is not breast-feeding, menstruation could return within 6 weeks of delivery. After 3 months, 70-90% of women menstruate; 6 months later, almost all have resumed menstruation (average time for resumption is 8 weeks). This timeline varies widely if the mother is breast-feeding. Restoration of normal menses can be interfered with by injectable contraceptives, stress/depression or sometimes even sleep deprivation with a new baby.
When taking a patient history, which of the following questions will most accurately ascertain the length of the patient’s menstrual cycle?
Correct Answer D:
The first day of the cycle is the first day of the menses. The length of the cycle is from the first day of one menses to the first day of the next menses. Many patients think that the length of the cycle is from the end of the menses to the beginning of the next. Thus, a number of women think that they have 21- to 23-day cycles.
→ Many patients count the days between periods as their cycle length. This will falsely shorten the length of their true cycle.
→ Even if the answer to this question is yes, there is no way to ascertain the actual length of their cycle.
→ See answer to A.
→ The last few days of a menses can be variable in length and degree of bleeding/spotting. It is less accurate to count this way than to count from the beginning of one cycle to the beginning of the next.
A 21-year-old married gravida 1 para 1 has not used her oral contraceptives for 6 months. She comes to your office for evaluation because her menstrual period is 2 weeks late. Her menses had been regular since discontinuing the oral contraceptives. A urine beta-hCG is negative.
Which one of the following is true regarding this situation?
Correct Answer A:
With the high level of sensitivity and specificity of current tests to measure hCG in serum and urine, pregnancy can now be diagnosed before the time of the first missed menstrual period. For current serum hCG assays, the low threshold for detection is 10-25 IU/L, while for urine assays it is 25-50 IU/L, which corresponds to approximately the seventh day after conception. Because the levels of hCG in the blood and urine are very similar, the tests are equivalent. Urine testing may reveal a positive result as early as 3-4 days after implantation. By the time of the expected menstrual period, the test will be positive 98% of the time. If a test is negative more than 1 week after the expected time of the menstrual period, it is almost certain the patient is not pregnant. To cover these rare instances where a woman has a low hCG and conceived later than expected, the test should be repeated in 1 week for a definitive result.
Since ectopic pregnancy is not a life-threatening problem for the mother until 2 months after conception, a patient with a negative urine hCG does not require ultrasonography to exclude ectopic pregnancy. Patients with a suspected ectopic pregnancy and a negative urine hCG should be followed closely, as early laparoscopic intervention can improve the chances of future fertility.
A 55-year-old postmenopausal female presents with a "period-like" vaginal bleeding for 5 days that stopped spontaneously.
Your best approach to diagnosis of this patient's problem would be to:
Correct Answer D: Any post menopausal woman who has vaginal bleeding should have an endometrial biopsy. Symptoms include vaginal bleed after menopause, bleeding after sexual intercourse, bleeding between periods in pre-menopausal women.
If you suspect endometrial cancer, conduct a series of tests to confirm the diagnosis. A complete personal and family medical history should be taken. A physical examination should be done, which will include a thorough pelvic examination.
A 52-year-old woman presents to your office complaining of vaginal bleeding. Her last bleeding episode was 2 years ago. She is not on hormone replacement therapy. Her hemoglobin is 134g/L. A vaginal ultrasound shows her uterus and adnexa to be of normal size and an endometrial stripe of 11 mm.
The next step in her evaluation should be:
Correct Answer C: In any woman over the age of 35, with abnormal uterine bleeding, the diagnosis of an endometrial malignancy must be entertained. With a postmenopausal woman having an endometrial stripe over 4-5 mm, cancer needs to be ruled out and tissue should be obtained. The simplest test is to proceed with an endometrial biopsy.
A. This therapy would be indicated as therapy for adenocarcinoma of the endometrium or for atypical endometrial hyperplasia. A diagnostic sampling of the endometrium is the first necessary test.
B. Although this test would lead to a diagnosis, an endometrial biopsy can be done more easily in the office with minimal discomfort.
D. This modality is used for the reproductive age female with severe symptomatic uterine bleeding in the absence of endometrial pathology.
E. A diagnosis of the endometrium must be made before hormonal therapy can be started in this case.
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