Abnormal Uterine Bleeding: OMed, UWise, Osmosis
A 28-year-old G2P0 (SAB2) experienced her second miscarriage within 14 months. A recent ultrasound was notable for two uterine fibroids. The patient is worried that the fibroids may have caused her early pregnancy losses. She is otherwise healthy and has no previous surgeries. She presents to you for further consultation. Which type of fibroid is more likely to cause subfertility? A. Submucosal B. Intramural C. Subserosal D. Pedunculated E. Cervical
A Leiomyomas are an infrequent cause of infertility, either by mechanical obstruction or distortion (and interference with implantation). When a mechanical obstruction of fallopian tubes, cervical canal or endometrial cavity is present and no other cause of infertility or recurrent miscarriage can be identified, myomectomy is usually followed by a prompt achievement of pregnancy. Submucosal myomas are most likely to cause infertility. Presumed mechanisms include: 1) focal endometrial vascular disturbance; 2) endometrial inflammation, and; 3) secretion of vasoactive substances. Submucosal fibroids are best treated by hysteroscopic resection.
A 39-year-old G1P1 comes to see you because of increased bleeding due to her known uterine fibroids, especially during her menses. She reports that her bleeding is so heavy that she has to miss two days of work every month. She has been using oral contraceptives and NSAIDs. Her most recent hematocrit was 27%. She is undecided about having more children. You discuss with her short and long-term options to decrease her bleeding. What is the next best step in the management of this patient? A. Blood transfusion B. Gonadotropin-releasing hormone agonists C. Endometrial ablation D. Uterine artery embolization E. Hysterectomy
B The goals of medical therapy are to temporarily reduce symptoms and to reduce myoma size. The therapy of choice is treatment with a GnRH agonist. The mean uterine size decreases 30-64% after three to six months of GnRH agonist treatment. Even though she is anemic, she is asymptomatic and able to work so a blood transfusion will not be indicated. Although uterine artery embolization and endometrial ablation effectively reduce bleeding, pain and fibroid size, they are contraindicated in a patient who desires future fertility. The failure rate is about 10-15%. A hysterectomy would obviously take care of her bleeding but would not be performed if she desires future fertility.
A 36-year-old G0 woman presents due to increasing facial hair growth and irregular menstrual cycles. She has gained 40 pounds over the last three years. Her symptoms began three years ago and have gradually worsened. She has never been pregnant and is not currently on any medications. On physical exam, she is overweight with dark hair growth at the sideburns and upper lip. The pelvic exam is normal. Which of the following would you expect to find in this patient? A. Decreased luteinizing hormone levels B. Elevated free testosterone C. Decreased prolactin level D. Increased ovarian estrogen production E. Elevated 17-hydroxyprogesterone
B. This patient likely has polycystic ovarian syndrome (PCOS). PCOS patients have testosterone levels at the upper limits of normal or slightly increased. Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens. LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production. Insulin resistance and chronic anovulation are hallmarks of PCOS. Prolactin levels may be elevated in amenorrhea but are not elevated in patients with PCOS.
Are fibroids malignant or benign?
Benign
What are the non-structural causes for a non pregnant young woman to bleed?
"COEIN" = coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, not specified
What are the structural causes of bleeding in a young woman?
"PALM" - polyps - adenomyosis - leiomyoma/fibroids - malignancy (cancer = usually older lady)
Woman is fat, hairy, infertile, irregular periods, ultrasound shows holes in ovaries. NBS to diagnose?
(1) Diagnose diabetes!!! (acanthosis nigricans isn't enough -- measure insulin, do glucose tolerance test, etc) (2) Measure *LH:FSH* ratio. LH:FSH ratio > 3 is BAD
What are the types of "ovulatory problems"?
(1) General anovulation (2) PCOS
What are the (5) types of leiomyomas/fibroids? Where are they located?
(1) Intramural - in myometrium (2) Subserosal - just below perimetrium (3) Submucosal - just below endometrium (4) Pedunculated - submucosal fibroid grows into cavity (5) Cervical - in cervix
Young woman has bleeding, pain, infertility. In pelvic exam her uterus feels bumpy/uneven. Ultrasound confirms diagnosis. First line treatment?
