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  #1  
Old 02-06-2014
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ObGyn Heavy Menstrual Flow?

38 year old female with two year history of heavy menstrual flow of 9 days every period. Menses occur every 32 days. There is no bleeding between menses. Next step in evaluation:
a. Coagulation profile
b. Pregnancy test
c. Endometrial biopsy
d. Pelvic ultrasound
e. TSH evaluation
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  #2  
Old 02-06-2014
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Uh, tough one!
I'm going with the biopsy. I suppose this is a case of dysfunctional uterine bleeding, and we need to exclude endometrial hyperplasia. But to be honest, I don't know a lot about this topic, it's kinda blurry in my mind when I think about that. On the other hand, in the clinical practise, I would definitely do a pelvic US.
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  #3  
Old 02-06-2014
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I was thinking E. because we have to make distinction bw ovulatory and anovulatory cycle. i'm guessing its anovulatory bc of the vignette. 9 days period and every 32 days menses . This is irregular. So therefore anovulatory means hormone imbalance so I'd do a TSH evaluation. I was thinking like this. Does it make any sense?

if it's ovulatory then i'd do the others.
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  #4  
Old 02-06-2014
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Well, periods are regular. And 32-day cycle length is normal. Not sure it's anovulation. Where from is this question anyway?
It could be D also, to exclude fibroids. Now I think this is definitely the right answer!
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  #5  
Old 02-06-2014
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how is 9 days normal?
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  #6  
Old 02-06-2014
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No, 9 isn't normal, but 32 is. So again, now I think US, to exclude fibroids
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Old 02-06-2014
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not pregnancy test or TSH bcoz she's having menses ( will do those in case of amenorrhea) not endometrial biopsy because she has heavy bleeding only during her menses not occasionally, so there is a menses connection. that leaves us with pelvic US (Leyomyoma) and coagulation profile (VWD),. IN Leiomyoma there will supposedly be a large uterus and px's presents with "intermenstural bleeding" . In VWD they have heavy bleeding "during menses".
So that leaves us with A.
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  #8  
Old 02-07-2014
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Regular cycles with menorrhagia (normally 2-7days).
I am confused between pelvic USG (it will give info endometrial thickness/leomyoma) and Coagulation profile.

IMO if USG is normal go for coagulation profile. Non invasive test 1st. Otherway also seems right.
But, How exactly to say which one 1st?
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  #9  
Old 02-07-2014
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I think that with von Willebrand dz, the patient would have menometrorrhagia earlier in life. But, it can be something else that interferes with coagulation. I agree, US first. There's no anovulation here.
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  #10  
Old 02-07-2014
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Default A

hey whats the correct answer , I would go for A...yea she is 32 yr old but still dont wanna start with biopsy
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  #11  
Old 02-07-2014
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i wood go with A, because having no intermenstrual bleeding means its not an anatomic cause, its something systemic, which leaves me with TSH and coagulation profile, obviously with no other s/s of hypo or hyperthyroidism, i ll do coagulation studies first.
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  #12  
Old 02-07-2014
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Default Abnormal vaginal bleeding, order of survey, KLN

1. Always exclude pregnancy
2. Exclude anatomical lesions
3. Inherited coagulopathy
4. Dysfunctional uterine bleeding

Also UW says that for all women >35 years of age, obese, hypertensive, diabetics, include endometrial biopsy in the work up.

I hope this excellent question would help us all remember something from gynecology. I found it very useful. Whipple23 shoot again!

Last edited by KovachMarina; 02-07-2014 at 11:22 AM.
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  #13  
Old 02-07-2014
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Your welcome everybody was definitely a tough and challenging one.
More to come soon
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  #14  
Old 02-07-2014
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But there are still multiple answers
What's the final answer ? Ultrasound or coagulation profile
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  #15  
Old 02-07-2014
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Hey, isn't it obvious that we don't know?!!!
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  #16  
Old 02-07-2014
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I asked 3 doctors today and I got 3 diff answers lol.
Should I be worried ??
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  #17  
Old 02-07-2014
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this question will definitely not appear on our exam, considering the fact we're discussing it so much! Murphy's law
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Old 02-09-2014
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I believe the answer is D. Pelvic Ultrasound. If the person has coagulation problems it will not only affect her menses. There will be other association problems such as easy bruising etc. if she is having periods for 2 yrs, chances are she is not pregnant. Also they would have giving more clues eg morning sickness or other clues. You do less invasive tests before invasive tests (biopsy). The pt probably has fibroids. Fibroids should be ruled out before biopsy. She is young and at childbearing age. Chances are she has fibroids or adenomyosis (if also has painful menses). If she has thyroid problems, more clues would have been given. All the tests listed can be done but I believe the best initial test in this situation is D. Pelvic Ultrasound.

Thanks,
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  #19  
Old 02-13-2014
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Hey guys

In MTB3 it says always rule out pregnancy (urine preg test) before considering fibroids.
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  #20  
Old 02-13-2014
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Wa90,

Yes you are right that it says in MTB3 that u should check for possible pregnancy, however, you also have to take the contest of the question into consideration.
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  #21  
Old 02-13-2014
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Quote:
Originally Posted by hoya View Post
Wa90,

Yes you are right that it says in MTB3 that u should check for possible pregnancy, however, you also have to take the contest of the question into consideration.
I read in uworld ..it says.. >35 yrs with DM,HTN or obese do endometrial biopsy.
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  #22  
Old 02-14-2014
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before to do biopsy first rule out pregnancy, then do US then biopsy
biopsu is most accurate but we need to start from iitial...
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  #23  
Old 02-14-2014
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Quote:
Originally Posted by DrAGA View Post
before to do biopsy first rule out pregnancy, then do US then biopsy
biopsu is most accurate but we need to start from iitial...
Yup yup ! That's right!
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  #24  
Old 10-03-2014
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I would definitely do A first. US second

this question is particularly difficult because of the lack of other guiding symptoms
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  #25  
Old 10-07-2014
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Idea!

I would check for coagulopathy!
it's easier than US i think
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  #26  
Old 11-28-2014
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Default I am ob gyn doctor

I am ob gyn doctor
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  #27  
Old 10-04-2015
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I think first it was heavy bleeding during menstruation for about 9 days and now there is no bleeding, then it could a or b.
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