SECTION A - MCQ ANSWERS (Q12-Q20)

Q12. Corpus Luteum Secretes ___

Q13. Shankha Nabhi Akriti (Trisected Uterus) - Third Avarta contains ___

• 1st Avarta - outer part
• 2nd Avarta - middle part
• 3rd Avarta (innermost) - Garbha (the embryo/fetus) resides here

Q14. Number of Garbhavriddhikara Bhavas according to Acharya Charaka

1. Matrija (from mother)
2. Pitrija (from father)
3. Atmaja (from soul/Atma)
4. Satmyaja (from Satmya - habituation)
5. Rasaja (from Rasa/nutrition)
6. Sattvaja (from Sattva/mind)

Q15. Most Common Presenting Part of Fetus at Term

Q16. Which of the Following is NOT a Viddha Lakshana of Artava Vaha Strotas?

• Artava Adarshanam - absence/non-appearance of menstrual blood (amenorrhea)
• Vandhyatva - infertility/sterility
• Asudra - scanty/difficult flow

Q17. Length of Fallopian Tube

1. Intramural (Interstitial) - 1 cm, within uterine wall
2. Isthmus - 3-4 cm, narrow straight part
3. Ampulla - 5 cm, widest part (site of fertilization)
4. Infundibulum - 1 cm, fimbriated end

Q18. Normal Weight of Placenta at Term

Q19. Garbha Poshan Nyaya According to Ashtanga Sangraha

1. Upasneha (absorption by moisture/osmosis) - nutrients are absorbed through the skin like a sponge absorbs water
2. Upsweda (absorption by vapor/diffusion) - nutrients reach the fetus through vapor-like diffusion

Q20. Angamarda, Ati Pravrutti, Daurgandhya (body ache, excessive flow, foul smell) - condition is ___

SECTION B - SHORT ANSWER QUESTIONS (Q.II)

Q.II.1. Fetus in Utero - Lie, Presentation, Attitude, Position

LIE (Situs)

• Longitudinal lie (99%) - fetal and maternal axes are parallel
• Transverse lie - fetal axis is at right angle to maternal axis
• Oblique lie - fetal axis is at 45 degrees (unstable, becomes longitudinal/transverse in labor)

PRESENTATION

• Cephalic (96%): Vertex (most common), Brow, Face, Sinciput
• Breech (3-4%): Frank breech, Complete breech, Footling/incomplete breech
• Shoulder (transverse/oblique lie)

ATTITUDE (Habitus)

• Universal flexion (good attitude) - Normal: head flexed on chest, thighs flexed on abdomen, legs flexed on thighs, arms crossed over chest - fetus assumes an "ovoid" shape
• Extension - abnormal (brow, face presentations)

POSITION

• Vertex - Occiput (O)
• Face - Mentum/Chin (M)
• Breech - Sacrum (S)
• Shoulder - Acromion/Scapula (A)

Q.II.2. PCOS - Short Note

1. Oligo-ovulation or anovulation
2. Clinical/biochemical hyperandrogenism
3. Polycystic ovaries on ultrasound (≥12 follicles of 2-9mm or ovarian volume >10 mL)

• Other etiologies must be excluded

• Insulin resistance → compensatory hyperinsulinemia
• Excess insulin stimulates ovarian androgen production
• Elevated LH:FSH ratio (LH elevated, FSH relatively low)
• Arrested follicle development → multiple small cysts
• Anovulation → chronic estrogen excess without progesterone opposition

• Menstrual irregularity (oligomenorrhea, amenorrhea)
• Hyperandrogenism - hirsutism, acne, alopecia (male pattern baldness)
• Obesity (especially central/android)
• Infertility (anovulatory)
• Acanthosis nigricans (insulin resistance marker)

• Serum LH:FSH ratio elevated (>2:1 or >3:1)
• Elevated testosterone, DHEAS, androstenedione
• Fasting glucose and insulin (HOMA-IR)
• Pelvic USG - "necklace sign" (multiple peripheral follicles)
• TSH, prolactin (to exclude other causes)

• Weight loss (5-10% weight reduction can restore ovulation)
• Oral contraceptive pills (OCP) - regulate menses, anti-androgenic
• Metformin - insulin sensitizer
• Clomiphene citrate - for ovulation induction (if fertility desired)
• Spironolactone/flutamide - for hirsutism
• Laparoscopic ovarian drilling - when drugs fail

