OBGYN - Abnormal Uterine Bleeding

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=Abnormal Uterine Bleeding=
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i2mCEl I am so grateful for your blog.Thanks Again. Cool.
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*Or "Mary, Mary, How does your lawn grow?"
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==Objectives==
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*Understand Menstrual cycle
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*Understand common causes of abnormal uterine bleeding
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*Simplify abnormal uterine bleeding
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==The Lawn (An analogy to remember): Menstrual cycle==
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*There are two major phases to the menstrual cycle: proliferative, secretory
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http://upload.wikimedia.org/wikipedia/commons/c/cd/MenstrualCycle2.png
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===Terminology===
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*Dysfunctional uterine bleeding:
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**has classically been used to describe '''excessive noncyclic endometrial bleeding unrelated to anatomical lesions of the uterus or to systemic disease'''
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**''it is a diagnosis of exclusion''
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*'''Think of dysfunctional uterine bleeding as ''anovulatory bleeding'''''
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**Anovulatory bleeding is usually the primary cause.
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*Anovulation may be related to a systemic medical disease or may be due to a variety of factors which affect the hypothalamic  pituitary axis.
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*Menorrhagia:
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**'''Excessive or prolonged menstrual bleeding.'''
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**Technically defined as '''blood loss greater than 80 mL per cycle and / or menstrual periods lasting longer than seven days'''.
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*However, both patients and clinicians are unreliable in their ability to predict the amount of blood loss and measurement of actual blood loss is not practical in a clinical setting.
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*'''In ovulatory women, menorrhagia is typically due to an anatomic lesion (eg, fibroid) or systemic disease''' (eg, hemostatic defect).
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*'''Anovulation is also a common cause of menorrhagia.'''
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*Metrorrhagia: light bleeding from the uterus at irregular intervals.
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*Menometrorrhagia: heavy bleeding from the uterus at irregular intervals.
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*Amenorrhea: absence of bleeding for '''at least three usual cycle lengths.'''
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*Oligomenorrhea: bleeding that occurs '''at an interval greater than 35 days.'''
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*Polymenorrhea: regular bleeding that occurs at an '''interval less than 24 days.'''
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*Intermenstrual bleeding: bleeding that '''occurs between menses''' or between expected hormone withdrawal bleeds in women using some forms of hormonal contraception or hormone replacement therapy.
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*Premenstrual spotting: light bleeding preceding regular menses.
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*Post coital spotting: vaginal bleeding that is noted within 24 hours of vaginal intercourse.
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===Post-Menopausal Endometrium===
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===DepoProvera Endometrium===
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===Menstrual cycle===
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*The proliferative phase of the uterine cycle is concurrent with the follicular phase of the ovarian cycle.
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**Recall that estrogen dominates in the proliferative phase.
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**Recall that estrogen is trying to make the uterus an acceptable place for implantation.
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*The secretory phase of the uterine cycle is concurrent with the luteal phase of the ovarian cycle.
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**Recall that progesterone (from the corpus luteum) dominates in the secretory phase.
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**Recall that progesterone is trying to make the uterus an acceptable place for the embryo to grow.
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http://upload.wikimedia.org/wikipedia/commons/c/cd/MenstrualCycle2.png
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===Anovulation===
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*Without ovulation, a corpus luteum is not made and progesterone levels are not elevated.
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*Without progesterone, the "grass isn't cut"; that is, the endometrial secretory layer doesn't stop proliferating.
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===Endometrial Hyperplasia===
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===Fibroids===
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===Endometrial Polyp===
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===Coagulopathy===
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===Estrogen===
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===Progesterone===
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===How to distinguish between hormonal and anatomical abnormal bleeding?===
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*Hormonal:
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**Anovulation
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**Hyperplasia / Cancer
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**Postmenopausal
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**Thyroid dysfunction
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*Anatomical
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**Polyps
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**Fibroids
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**Coagulopathy
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*By the results of the workup!!
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*By the response to treatment!!
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====History====
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*Intermenstrual Spotting
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**Think uterus: polyp, cervical cancer, IUD, infection
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**Think ovulation: drop in estrogen just before ovulation
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*Regular, Heavy Bleeding
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**Think ovulatory with an anatomical issue (fibroids, polyps most common but don’t forget vWd)
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*Irregular, Heavy Bleeding
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**Think anovulation (PCOS, thyroid most common)
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====Physical Exam====
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*Check Bowel / Bladder
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*Check Vulva
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*Check Vagina
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*Check Cervix
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*Feel Uterus
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*Check Skin (Hair, Hump and Hirsutism)
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====Comprehensive Differential====
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*Uterus: fibroids, polyps, hyperplasia, cancer, adenomyosis, endometritis, anovulation
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*Cervix: polyps, ectropion, endometriosis, cancer, cervicitis
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*Vulva: skin tags, infections, cancer, trauma
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*Vagina: atrophy, polyps, infection, trauma, cancer
