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  #1  
Old 09-19-2012
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ObGyn Obese woman with irregular periods

A 22-year-old obese woman presents to the obstetrics-gynecology clinic complaining of mild abdominal pain and vaginal bleeding. The patient states that she is sexually active with her boyfriend and uses condoms “basically all the time.” She states that her last menstrual period was 7 weeks ago and insists that her periods have always been irregular, occurring every 3 to 4 months. She denies any past medical history but states that she used to have a problem with excess facial hair prior to starting low-dose oral contraceptive pills. Which of the following is the best next step in diagnosis?

(A) Endometrial biopsy
(B) Measure prothrombin time/partial thromboplastin time
(C) Measure thyroid-stimulating hormone level
(D) Measure urine β-human chorionic gonadotropin level
(E) Progesterone challenge
(F) Ultrasound of the ovaries
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Old 09-19-2012
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Would go with D, always exclude pregnancy in woman of child bearing age
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Old 09-19-2012
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Quote:
Originally Posted by Anders View Post
Would go with D, always exclude pregnancy in woman of child bearing age
I would go with D too for the same reason!
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Old 09-19-2012
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Patient: Doctor, there is no way I can be pregnant.........

Dr. Sakala: yeah....right.........
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Old 09-19-2012
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EVEN IF SHE WAS A NUN, OR THE BEST NUN EVER, SHE IS PREGNANT UNTIL PROVEN OTHERWISE hence D ..=)
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Old 09-20-2012
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She says she uses condoms all the time ... But condums can have holes ??
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The correct answer is D. Pregnancy (intrauterine or ectopic) must always be ruled out in a woman of childbearing age with abnormal uterine bleeding. Ectopic pregnancy is a diagnosis that cannot be missed because it can result in maternal death, with shock secondary to tubal rupture. Although some patients with ectopic pregnancy present with hemodynamic instability, more than 50% of patients are asymptomatic before tubal rupture and do not have an identifiable risk factor for ectopic pregnancy. Patients may simply present with abnormal vaginal bleeding and abdominal pain.
Answer A is incorrect. Endometrial biopsy should be performed in all women older than 35 years who have abnormal uterine bleeding. Although not a common cause of abnormal uterine bleeding, endometrial carcinoma must always be ruled out in that age group. This patient is at a much lower risk for endometrial cancer given her age and, therefore, an endometrial biopsy is inappropriate at this point.
Answer B is incorrect. Coagulopathies are not a common cause of uterine bleeding but can be considered after other more frequent possibilities have been ruled out.
Answer C is incorrect. Hypothyroidism can cause heavy uterine bleeding and can be part of the work-up; however, it is not the first step in the diagnostic evaluation of this patient.
Answer E is incorrect. The most common cause of vaginal bleeding in this patient’s age group is anovulatory bleeding. The administration of a progesterone challenge is important in determining the etiology of anovulatory bleeding because a negative result indicates insufficient estrogen production, whereas a positive result indicates adequate endogenous estrogen production. However, urine or serum β-hCG measurement is the fi rst step in evaluating this patient to rule out pregnancy.
Answer F is incorrect. Given the history of obesity, hirsutism, and irregular menses, polycystic ovarian disease is high on the differential diagnosis. An ultrasound of the ovaries is therefore appropriate to evaluate for ovarian cysts; however,
it is not the first step in evaluation of this patient because pregnancy should be ruled out first.
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