(1) OCPs (prevent growth from estrogen) (2) NSAIDs for pain
Woman gets bleeding after menopause. Diagnosis?
(1) Vaginal atrophy <-- Most common (2) Endometrial cancer
How do OCPs help PCOS?
(Progesterone only OCPs) Progesterone causes endometrium to go from proliferative to secretory phase
Which demographic gets the most leiomyomas (6)?
- Premenopausal women - Pregnant women - Never being pregnant (many menstrual cycles) - Never breastfeeding (many menstrual cycles) - Exposure to diethylstilbestrol (h/e most assocd w/ clear cell carcinoma) - African American Women MH: anything w/ increased estrogen
Abortions -- covered in previous cards!!
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Read Only: Coagulopathies may be diagnosed for the FIRST TIME when girl starts periods, she may have been asymptomatic beforehand
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A 44-year-old G1P1 was placed on three months of a GnRH agonist in order to diminish the size of a 5 cm submucosal myoma and allow it to be accessible to a hysteroscopic removal. About two weeks prior to surgery, she was no longer having severe menorrhagia although the drug side effects were becoming incapacitating. During the pre-operative visit, she asks you if she could simply stop the GnRH agonist and wait to see if her symptoms eventually return. What can you inform her about the response of the fibroids after the cessation of GnRH agonist therapy? A. Will not grow/continues to get smaller B. Will resume their former growth potential C. Become calcified D. Will grow at a more rapid rate E. Will re-grow but to only about half their original size
A Maximal response is usually achieved by three months of GnRH agonist treatment. The reduction in size correlates with the estradiol level and with body weight. Hot flashes are experienced by >75% of patients, usually in three to four weeks after start of treatment, although they should not persist for longer than one to two months from end of treatment. After cessation of treatment, menses return in four to ten weeks, and myoma and uterine size return to pretreatment levels in three to four months. The regrowth is consistent with the fact that reduction in size is not due to a cytotoxic effect. However, it is not true that secondary to the GnRH agonist withdrawal they will grow at a more rapid rate.
An 18-year-old G0 woman comes to the office due to vaginal spotting for the last two weeks. Her menstrual periods were regular until last month, occurring every 28-32 days. Menarche was at age 13. She started oral contraceptives three months ago. On pelvic examination, the uterus is normal in size, slightly tender with a mass palpable in the right adnexal region. No adnexal tenderness is noted. Which of the following tests is the most appropriate next step in the management of this patient? A. Endometrial biopsy B. Pelvic MRI C. Pelvic ultrasound D. Abdominal CT Scan E. Urine pregnancy test
E. It is vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding. Pelvic ultrasound could be considered as a next step if the pregnancy test is negative in order to evaluate the adnexal finding. Abdominal CT or MRI would not be performed in this patient unless advanced adnexal pathology was found on pelvic sonography. Endometrial biopsy would rarely be indicated in a teen with abnormal bleeding, unless morbidly obese and anovulatory.
Girl/woman has lots of menstrual bleeding. What to do?
Give iron, OCPs
What do you give before fibroid surgery?
GnRH agonist -- leuprolide only if patient doesn't want kids/postmenopausal
Fibroids/leiomyoma = - How do they grow?
Grows in response to estrogen/progesterone (1. Has aromatase which converts androgens to estrogens 2. Has estrogen and progesterone receptors)
Menometrorrhagia =
Heavy and irregular bleeding
Menorrhagia =
Heavy bleeding
HELP! Young woman bleeding. Differential?
MH: P.A.D. Pregnancy = normal, ectopic, abortion Anatomy and Dysfunction = PALM COEIN (Polyps, adenomyosis, leiomyoma/fibroids, malignancy/cancer; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not specificied)
Causes of bleeding in a pregnant woman?
Normal pregnancy Ectopic pregnancy Abortion
Polyps - Presentation? - How to diagnose? - How to *treat*?