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*Systemic: thyroid, pituitary, PCOS, stress, smoking, coagulopathy, renal / liver disease, hormone secreting tumors, leukemia, platelet dysfunction.
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*Drugs: Contraceptives, anticoagulants, steroids, chemotherapy, antipsychotics, dilantin
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===Medical Therapy===
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*Acute, Profuse Hemorrhage:
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**High Dose IV estrogen
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*Chronic, Stable Hemorrhage:
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**High Dose Oral Estrogen
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**High Dose Contraceptives (Speroff)
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**High Dose Progesterone
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**NSAIDs
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**Mirena IUD
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**Lupron
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===Surgical Therapy===
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*Acute, Profuse Hemorrhage
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**D & C
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*Chronic, Stable Hemorrhage
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**D & C
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**Hysteroscopy
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***Polypectomy
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***Resection
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**Ablation
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**Hysterectomy
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====Polypectomy: Weed Killer====
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====Endometrial Curetting: Sod Cutting====
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==Questions==
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*67 yo AA female presents to you with postmenopausal bleeding.
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*The most likely cause of her bleeding is?
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**'''Atrophic vaginitis'''
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**Atrophic endometrium
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**Anovulatory bleeding
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**Trauma
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**Endometrial cancer
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*27 yo AA female presents to you with postcoital bleeding.
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*The most likely cause of her bleeding is?
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**Atrophic vaginitis
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**'''Cervical Bleeding'''
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**Anovulatory bleeding
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**Trauma
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**Endometrial cancer
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*27 yo AA female presents to you with irregular, heavy bleeding. She weighs over 300 lbs.
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*The most likely cause of her bleeding is?
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**Atrophic vaginitis
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**Cervical Bleeding
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**'''Anovulatory bleeding'''
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**Trauma
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**Endometrial cancer
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*47 yo AA female presents to you with frequent, irregular, heavy bleeding. She weighs over 300 lbs.
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*The second step of her evaluation is?
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**Ultrasound
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**CT scan
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**FSH and LH
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**TSH
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**'''Endometrial biopsy'''
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*47 yo AA female presents to you with frequent, irregular, heavy bleeding. She weighs over 300 lbs.
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*The most likely cause of her bleeding is?
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**Atrophic vaginitis
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**Fibroids
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**'''Anovulatory bleeding'''
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**Endometrial Polyp
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**Endometrial cancer
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*47 yo AA female presents to you with regular, heavy bleeding. She weighs over 300 lbs.
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*The most likely cause of her bleeding is?
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**Atrophic vaginitis
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**'''Fibroids'''
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**Anovulatory bleeding
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**Endometrial Polyp
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**Endometrial cancer
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*Label the hormones.
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**Estradiol
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**Progesterone
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**'''Luteinizing Hormone'''
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**Follicle Stimulating Hormone
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*Label the hormones.
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**'''Estradiol'''
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**Progesterone
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**Luteinizing Hormone
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**Follicle Stimulating Hormone
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*Label the hormones.
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**Estradiol
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**Progesterone
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**Luteinizing Hormone
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**'''Follicle Stimulating Hormone'''
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*Label the hormones.
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**Estradiol
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**'''Progesterone'''
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**Luteinizing Hormone
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**Follicle Stimulating Hormone
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*25 yo Asian woman with new onset heavy, irregular menses presents to your office. Your history reveals almost daily bleeding that interferes with her ADL.
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*Physical exam reveals a slightly overweight (BMI=29) woman with no abnormal physical findings.
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*The most likely diagnosis is:
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**Fibroids
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**'''Anovulatory cycles'''
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**Polyp
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**Pemature ovarian failure
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**Endometrial Cancer
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*A 70 yo white woman presents to your office from a nursing home with no complaints. No nursing home staff accompanied her to the office. You call the nursing home and speak with her PCA who tells you she noticed a small amount of blood in her diaper for
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a few days last week.
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*The most likely diagnosis is:
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**Urinary tract infection
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**Rectal cancer
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**Cervical cancer
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**Atrophic endometrium
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**'''Atrophic vaginitis'''
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Revision as of 13:24, 8 March 2012

i2mCEl I am so grateful for your blog.Thanks Again. Cool.

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