Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

Abnormal Uterine Bleeding

8–1. All EXCEPT which of the following definitions of abnormal uterine bleeding are true?

a. Metrorrhagia describes intermenstrual bleeding.

b. Oligomenorrhea refers to cycles with intervals shorter than 35 days.

c. Hypomenorrhea refers to menses with diminished flow or shortened interval.

d. Menorrhagia is defined as prolonged or heavy cyclic menstruation, with menses lasting longer than 7 days or exceeding 80 mL of blood loss.

8–2. All EXCEPT which of the following tools are clinically useful to estimate menstrual blood loss?

a. Pad counts

b. Hemoglobin and hematocrit

c. Pictorial blood assessment chart

d. Sodium hydroxide extraction of hemoglobin

8–3. The most common etiologies of bleeding have been correctly paired with their age demographic in all EXCEPT which of the following?

a. Adolescence—anovulation

b. Childhood—vulvovaginitis

c. Perimenopause—anovulation

d. Menopause—endometrial carcinoma

8–4. Which of the following mechanisms are responsible for control of blood loss during menses?

a. Thrombi

b. Platelet aggregation

c. Vasoconstriction of endometrial arteries

d. All of the above

8–5. Which of the following may be reasonably considered in the evaluation of postcoital vaginal bleeding?

a. Conization

b. Cystoscopy

c. Colposcopy

d. Proctoscopy

8–6. Which of the following clinical findings may be associated with abnormal uterine bleeding?

a. Obesity

b. Bruising

c. Acanthosis nigricans

d. All of the above

8–7. Which laboratory criteria listed below is consistent with iron-deficiency anemia?

a. Low serum ferritin level

b. Normal hemoglobin and hematocrit

c. Low total iron-binding capacity (TIBC)

d. Increase in mean corpuscular hemoglobin (MCV)

8–8. A patient seeing you for menorrhagia reveals that she has a personal history of gingival bleeding and that during a recent tooth extraction, she bled excessively. You decide to screen her for a coagulation disorder. You order all EXCEPT which of the following laboratory tests?

a. Bleeding time

b. Prothrombin time (PT)

c. Partial thromboplastin time (PTT)

d. Complete blood count (CBC) with platelets

8–9. Which of the following is a limitation of flexible plastic samplers (i.e., Pipelle) used for endometrial biopsy (EMB) in the evaluation of abnormal uterine bleeding?

a. Low rate of inadequate sampling

b. Ability to be performed in an office setting

c. Less patient discomfort compared to stiff metal curette

d. Low sensitivity and high false-negative rate for focal endometrial pathology

8–10. Which of the following are advantages of transvaginal sonography in the evaluation of abnormal uterine bleeding?

a. Ability to reduce use of endometrial biopsy

b. Simultaneous assessment of myometrium and endometrium

c. Greater patient comfort compared with endometrial biopsy or hysteroscopy

d. All of the above

8–11. What is the primary advantage of saline infusion sonography compared with transvaginal sonography?


a. Less patient discomfort

b. Superior detection of intracavitary masses

c. Ability to perform at any time of the cycle

d. Simultaneous assessment of myometrium and endometrium

8–12. A 60-year-old postmenopausal woman presents for evaluation of bleeding, which you have determined from your physical examination to be uterine in origin. Which of the following diagnostic procedures is a logical first step in her evaluation?

a. Colposcopy

b. Diagnostic hysteroscopy

c. Transvaginal sonography

d. Saline-infusion sonography

8–13. Characteristics of the soft, fleshy intrauterine growth, shown here exhibiting a single feeder vessel, include which of the following?


a. The main diagnostic tool is the Pap smear.

b. It is an uncommon cause of abnormal uterine bleeding.

c. Infertility has been linked directly with this growth.

d. Use of oral contraceptive pills appears to be protective.

8–14. Which characteristics are risk factors for malignant transformation of the structural lesion shown here?


Photograph contributed by Dr. Mayra Thompson.

a. Tamoxifen use

b. Postmenopausal status

c. Size greater than 1.5 cm

d. All of the above

8–15. Your 27-year-old patient who recently underwent dilatation and curettage for an incomplete abortion presents to the office with new-onset menorrhagia. Transvaginal sonography reveals this hypoechoic tubular structure within the myometrium, with large-caliber vessels and blood flow reversal, as displayed here. What is the next most appropriate step in her evaluation?


a. Angiography

b. Hysteroscopy

c. Saline-infusion sonography

d. Computed tomography (CT) of pelvis with contrast

8–16. Which of the following explanations have been suggested as the etiology for abnormal uterine bleeding with use of the device shown below in this three-dimensional sonogram?


