Then on physical examination I inspect the vulva, the vagina, the cervix, any lesions, polyps. Do they have condyloma, any cervicitis, then the uterus for its size, shape, and on examination the adnexa. Also I try and correlate any bleeding they are having, any intermenstrual bleeding. Occasionally I’ll get a patient sent to me for uterine bleeding who’s having hemorrhagic cystitis. So if it’s only when they are emptying their bladder or something, you may think about doing a cath U/A for hemorrhagic cystitis, which can be interpreted as vaginal bleeding. CBC as I mentioned earlier, to evaluate anemia, platelets, possibility for infection. People with chronic PID will have normal differential and normal white count but may continue to have an increased sedimentation rate. Pregnancy test, as I teach my residents and students, Severson’s first rule of obstetrics is every patient is pregnant until proven otherwise. That will keep you out of a lot of trouble, especially with bleeding and spotting. Clotting factors, if they are indicated or if you suspect you may have an undiagnosed blood dyscrasia, and a Pap smear. Don’t forget the Pap smear. If she’s not bleeding, do a Pap smear. Make sure that you get a good one. If she is bleeding, make sure she doesn’t have large visible cervical lesion. If she does, just biopsy it. Just take a biopsy forceps, take a piece out of it, and then use some Monsel solution to tamponade the bleeding.
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Non-invasive tests that we have available are transvaginal ultrasound. We can perform those now. We can also perform sono-hysteroscopy where we infuse a little saline into the endometrial cavity, do a transvaginal ultrasound, and we can actually visibly identify polyps, submucous fibroids and pedunculated fibroids and tumors in the endometrial cavity without having to invade the cervix.
Invasive testing: endometrial biopsy. If you have any question at all, my tendency to do an endometrial biopsy is very great. I have a low tolerance for women that bleed because I’ve seen several 32-year-old patients with endometrial cancer. So if I have somebody that is not responding to treatment, who is young – I say young, I consider that under 35 – then I’ll biopsy them. If they are over 35 I strongly feel that you ought to go ahead and biopsy them before you start any treatment. That will at least give you a starting place and give you a pathologic diagnosis to help you with your case. D&C is really a blind procedure anymore. I favor a hysteroscopy and directed biopsies, which you have to do in the operating room. So a D&C you will only sample about 40% of the endometrium. You will miss polyps, you will miss submucous fibroids, so I think that the status of care in increasing and the standard in the future is going to be that patients will have hysteroscopies combined with either a D&C or a directed biopsy.
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Now, how can we treat the bleeding? We have treatment for ovulatory bleeding that may just require placing the patient on progestins where they just need to either have their progesterone levels boosted a little bit by taking a supplemental progestin and getting kind of a medical D&C performed on a monthly basis. I’ll treat those patients on days 14-23 of their cycle, with 10 mg of Provera a day. Or I’ll offer them oral contraceptives to take and to control their menstrual cycles. These are also the patients you can try on nonsteroidal antiinflammatories if they are for sure ovulatory. That may help by the mechanism of thromboxane production. Anovulatory patients, as I mentioned earlier, if they are not interested in pregnancy and we are not going to use Clomid and attempt to achieve a pregnancy, I offer them progestins either on a monthly basis – if they don’t want to do that – then every three months at a minimum. Oral contraceptives, I feel, are very good in helping to protract the hypothalamic pituitary axis. If we do an endometrial biopsy and we find a hyperplasia, as long as it’s a simple hyperplasia, treating it with progestins, Provera 10 mg a day for 15 days every month for six months and then re-biopsy them, would be my procedure of choice.
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