Q.II.3. Amniotic Fluid - Functions & Abnormalities

Functions:

1. Mechanical protection - cushions the fetus from external trauma
2. Temperature regulation - maintains constant thermal environment
3. Allows fetal movement - prevents deformities, allows musculoskeletal development
4. Prevents adhesions - prevents amnion from adhering to fetus
5. Provides space for growth - fetus can grow freely
6. Fetal lung development - fetal breathing movements with swallowing of amniotic fluid
7. Fetal nutrition - minor contribution through swallowing
8. Antibacterial - contains immunoglobulins and lysozyme
9. Umbilical cord protection - prevents cord compression
10. Clinical uses - amniocentesis for prenatal diagnosis

Abnormalities:

• Causes: Maternal diabetes (most common), fetal GIT obstruction (esophageal atresia, duodenal atresia), neural tube defects (anencephaly), multiple pregnancies, fetal hydrops
• Complications: Preterm labor, cord prolapse, malpresentation, PPH, placental abruption

• Causes: Renal agenesis (Potter syndrome), posterior urethral valves, IUGR, post-term pregnancy, PPROM
• Complications: Cord compression, meconium aspiration, limb deformities, pulmonary hypoplasia
• Potter sequence - renal agenesis → oligohydramnios → pulmonary hypoplasia + limb deformities + characteristic facial features

Q.II.4. Rajanivrutti Vikara (Menopause)

• Dryness of vagina (Yoni Shushkata)
• Body pain, joint pain
• Mood changes, anxiety, insomnia
• Hot flashes (Daha)

• Vasomotor symptoms - hot flushes, night sweats
• Psychological - depression, irritability, mood swings
• Urogenital atrophy - vaginal dryness, dyspareunia, recurrent UTI
• Osteoporosis (Asthi Kshaya) - bone loss due to estrogen deficiency
• Cardiovascular disease risk increased
• Skin changes - dryness, wrinkling

• Shatavari (Asparagus racemosus) - phytoestrogenic
• Ashwagandha - adaptogenic
• Kumari (Aloe vera) - hormonal balance
• Bala, Nagbala - strengthening Dhatus
• Panchakarma - Snehana, Basti (medicated enemas)
• Dietary advice - nutritive, unctuous foods

• Hormone Replacement Therapy (HRT) - estrogen ± progesterone
• Non-hormonal: SSRIs, SNRIs for vasomotor symptoms
• Calcium + Vitamin D for bone protection
• Lifestyle modifications

Q.II.5. Anatomy of Female Internal Genitalia (with Labelled Diagram)

Organs:

1. Uterus
2. Fallopian tubes (2)
3. Ovaries (2)
4. Vagina

UTERUS:

• Shape: Pear-shaped, hollow muscular organ
• Size: 8 cm long × 5 cm wide × 2.5 cm thick (nulliparous)
• Weight: 60-80 gm (nulliparous)
• Parts: Fundus, Body (corpus), Isthmus (0.5 cm), Cervix (3 cm)
• Layers: Perimetrium (outer), Myometrium (middle - smooth muscle), Endometrium (inner - functional/basal layers)
• Normal position: Anteverted, Anteflexed
• Blood supply: Uterine artery (branch of internal iliac)
• Supports: Cardinal ligament (Mackenrodt's), Uterosacral ligament, Round ligament, Broad ligament

FALLOPIAN TUBES:

• Length: 10 cm
• Parts: Intramural (1cm), Isthmus (3cm), Ampulla (5cm - site of fertilization), Infundibulum with fimbriae (1cm)
• Function: Transport ovum, site of fertilization

OVARIES:

• Size: 3 × 2 × 1 cm (almond-shaped)
• Weight: 6-8 gm
• Position: In the ovarian fossa (lateral pelvic wall)
• Functions: Ovum production, hormone secretion (estrogen, progesterone)
• Blood supply: Ovarian artery (from aorta at L1 level)

VAGINA:

• Length: Anterior wall 7.5 cm, Posterior wall 9 cm
• Parts: Upper, middle, lower third
• Fornices: Anterior, posterior (deepest), lateral (right & left)
• Relations: Anteriorly - bladder/urethra; Posteriorly - rectum/POD; Laterally - ureters

DIAGRAM (Frontal Section):

        Fundus
        ____
   /   /    \   \
  | Fallopian|   |  Fallopian
  |  tube   | U |   tube
  | Ovary   | t |  Ovary
  |         | e |
  |  Body   | r |
  |         | u |
  |         | s |
         Cervix
           |
         Vagina

Q.II.6. Cusco's Speculum - Use, Method of Sterilisation, Contraindications

What is Cusco's Speculum?