a. Malposition of the device

b. Unbalanced ratio of prostaglandins and thromboxane

c. Increased endometrial vascularity, congestion, and degeneration

d. All of the above

8–17. A patient for whom you initiated combination oral contraceptive pills (COCs) 3 months ago returns to the office for a routine COC reevaluation. She complains of light but irregular bleeding during this time, but states that it is improving. What is your diagnosis and plan of care?

a. COC intolerance requiring method discontinuation

b. Breakthrough bleeding requiring counseling and reassurance

c. Endometrial pathology necessitating transvaginal sonography

d. Hormonal imbalance requiring selection of a different COC formulation

8–18. In which situation should irregular spotting or bleeding be evaluated in a postmenopausal patient on hormone replacement therapy (HRT)?

a. History of endometrial polyps

b. Continued bleeding after 6 months of HRT use

c. Abnormal bleeding that develops after initial amenorrhea

d. All of the above

8–19. Which of the following statements regarding tamoxifen is true?

a. It acts as an estrogen agonist in the breast and uterus.

b. Tamoxifen use has been linked to endometrial polyps, hyperplasia, and carcinoma but not to uterine sarcomas.

c. Women using tamoxifen should undergo evaluation for endometrial cancer only if symptoms of bleeding develop.

d. It is a selective estrogen-receptor modulator (SERM) used as an adjunct for treatment of estrogen-receptor-negative breast cancer.

8–20. Systemic causes of abnormal uterine bleeding include which of the following?

a. Liver disease

b. Severe renal dysfunction

c. Hypo- and hyperthyroidism

d. All of the above

8–21. Which is an effective first-line treatment for women with menorrhagia and von Willebrand disease?

a. Endometrial ablation

b. Dilatation and curettage (D&C)

c. Combination oral contraceptive pills (COCs)

d. Nonsteroidal anti-inflammatory drugs (NSAIDs)

8–22. Which of the following statements regarding dysfunctional uterine bleeding (DUB) is true?

a. Eighty to 90 percent of DUB is associated with ovulation.

b. Up to half of women with abnormal uterine bleeding will have DUB.

c. If structural causes of abnormal uterine bleeding cannot be excluded, the term DUB is used.

d. Bleeding associated with anovulation is thought to stem predominantly from vascular dilatation alone.

8–23. Which of the following medications used to treat dysfunction uterine bleeding (DUB) is correctly paired with its mechanism of action?

a. Tranexamic acid—increased plasmin levels

b. Nonsteroidal anti-inflammatory drugs (NSAIDs)— stimulation of cyclooxygenase (COX-1 and 2)

c. Oral progestins—inhibition of endometrial growth with organized sloughing following their withdrawal

d. Combination oral contraceptive pills (COCs)— endometrial atrophy with diminished prostaglandin synthesis and increased endometrial fibrinolysis

8–24. Which of the following statements is true regarding the efficacy of the option shown here in this three-dimensional sonogram for the treatment of dysfunctional uterine bleeding (DUB)?


a. It has been shown to reduce menstrual loss by more than 75 percent after 3 months’ use.

b. It has been shown to be more effective than mefenamic acid or oral progestins in decreasing uterine blood loss.

c. Compared with endometrial ablation, this method appears to have similar therapeutic effects up to 2 years after treatment.

d. All of the above

8–25. A patient presents to the emergency department with complaints of a 1-day history of heavy vaginal bleeding. She is tachycardic but not hypotensive, and vital signs do not change with positional changes from lying to sitting. Physical examination demonstrates bleeding from above the cervical os and continued pooling of blood in the vagina. Laboratory studies reveal she is anemic. Which of the following choices is the most appropriate first-line agent in attempting to control her active uterine bleeding?

a. Tranexamic acid

b. Intravenous estrogen

c. Gonadotropin-releasing hormone (GnRH) agonist

d. Combination oral contraceptive pill (COC) taper

8–26. Which of the following statements regarding tranexamic acid is true?

a. To be most effective, it requires administration before and during menses.

b. Contraindications to its usage include a history or intrinsic risk of thromboembolic disease.

c. It does affect other blood coagulation parameters, such as platelet count, prothrombin time (PT), and partial thromboplastin time (PTT).

d. It is an antifibrinolytic drug that permanently blocks lysine binding sites on plasminogen, thereby decreasing plasmin levels and fibrinolytic activity.

8–27. When counseling a patient for endometrial ablation, which of the following points is important to discuss with her?

a. Three fourths of women after ablation experience significantly decreased flow.

b. Approximately 10 to 15 percent of women will need subsequent hysterectomy by 5 years after the ablation.

c. Following ablation, later evaluation of the endometrium for recurrent abnormal bleeding can be difficult due to resultant distortion of the endome-trial cavity.

d. All of the above

8–28. All EXCEPT which of the following are contraindications for endometrial ablation?

a. Postmenopausal status

b. Prior classical cesarean delivery

c. Anatomically normal endometrial cavity

d. Women wishing to preserve their fertility

Chapter 8 ANSWER KEY