Not covered in OMED...(less common) H/e Treatment: - Do NOT give OCPs or NSAIDs!! - Do SURGERY!!!!
Adenomyosis = - Presentation? - How to diagnose? - How to treat?
Not covered in OMED....(less common)
How to manage ectopic pregnancy?
Not ruptured = salpingostomy Ruptured = salpingectomy Alternative = METHOTREXATE
Woman is fat, hairy, infertile, irregular periods, ultrasound shows holes in ovaries. Diagnosis?
PCOS
Fibroids/leiomyoma = - Presentation?
Pain *Bleeding* (and iron deficiency anemia) Infertility (no room to implant) Asymmetric/nodular feeling in pelvic exam
Mass of smooth muscle occupying uterus space Diagnosis?
Pedunculated fibroid - Note: submucosal fibroid causes more infertility than pedunculated
Appearance of polyps vs adenomyoma vs leiomyoma/fibroids?
Polyps - pedunculated masses in uterus "asymmetric" Adenomyoma - uterus gets thicker all around "symmetric" (layers of myometrium dig deeper into uterus) Leiomyoma/fibroids - bulging masses in uterus "asymmetric"
Fibroids/leiomyoma in pregnant woman = - Complications?
Preterm labor Breech position Infertility Postpartum hemorrhage
Girl gets bleeding before puberty. NBS?
Speculum exam under general anesthesia
Mass of smooth muscle just below endometrium Diagnosis? Complication?
Submucosal fibroid Complication: - Can grow into uterine cavity and become pedunculated - *Infertility* - Miscarriage
Mass of smooth muscle just below peritoneum. Diagnosis? Complication?
Subserosal fibroid Complication: Can leave the perimetrium and develop own blood supply
Young woman has bleeding, pain, infertility. In pelvic exam her uterus feels bumpy/uneven. Ultrasound confirms diagnosis. OCPs and NSAIDs don't help. Second line treatment?
Surgery!! (1) Give *leuprolide* (GnRH analog) to make it smaller (doesn't want kids!) (2) Choose operation: Wants babies - *myomectomy* (remove fibroid) Doesn't want babies - *hysterectomy* (rare: uterine artery embolization to cut of blood flow)
What is the most common structural problem that causes a young woman to bleed?
Fibroids/leiomyoma (mh = to lie is to fib)
Young woman has bleeding, pain, infertility. In pelvic exam her uterus feels bumpy/uneven. Diagnosis?
Fibroids/leiomyomas
Girl/woman has bleeding with low blood pressure. NBS (first line, second line)? Discharge meds?
First Line: (1) IV fluids (2) RBC transfusions as needed (3) IV estrogen Second Line: Surgery (4 options) (1) Intracavitary balloon tamponade (2) Uterine artery embolization (3) D + C (temporary) (4) Hysterectomy Discharge: iron, OCPs
Irregular periods + super heavy periods. First line treatment? Second line treatment?
First line: OCPs and NSAIDs (surprisingly won't make bleeding worse!!) Second line: Ablation or hysterectomy
Young woman bleeding. NBS?
Urine pregnancy test
Fibroids/leiomyoma = - What is it?
What is it = a mass of myometrium (smooth muscle) in the uterus
Coagulopathies that would causes non pregnant young woman to bleed?
Thrombocytopenia Von Willebrand Disease Liver disease Kidney disease
Woman is fat, hairy, infertile, irregular periods, ultrasound shows holes in ovaries. Treatment?
Diagnosis = PCOS (1) Weight loss (2) Metformin (3) OCPs (4) Spirinolactone
How long do you give GnRH agonist / leuprolide for fibroid surgery?