Uses:

1. Inspection of vagina and cervix
2. Pap smear/cervical cytology (Papanicolaou test)
3. Taking high vaginal swabs (HVS) and endocervical swabs
4. Colposcopy
5. Cervical biopsy
6. IUCD insertion/removal
7. Treatment of cervical erosion (cauterization, cryotherapy)
8. Visual inspection with Acetic Acid (VIA) / Lugol's iodine (VILI)
9. Minor surgical procedures (cervical polypectomy)

Method of Sterilisation:

• Preferred: Autoclaving (steam sterilization at 121°C, 15 psi, 15 minutes)
• High-level disinfection: Soaking in 2% glutaraldehyde for 20 minutes
• Chemical sterilization: Cidex (ortho-phthalaldehyde)
• Boiling: 100°C for 20 minutes (less effective for spores)
• Disposable plastic specula are now widely used (single-use, no sterilization needed)

Contraindications:

• Virginal state (intact hymen) - unless absolutely necessary
• Severe vaginal stenosis/atresia
• Acute vaginitis/vulvitis (relative contraindication - painful)
• Patient refusal
• Severe atrophic vaginitis (extreme caution needed)
• Menorrhagia/active heavy bleeding may make examination difficult

Q.II.7. Garbhasthapak Gana

1. Shatavari (Asparagus racemosus) - uterine tonic, nutritive
2. Shatapushpa (Anethum sowa) - promotes hormonal balance
3. Shatavali - nutritive
4. Ashwagandha (Withania somnifera) - strengthening, adaptogenic
5. Vidarikanda (Pueraria tuberosa) - nutritive, anabolic
6. Payasya (Ipomoea digitata) - promotes milk and nutrition
7. Kapikachhu (Mucuna pruriens) - reproductive tonic
8. Godhumha (Triticum aestivum - wheat) - nutritive
9. Ikshuraka - diuretic, nutritive
10. Sthira (Desmodium gangeticum) - strengthening

• Balya (strengthening) - strengthens uterus and fetus
• Vrushya (aphrodisiac/reproductive tonic)
• Garbhaposhak (fetal nourishment)
• Used in habitual abortion, infertility, preterm labor
• Used in Garbhini Paricharya (antenatal care)

Q.II.8. Importance of Ultrasonography in Obstetrics & Gynaecology

In OBSTETRICS:

• Confirm intrauterine pregnancy, viability
• Detect ectopic pregnancy
• Dating (gestational age by CRL - Crown Rump Length)
• Detect multiple pregnancy
• Detect chromosomal anomalies (Nuchal Translucency - NT scan at 11-14 weeks)
• Diagnose molar pregnancy

• Anomaly scan / Level II USG (18-20 weeks) - detailed fetal anatomy
• Detect neural tube defects, cardiac defects, skeletal dysplasias, abdominal wall defects
• Placental location (placenta previa detection)
• Amniotic fluid assessment
• Cervical length measurement (risk of preterm labor)

• Fetal growth monitoring (BPD, HC, AC, FL measurements)
• Fetal weight estimation
• Presentation and lie of fetus
• Placenta previa, placental abruption
• Amniotic fluid index (AFI)
• Doppler studies - fetal wellbeing (umbilical artery, middle cerebral artery)
• Biophysical Profile (BPP)

• Confirm presentation
• Placental location before LSCS

In GYNAECOLOGY:

• Diagnosis of fibroids (uterine leiomyomas) - size, number, location
• Diagnosis of ovarian cysts - simple/complex
• PCOS diagnosis (necklace sign)
• Endometrial thickness measurement (endometrial hyperplasia, carcinoma)
• Detection of uterine anomalies (bicornuate, septate uterus)
• Ectopic pregnancy
• PID (pelvic inflammatory disease)
• Hysterosalpingography (HSG) guidance
• Follicular monitoring for ART (IVF/IUI)
• Sonosalpingography
• IUCD localization
• Guided biopsy and aspiration

SECTION B - LONG ANSWER QUESTIONS (Q.III)

Q.III.1. Masanumasik Garbhini Paricharya (Month-Wise Antenatal Care)

