176
RESULTS INTERPRETATION
Case 1
Ms Mitchell is 29 years old. She has been referred to your gynaecology outpatient clinic with a history of irregular bleeding over the previous 4 months. She has been taking oral contraception over the past 12 months. She has had one full-term normal delivery. Her last cervical smear test was 2 years ago and was normal. She is a heavy smoker.
Results
Ultrasound scan
●
Normal sized anteverted uterus, endometrium 4 mm, and midline not seen
●
There are three echogenic areas within the cavity – ?polyps
●
Both ovaries multifollicular
●
Normal adnexae
Answer
Further information required
●
Type of oral contraception – exclude progestogen
●
Any problems taking oral contraception?
●
Any other medication?
●
What is her body mass index?
Explanation of results
●
Looks like endometrial polyps
Further management options
●
Hysteroscopy/D&C and polypectomy
●
Location either outpatient or day case, depending on the patient
●
Would mirena IUCD be a better option in view of her being a heavy smoker?
Global score
0
1
2
3
4
177
CIRCUIT C
Case 2
Miss Hennessey is 18 years old and in the first year of a 3-year degree course at university. She presents with a history of secondary amenorrhoea for 18 months. She is also concerned about hirsutism, particularly on her forearms. Her menarche was at 13 years of age and her periods have always been a little erratic.
Her height is 1.67 m and her weight is 43.8 kg, giving a BMI of 16.3.
Results
●
LH – 4.7 IU/L
●
FSH – 9.3 IU/L
●
Prolactin – 205 mU/L (83–527)
●
Testosterone – 1.8 nmol/L (0.5–3.0)
●
Cortisol – 424 nmol/L (171–800)
●
SHBG – 25 nmol/L (38–103)
Ultrasound scan
●
Normal sized anteverted uterus, clear cavity
●
Left ovary 22 × 15 mm, right ovary 24 × 14 mm
●
Multiple tiny follicles consistent with PCOS
●
Free fluid in the pouch of Douglas
Answers
Questions
●
Why is her BMI so low?
●
What are the patient’s expectations?
Explanation
●
Most likely diagnosis is PCOS, but her low BMI may be a contributing factor
– is there any eating disorder?
Options
●
Do nothing
●
OCP (Dianette) – clomid may be inappropriate at this time
●
Induce a withdrawal bleed with provera, but exclude pregnancy
●
Cosmesis for hairiness – e.g. waxing, electrolysis
●
Warn of need for contraception
●
Does the BMI need investigation – either malabsorption or psychiatric referral?
Global score
0
1
2
3
4
178
RESULTS INTERPRETATION
Case 3
Mrs Hutchinson, aged 37 years, returns to your clinic for the results of her fertility investigations. She has a regular cycle and no significant history of note.
Results
●
Hysterosalpingogram – normal spill of dye through both tubes
●
Day 21 serum progesterone – 72 nmol/L
●
Sperm count
– volume: 1.5 mL
– count: 8 million/mL
– motility: 40%
– progressive motility: 50%
– abnormal forms within normal limits
Answers
Questions
●
Around the sample collection and any delay in getting it to the lab
●
Partner’s habits re. smoking and marijuana
●
Type of job/undergarments/baths/illnesses
Explanation
●
Patient’s results normal
●
Sperm count low, may reflect his health 2 months earlier
●
Concern as to whether this is the highest or lowest count Options
●
Repeat sperm count at least once
●
Possible need for andrology referral
●
Decide what the couple want and discuss accordingly
●
IUI husband or donor, IVF/ICSI, adoption
●
Depends on the couple’s views but need to take age into account Global score
0
1
2
3
4
179
CIRCUIT C
Case 4
Mrs Jones, aged 59 years, was admitted last night with a history of postmenopausal bleeding which has been happening over the past 3 years. She was unable to pass urine and has recently had difficulty in doing so. She has recently had an abnormal smear and is awaiting a colposcopy appointment. She has no other health problems or any relevant history. Her blood pressure is 150/80. Abdominal examination was unremarkable but vaginal examination revealed a frozen pelvis.
Results
●
Hb – 8.3 g
●
WCC – 19.0
●
Platelets – 641
●
Na – 126
●
K – 6.0
●
Urea – 38.1
●
Creatinine – 820
Answers
Questions
●
What was the smear abnormality?
●
Does she have any pain?
●
When did she pass urine?
Explanation
●
Anaemia probably secondary to her PMB but she has renal failure, which needs to be dealt with.
Options
●
Needs ultrasound scan to see if she has hydronephrosis
●
Needs dialysis followed by insertion of nephrostomy tubes
●
Referral to the urologists – need to establish a diagnosis and may need EUA, cystoscopy and sigmoidoscopy
●
Most likely to be carcinoma of cervix and then will need radiotherapy Global score
0
1
2
3
4
180
RESULTS INTERPRETATION
Case 5
Mrs Astride, aged 43 years, recently underwent an evacuation of uterus for an incomplete miscarriage. She has had one previous pregnancy complicated with pre-eclampsia. She has had some further bleeding and attends the early pregnancy assessment unit for review 10 days after her evacuation and the results from that time are below.
Results
Histology – products of conception consistent with a complete hydatidiform mole.
Answers
Questions
●
How much bleeding is present?
●
Is the os still open?
●
Has a repeat scan been undertaken and, if so, what does it show?
Explanation
●
May have some retained products of conception
●
May have an endometritis
Options
●
May need repeat suction evacuation
●
Needs registration with centre (Charing Cross, Sheffield or Dundee)
●
Chest X-ray may be needed
●
BHCG levels to be done; serum would be useful
●
Advice about contraception and planning for further pregnancies needs to be addressed
Global score
0
1
2
3
4
181