3 months! After 3 months, the effect of GnRH is permanent -- fibroid is small as possible and won't grow any more only if patient doesn't want kids/post menopausal
A 35-year-old G2P2 woman comes to the office due to heavy menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow and duration. The periods are now interfering with her daily activities. The patient had two spontaneous vaginal deliveries. She smokes one pack of cigarettes per day. On pelvic examination, the cervix appears normal and the uterus is normal in size, without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic ultrasound, a 2 cm submucosal leiomyoma is noted. An endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. Which of the following would be the best therapeutic option for this patient if she desires to have another child? A. Hysteroscopy with myoma resection B. Laparoscopic myomectomy C. Endometrial ablation D. Oral contraceptives E. Dilation and curettage
A. Hysteroscopic myomectomy preserves the uterus, while removing the pathology causing the patient's symptoms. A laparoscopic approach is not indicated as the myoma is submucosal and not accessible using a laparoscopic approach. Endometrial ablation destroys the endometrium and can create Asherman's syndrome, thus it is reserved for patients who have completed childbearing. Dilation and curettage is unlikely to remove the myoma and is a blind procedure (carried out without direct visualization). Oral contraceptives would typically help with heavy menses, but are contraindicated in this patient, who is over 35 and smokes.
A 35-year-old G0 woman comes to the office because of six months of spotting between her periods and a desire for a pregnancy. She reports using 30 pads/cycle the last two months and has blood clots and cramping pain. Prior menses were light and required 15 pads/cycle. She has been trying to conceive for six months. Her work-up included a transvaginal ultrasound which revealed a 2 cm endometrial polyp. What is the next best step in the management of this patient? A. Hysteroscopic polypectomy B. Observation C. Combination birth control pills D. Endometrial ablation E. In-vitro fertilization
A. Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice. While her inability to get pregnant may be more complicated than just her polyp, removal of the polyp should occur prior to infertility treatments.
Girl/woman has bleeding with low blood pressure. Diagnosis?
Acute uterine bleeding (emergency!!)
Irregular periods + super heavy periods. Diagnosis?
Anovulation -- no ovulation, endometrium builds up --> bleeds all at once
HELP. When to not give GnRH agonist?
Do not give if PRE menopausal
A 50-year-old G3P3 complains of menorrhagia. Physical examination is notable for a 14-week size irregularly shaped uterus. Her hematocrit is 35%. Which of the following is the next most appropriate step in this patient's management? A. Hysteroscopy B. Endometrial sampling C. Treatment with GnRH analogue D. Hysterectomy E. Myomectomy
B The majority of patients with uterine fibroids do not require surgical treatment. If patients present with menstrual abnormalities, the endometrial cavity may be sampled to rule out endometrial hyperplasia or cancer. This is most important in patients in their late reproductive years or postmenopausal years. If the patient's bleeding is not heavy enough to cause iron deficiency anemia, reassurance and observation may be all that are necessary. Treatment with GnRH analogues to inhibit estrogen secretion may be used as a temporizing measure. This is helpful in premenopausal women who are likely to be anovulatory with relatively more endogenous estrogen. Treatment with GnRH analogues can be used for three to six months prior to a hysterectomy to decrease the uterine size and increase a patient's hematocrit. This may also lead to technically easier surgery and decreased intraoperative blood loss. Treatment with GnRH analogue can also be used in perimenopausal women as a temporary medical therapy until natural menopause occurs. Myomectomy may be an appropriate treatment for a younger patient who desires future fertility. Hysteroscopy is not indicated at this point prior to endometrial sampling. Hysterectomy is a definitive treatment for women who have completed childbearing. Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.
A 32-year-old G0 woman presents with irregular menses occurring every six to eight weeks for the past eight months. The bleeding alternates between light and heavy. Her irregular menses were treated successfully with medroxyprogesterone acetate (MPA), 10 mg every day, taken for 10 days each month. By which mechanism does the MPA control her periods? A.Stimulates rapid endometrial growth and regeneration of glandular stumps B. Converts endometrium from proliferative to secretory C. Promotes release of Prostaglandin F2α D. Regenerates functional layer of the endometrium E. Decreases luteal phase inhibin production
B. Patients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium. Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium. Inhibin is increased in the luteal phase.
Pregnant woman has fibroid. Treatment?
Do not treat!!! Only treat if symptomatic!!! Fibroids can be bad for the fetus, but rarely causes problem!