GENERAL PRINCIPLES:

• Ahara (Diet): Nutritive, easily digestible, unctuous, warm, fresh
• Vihara (Regimen): Gentle exercise, adequate rest, avoid exertion
• Avoid: Suppression of natural urges, trauma, grief, fasting, incompatible foods
• Daily Anuvasana Basti (medicated oil enema) is specifically recommended from 8th month onward

MONTH-WISE (MASANUMASIK) PARICHARYA:

GENERAL CONTRAINDICATIONS IN PREGNANCY:

• Avoid Vega Dharana (suppressing natural urges)
• Avoid sleeping on back (Uttana Shayana) for prolonged periods
• Avoid sexual intercourse in early and late pregnancy
• Avoid trauma, grief, fear, exertion
• Avoid Viruddha Ahara (incompatible foods)
• Avoid excessive fasting
• Avoid emetic/purgative therapies (Shodhana Karma) in general
• Avoid heavy massage/Udgharaana of abdomen

DAUHRIDA (Foetal Cravings - 4th Month):

• Khanja (lameness)
• Kubja (hunchback)
• Pangu (cripple)
• Andha (blindness)
• Muka (dumbness) If not fulfilled → Karshya (emaciation), Vaikruta (deformities)

Q.III.2. Amenorrhea - Definition, Classification, Causes, Diagnosis, Management

DEFINITION:

CLASSIFICATION:

• Age 15 years in the presence of normal secondary sexual characteristics (breast development, pubic hair) - WHO definition
• Age 13 years in the absence of any secondary sexual characteristics

CAUSES:

PRIMARY AMENORRHEA:

• Kallmann syndrome (GnRH deficiency + anosmia)
• Functional hypothalamic amenorrhea (stress, anorexia)
• Structural abnormalities

• Hypopituitarism
• Isolated gonadotropin deficiency

• Turner syndrome (45,X) - most common cause of primary amenorrhea
• Gonadal dysgenesis
• Pure gonadal dysgenesis (46,XX or 46,XY)
• Resistant ovary syndrome

• Imperforate hymen
• Transverse vaginal septum
• Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) - absent vagina/uterus
• Androgen Insensitivity Syndrome (AIS) / Testicular Feminization - 46,XY with female phenotype

• Hypothyroidism, Cushing's syndrome
• Premature ovarian failure

SECONDARY AMENORRHEA:

• Pregnancy (most common cause - must always be excluded first)
• Lactation
• Menopause
• Adolescent phase after menarche

• Functional - stress, weight loss, exercise (athlete's amenorrhea)
• Anorexia nervosa
• Chronic illness

• Hyperprolactinemia (pituitary adenoma/prolactinoma) - most common pathological cause
• Sheehan syndrome (postpartum pituitary necrosis)
• Empty sella syndrome
• Acromegaly, Cushing's disease

• Premature Ovarian Insufficiency/Failure (POF) - before age 40
• PCOS (normogonadotropic or slightly elevated LH)
• Ovarian tumors (androgen-secreting)

• Asherman's syndrome - intrauterine adhesions (post-D&C, post-myomectomy, post-TB)
• Cervical stenosis
• Endometrial TB

• Thyroid disorders (hypothyroidism/hyperthyroidism)
• Adrenal disorders (Cushing's, adrenal hyperplasia)
• Diabetes mellitus
• Liver disease

DIAGNOSIS (Workup):

• Age at menarche, menstrual history
• Weight changes, exercise, stress
• Galactorrhea (suggests hyperprolactinemia)
• Hirsutism/virilization (androgen excess)
• Hot flashes (ovarian failure)
• Anosmia (Kallmann)

• Serum FSH, LH
• Serum Prolactin
• TSH (thyroid)
• Serum testosterone, DHEAS
• Pelvic USG

• Karyotype (if primary amenorrhea)
• MRI Brain/Pituitary (if pituitary pathology suspected)
• Progesterone withdrawal test (assess estrogen status and outflow tract patency)
• Hysteroscopy (Asherman's syndrome)

• High FSH/LH → Hypergonadotropic → Ovarian failure (Turner, POF)
• Low FSH/LH → Hypogonadotropic → Hypothalamic/Pituitary cause
• Normal FSH/LH with anovulation → PCOS (usually)

MANAGEMENT:

• Identify and treat the underlying Dosha
• Katu-Tikta-Ushna (pungent, bitter, hot) diet and herbs to stimulate Artava
• Shatapushpa (Anethum sowa), Kumari (Aloe vera), Nirgundi
• Rajapravartini Vati - classical Ayurvedic formulation for amenorrhea
• Kanchanara Guggulu - if structural cause
• Panchakarma - Uttara Basti (medicated enema via vaginal route)
• Yoni Pichu, Yoni Dhupana

Q.III.3. Rutuchakra and Mechanism of Menstrual Cycle

RUTUCHAKRA (Ayurvedic Menstrual Cycle):

• Duration: 28-30 days (one lunar month = one Ritu)
• Duration of flow: 3-5 days (Charaka says 3-4 days, Sushruta says up to 5 days)
• Quantity: 4 Anjali (cupped palm measures) = approximately 80 mL
• Color: Rakta (red) initially, changes slightly toward end
• Consistency: Like blood from a fresh wound, not too thick, not too thin

1. Rajah Srava (Days 1-5): Artava flows out (menstrual phase)
2. Rutukala/Ritu (Days 5-16): Post-menstrual clean phase, ovulatory window - most fertile period (corresponding to proliferative/follicular phase)
3. Rutuvyatita (Days 16-28): Post-ovulatory phase (corresponding to secretory/luteal phase)

MECHANISM OF MENSTRUAL CYCLE (Modern):

PHASE 1: MENSTRUAL PHASE (Days 1-5)

• Progesterone and estrogen fall (corpus luteum degenerates)
• Endometrium (functional layer) sheds
• Prostaglandins cause myometrial contractions (dysmenorrhea)
• Blood flow: 30-80 mL
• Cervical OS slightly open

PHASE 2: PROLIFERATIVE (FOLLICULAR) PHASE (Days 5-14)

• FSH rises → stimulates follicular development (cohort of follicles recruited)
• Dominant follicle selected (Follicle of Graaf) → produces Estrogen
• Rising Estrogen → proliferates endometrium (glandular and stromal growth)
• Estrogen feeds back on hypothalamus/pituitary - initially negative feedback, then at high concentration switches to positive feedback
• LH surge (peak) at Day 12-13

• Thickness increases from 2 mm to 8-10 mm
• Glands become straight and tubular
• Spiral arteries develop
• Cervical mucus becomes thin, watery, clear, abundant ("ferning" pattern, Spinnbarkeit - egg white consistency)

• Triggered by LH surge (peak 24-36 hours before ovulation)
• Mature Graafian follicle ruptures, secondary oocyte is released
• Oocyte is captured by fimbriae of fallopian tube

PHASE 3: SECRETORY (LUTEAL) PHASE (Days 14-28)

• Ruptured follicle → Corpus Luteum (under LH influence)
• Corpus luteum secretes Progesterone (dominant) + Estrogen
• Progesterone → prepares endometrium for implantation
• High P + E → negative feedback on FSH and LH (suppress new follicular growth)
• If no fertilization: Corpus luteum degenerates at Day 23-24 → Progesterone falls → Menstruation
• If fertilization: hCG from trophoblast maintains corpus luteum

• Glands become tortuous (corkscrew), secretory with glycogen vacuoles
• Stroma becomes edematous, decidual
• Spiral arteries become coiled
• Endometrium is "secretary" - ready for implantation (days 20-24 = implantation window)

HORMONAL CYCLE DIAGRAM:

   Day: 1        7        14       21       28
        |        |        |        |        |
FSH:    ____^____          ^___________
LH:              _______^^(surge)___
Estrogen:        ___^___         _^_
Progesterone:             ____________^^^_____
Endometrium: SHED | PROLIFERATE   | SECRETORY |
             (Menses)  (Follicular)  (Luteal)
                        OVULATION
                            ↑
                          Day 14

Q.III.4. Asrigdara (Abnormal Uterine Bleeding) - Detailed

DEFINITION (Ayurvedic):

MODERN CORRELATION:

• Menorrhagia - heavy periods (>80 mL or >7 days)
• Metrorrhagia - irregular bleeding between periods
• Menometrorrhagia - heavy and irregular
• Polymenorrhea - frequent cycles (<21 days)

NIDANA (Etiology/Causes):