A 47-year-old G2P2 comes to see you because she is concerned that she has uterine fibroids, as she recently gained about 20 pounds around her waist. Her mother had a hysterectomy for large fibroids that "made her look like she was 40 weeks pregnant." She has smoked one pack of cigarettes a day for the last 35 years. She reports normal menstrual cycles. Her weight is 216 pounds and she is 5 feet 4 inches tall. Her exam is extremely limited by her body habitus. A beta-hCG is negative. A pelvic ultrasound shows a 4 cm intramural fibroid. What is the next best step in the management of this patient? A. Obtain a pelvic MRI B. Perform laparoscopic myomectomy C. Counsel her on diet and exercise D. Perform a hysterectomy E. Recommend bariatric surgery
C The mostly likely cause of this patient's weight gain is excessive dietary intake and lack of exercise. She should be counseled on healthy habits and quitting smoking. The treatment of asymptomatic relatively small fibroid is not indicated. She does not qualify for bariatric surgery based on her BMI.
A 48-year-old G2P2 complains of progressively heavier and longer menstrual periods over the last year. Prior to this year the patient had normal periods. She denies any symptoms other than fatigue over the last few months. Physical examination is unremarkable except for the pelvic examination. The patient is noted to have an irregularly shaped 16-week size uterus. The patient's hematocrit is 28%. What is this patient's most likely diagnosis? A. Endometrial hyperplasia B. Endometrial carcinoma C. Uterine fibroids D. Uterine leiomyosarcoma E. Adenomyosis
C The patient's history and physical examination is typical for a perimenopausal woman with probable uterine fibroids. Although it is possible that she could have underlying endometrial hyperplasia, the most likely diagnosis is uterine fibroids. Uterine leiomyosarcoma should be considered in a postmenopausal woman with bleeding, pelvic pain coupled with uterine enlargement, and vaginal discharge, but it is exceedingly rare. Endometrial hyperplasia is more common in perimenopausal women who do not ovulate regularly and postmenopausal women. Endometrial carcinoma is typically a disease of postmenopausal women, although 5-10% of cases occur in women who are menstruating and 10-15% of cases occur in perimenopausal women. Adenomyosis may result in a symmetrically enlarged "boggy" uterus, but usually presents with dysmenorrhea in addition to menorrhagia.
A 45-year-old G2P2 woman comes to the office because of heavy and irregular menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow over time. The periods are interfering with her daily activities. The patient has had two spontaneous vaginal deliveries, followed by a tubal ligation three years ago. On pelvic examination, the cervix appears normal and the uterus is normal in size without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic ultrasound, she has a normal size uterus and a 2 cm simple cyst on the right ovary. Endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. What is the most likely diagnosis in this patient? A. Polycystic ovarian syndrome B. Mid-cycle bleeding C. Abnormal uterine bleeding D. Benign cystic teratoma E. Ovarian cancer
C. Abnormal uterine bleeding is a term used to describe uterine bleeding abnormalities. This term can encompass both structural causes (polyp, adenomyosis. Leiomyoma, or malignancy [or hyperplasia]) as well as non-structural causes (coagulopathies, ovulatory dysfunction, endometrial, iatrogenic or not classified). The acronym PALM-COEIN is a means for this classification. This patient had a complete workup, including TSH, Prolactin, pelvic ultrasound and endometrial biopsy, which were all normal. Mid-cycle bleeding at the time of ovulation is due to the drop in estrogen. Ovarian teratomas are not associated with abnormal menses. They typically present with abdominal or pelvic pain which may be associated with torsion. The 2 cm cyst is a functional cyst and is a common finding in ovulatory patients.
A 14-year-old G0 female reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Her previous medical history is unremarkable. The patient has a normal body habitus for her age. Appropriate breast and pubic hair development is present. Her hemoglobin is 9.1 mg/dl, hematocrit 27.8%, a urine pregnancy test is negative. Which of the following etiologies for menorrhagia is most likely the cause of her symptoms? A. Uterine leiomyoma B. Thyroid disorder C. Coagulation disorder D. Endometrial hyperplasia E. Chronic endometritis
C. Disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common. Leiomyomas typically present in women in their 30's and 40's. Endometrial hyperplasia can occur in younger anovulatory patients, but the short duration of this patient's symptoms makes this less likely. She does not have any signs of infection or thyroid disease.