• Excessive intake of Katu (pungent), Amla (sour), Lavana (salty), Ushna (hot), Tikshna (sharp) foods
• Excessive Vyayama (exercise/exertion)
• Vegadharan (suppression of natural urges)
• Shoka (grief), Krodha (anger), Bhaya (fear), Chinta (anxiety)
• Excessive Maithuna (sexual intercourse)
• Injury to Artava Vaha Strotas

• P - Polyps (endometrial/cervical)
• A - Adenomyosis
• L - Leiomyomas (fibroids) - especially submucosal
• M - Malignancy and hyperplasia

• C - Coagulopathy (von Willebrand disease, thrombocytopenia)
• O - Ovulatory dysfunction (PCOS, thyroid disease, hyperprolactinemia)
• E - Endometrial (endometritis)
• I - Iatrogenic (IUCD, anticoagulants, hormones)
• N - Not yet classified

PURVAROOPA (Premonitory Symptoms):

• Mrudu Vedana (mild pain) in pelvis
• Feeling of heaviness in lower abdomen
• Mild back pain

ROOPA (Symptoms/Clinical Features):

• Blood is dark, frothy, thin, blackish
• Severe pain during flow
• Irregular, scanty or excessive
• Associated with Vata symptoms: dryness, constipation, pain

• Blood is red, yellow, blue, offensive odor, hot
• Burning sensation
• Associated with fever, thirst, burning

• Blood is pale, slimy, with mucus, cold
• No much pain
• Associated with heaviness, nausea

• Angamarda - body ache
• Ati Pravrutti - excessive discharge
• Daurgandhya - foul smell

• Heavy menstrual bleeding (soaking >1 pad/hour for several hours)
• Prolonged bleeding (>7 days)
• Intermenstrual spotting/bleeding
• Anemia (pallor, fatigue, dyspnea)
• Dysmenorrhea
• Pelvic pain or pressure

UPADRAVA (Complications):

• Pandu (anemia) - from Rakta Kshaya (blood loss)
• Daurbalya (weakness)
• Infertility (Vandhyatva)
• Bhrama (giddiness) due to Rakta Kshaya
• In severe cases: shock, cardiac complications

DIAGNOSIS:

• Detailed history: menstrual pattern, associated symptoms
• Physical examination: pallor, abdominal/pelvic exam, per speculum, per vaginal examination
• Investigations:
  • CBC (anemia assessment)
  • Pelvic USG (structural causes - fibroids, polyps)
  • Hormonal profile (FSH, LH, prolactin, TSH, testosterone)
  • Endometrial biopsy/curettage
  • Hysteroscopy (gold standard for intrauterine pathology)
  • Coagulation profile (PT, aPTT, bleeding time)
  • β-hCG (to rule out pregnancy-related bleeding)
  • Pap smear (cervical causes)
  • MRI (adenomyosis, fibroid mapping)

CHIKITSA (MANAGEMENT):

• Vamana (emesis) for Kaphaja type
• Virechana (purgation) for Pittaja type
• Basti for Vataja type

• Vataja: Shatavari ghrita, Bala taila, Ashwagandha
• Pittaja: Praval Pishti, Chandrakala Rasa, Ushirasava, Nyagrodhadi Churna
• Kaphaja: Kanchanara Guggulu, Trikatu

• Pushyanuga Churna - classical polyherbal formula for uterine bleeding
• Bolbaddha Rasa
• Chandraprabha Vati
• Raktapittantak Lauha
• Ashoka Ghrita - Saraca asoca is the main drug
• Lodhrasava, Ashokarishta

• Lodhra (Symplocos racemosa) - chief drug for Asrigdara
• Ashoka (Saraca indica) - uterine tonic, hemostatic
• Nagakeshara
• Raktachandan (Red sandalwood)

• Combined oral contraceptive pills (OCP) - regulate cycle, reduce flow
• Progesterone therapy (norethisterone) - 5 mg TDS from day 15-26
• Progestogen IUS (Mirena/LNG-IUS) - very effective for menorrhagia
• GnRH analogues (temporary menopause - for fibroids pre-surgery)

• Tranexamic acid (antifibrinolytic) - reduces flow by 50%
• NSAIDs (mefenamic acid) - reduce flow + dysmenorrhea
• Iron supplementation for anemia

• Endometrial ablation - destruction of endometrium (Novasure, thermal balloon)
• Hysteroscopic removal of polyps/submucous fibroids
• Myomectomy - conservative fibroid removal
• Hysterectomy - definitive treatment for completed family