Mass of smooth muscle at cervix Diagnosis?
Cervical fibroid
Previously you learned: if a pregnant woman is bleeding, check some labs. What betaHCG values tell you the pregnancy is abnormal? If betaHCG is abnormal what's the NBS?
Check betaHCG. If betaHCG < 2000 it's abnormal. If ~ 1500, wait 48 hrs. If betaHCG does NOT double in 48 hours it's abnormal. Abnormal pregnancy = ectopic or abortion NBS: ultrasound
A 41-year-old G3P3 woman reports heavy menstrual periods occurring every 26 days lasting eight days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every two hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient's complaint? A. Follicle stimulating hormone level B. Prolactin level C. Coagulation studies D. Pelvic ultrasound E. Hysteroscopy
D. A pelvic ultrasound would image the endometrium and assess for endometrial pathology such as polyps or submucosal fibroids. In the absence of menopausal symptoms, FSH is unlikely to be helpful. The patient is unlikely to have a coagulation disorder, as she has had three spontaneous vaginal deliveries without postpartum hemorrhage. Hysteroscopy is more invasive than an ultrasound as a first step and would not be helpful if the cause of abnormal bleeding is myometrial pathology such as intramural and subserosal fibroids or adenomyosis. Hyperprolactinemia is found with prolactin-secreting adenomas associated with amenorrhea.
Young woman has bleeding, pain, infertility. In pelvic exam her uterus feels bumpy/uneven. NBS?
Diagnose with PELVIC ULTRASOUND (or hysteroscopy) Pelvic exam (Biopsy - rare, rule out sarcoma "whirls")
Woman is fat, hairy, infertile, irregular periods, ultrasound shows holes in ovaries. Wants babies. What to give?
Diagnosis = PCOS Fertility treatment (causes ovulation) = - Clomiphene - Pergolan
A 31-year-old G0 has been diagnosed with uterine fibroids. A fluid contrast ultrasound confirmed the presence of two intramural fibroids measuring 5 x 6 cm and 2 x 3 cm that appear to be distorting the patient's uterine cavity. The patient has a two-year history of infertility. She has had a thorough infertility work up. No etiology for her infertility has been identified. Which of the following treatments is most appropriate for this patient? A. Hysteroscopy B. Uterine curettage C. Gonadotropin-releasing hormone agonist D. Uterine artery embolization E. Myomectomy
E. Myomectomy is warranted in younger patients whose fertility is compromised by the presence of fibroids that cause significant distortion of the uterine cavity. A myomectomy may be indicated in infertility patients when the fibroids are of sufficient size or location to be a probable cause of infertility and when no more likely explanation exists for the failure to conceive. Hysteroscopy is a procedure that involves placing a scope through the cervical os to assess the endometrial cavity. The patient has already been diagnosed with uterine fibroids that are distorting her cavity and she has already had a fluid contrast ultrasound, so it is unnecessary to perform hysteroscopy on this patient. Treatment with GnRH agonists can be useful to shrink fibroids in anticipation of surgery, or if menopause is expected soon. This patient desires future childbearing, therefore, its use would not be an appropriate option. Uterine artery embolization can be recommended for women who have completed child-bearing because of the unclear long-term effects on fertility.
Girl gets bleeding before puberty. Diagnosis?
Either: (1) Foreign object insertion (2) Sexual abuse (3) Sarcoma botyroides (4) Precocious puberty
Woman after 50 has bad fibroids. NBS?
Endometrial biopsy Post menopausal woman shouldn't have fibroids -- likely cancer!
Woman gets bleeding after menopause. NBS?
Endometrial sampling (vaginal atrophy = more common but assume the worst)
Mass of smooth muscle in myometrium. Diagnosis? Complication?
Intramural fibroid Complications: - Infertility - Miscarriage
Metorrhagia =
Irregular bleeding
What is the most common BENIGN tumor in women?
Leiomyoma