Abnormal uterine bleeding: Difference between revisions

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imagings
imagings
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Cervical cancer<ref name="pmid23336450">{{cite journal |vauthors=Hippisley-Cox J, Coupland C |title=Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm |journal=Br J Gen Pract |volume=63 |issue=606 |pages=e11–21 |date=January 2013 |pmid=23336450 |pmc=3529288 |doi=10.3399/bjgp13X660733 |url=}}</ref><ref name="DunyoEffah2018">{{cite journal|last1=Dunyo|first1=Priscilla|last2=Effah|first2=Kofi|last3=Udofia|first3=Emilia Asuquo|title=Factors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study|journal=BMC Public Health|volume=18|issue=1|year=2018|issn=1471-2458|doi=10.1186/s12889-018-6065-6}}</ref><ref name="pmid30603660">{{cite journal |vauthors=Khalife D, El Housheimi A, Khalil A, Saba C S, Seoud M, Rammal R, Abdallah IE, Abdallah R |title=Treatment of cervical cancer metastatic to the abdominal wall with reconstruction using a composite myocutaneous flap: A case report |journal=Gynecol Oncol Rep |volume=27 |issue= |pages=38–41 |date=February 2019 |pmid=30603660 |pmc=6302027 |doi=10.1016/j.gore.2018.12.006 |url=}}</ref><ref>{{cite journal|doi=10.1097/PAS.0000000000000498.}}</ref><ref name="pmid8828559">{{cite journal |vauthors=Brenner PF |title=Differential diagnosis of abnormal uterine bleeding |journal=Am. J. Obstet. Gynecol. |volume=175 |issue=3 Pt 2 |pages=766–9 |date=September 1996 |pmid=8828559 |doi= |url=}}</ref><ref name="AlcázarArribas2014">{{cite journal|last1=Alcázar|first1=Juan Luis|last2=Arribas|first2=Sara|last3=Mínguez|first3=José Angel|last4=Jurado|first4=Matías|title=The Role of Ultrasound in the Assessment of Uterine Cervical Cancer|journal=The Journal of Obstetrics and Gynecology of India|volume=64|issue=5|year=2014|pages=311–316|issn=0971-9202|doi=10.1007/s13224-014-0622-4}}</ref><ref name="pmid25223869">{{cite journal |vauthors=Qing L, Xiang T, Guofu Z, Weiwei F |title=Leukemoid reaction in cervical cancer: a case report and review of the literature |journal=BMC Cancer |volume=14 |issue= |pages=670 |date=September 2014 |pmid=25223869 |pmc=4174654 |doi=10.1186/1471-2407-14-670 |url=}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Cervical cancer<ref name="pmid23336450">{{cite journal |vauthors=Hippisley-Cox J, Coupland C |title=Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm |journal=Br J Gen Pract |volume=63 |issue=606 |pages=e11–21 |date=January 2013 |pmid=23336450 |pmc=3529288 |doi=10.3399/bjgp13X660733 |url=}}</ref><ref name="DunyoEffah2018">{{cite journal|last1=Dunyo|first1=Priscilla|last2=Effah|first2=Kofi|last3=Udofia|first3=Emilia Asuquo|title=Factors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study|journal=BMC Public Health|volume=18|issue=1|year=2018|issn=1471-2458|doi=10.1186/s12889-018-6065-6}}</ref><ref name="pmid30603660">{{cite journal |vauthors=Khalife D, El Housheimi A, Khalil A, Saba C S, Seoud M, Rammal R, Abdallah IE, Abdallah R |title=Treatment of cervical cancer metastatic to the abdominal wall with reconstruction using a composite myocutaneous flap: A case report |journal=Gynecol Oncol Rep |volume=27 |issue= |pages=38–41 |date=February 2019 |pmid=30603660 |pmc=6302027 |doi=10.1016/j.gore.2018.12.006 |url=}}</ref><ref>{{cite journal|doi=10.1097/PAS.0000000000000498.}}</ref><ref name="pmid8828559">{{cite journal |vauthors=Brenner PF |title=Differential diagnosis of abnormal uterine bleeding |journal=Am. J. Obstet. Gynecol. |volume=175 |issue=3 Pt 2 |pages=766–9 |date=September 1996 |pmid=8828559 |doi= |url=}}</ref><ref name="AlcázarArribas2014">{{cite journal|last1=Alcázar|first1=Juan Luis|last2=Arribas|first2=Sara|last3=Mínguez|first3=José Angel|last4=Jurado|first4=Matías|title=The Role of Ultrasound in the Assessment of Uterine Cervical Cancer|journal=The Journal of Obstetrics and Gynecology of India|volume=64|issue=5|year=2014|pages=311–316|issn=0971-9202|doi=10.1007/s13224-014-0622-4}}</ref><ref name="pmid25223869">{{cite journal |vauthors=Qing L, Xiang T, Guofu Z, Weiwei F |title=Leukemoid reaction in cervical cancer: a case report and review of the literature |journal=BMC Cancer |volume=14 |issue= |pages=670 |date=September 2014 |pmid=25223869 |pmc=4174654 |doi=10.1186/1471-2407-14-670 |url=}}</ref><ref name="pmid252238692">{{cite journal |vauthors=Qing L, Xiang T, Guofu Z, Weiwei F |title=Leukemoid reaction in cervical cancer: a case report and review of the literature |journal=BMC Cancer |volume=14 |issue= |pages=670 |date=September 2014 |pmid=25223869 |pmc=4174654 |doi=10.1186/1471-2407-14-670 |url=}}</ref>
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* Postmenopausal  
* Postmenopausal  
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* STI: ±Chlamydia  
* STI: ±Chlamydia  
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* ↑ CA-125
* Leukomoid reaction
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* Large cervical cancer
* Large cervical cancer
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* ↓ RBC count
* ↓ Hb, ↓ Hct
* ↓ Serum Iron
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* Hyper/hypoechogenic masses with or without cysts
* Hyper/hypoechogenic masses with or without cysts
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* Pelvic mass
* Pelvic mass
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* ↑ CA-125
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* Normal or thickened endometrium
* Normal or thickened endometrium
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| style="background: #F5F5F5; padding: 5px;" |±
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* Cervical motion tenderness
* Cervical motion tenderness
* Retroverted uterus
* Retroverted uterus
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* Polypoid mass protruding into the endocervical canal.
* Polypoid mass protruding into the endocervical canal.
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* Enlarged uterus may present as abdominal mass
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* Soft and disporportionally enlarged uterus.
* Soft and disporportionally enlarged uterus.
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| style="background: #F5F5F5; padding: 5px;" |±
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* Hysterectomy and biopsy  
* Hysterectomy and biopsy  
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |DES exposure (Clear cell adenocarcinoma)<ref name="pmid28275694">{{cite journal |vauthors=Tantitamit T, Hamontri S, Rangsiratanakul L |title=Clear cell adenocarcinoma of the cervix in second generation young women who are without maternal exposure to diethylstilbestrol: A case report |journal=Gynecol Oncol Rep |volume=20 |issue= |pages=34–36 |date=May 2017 |pmid=28275694 |pmc=5328756 |doi=10.1016/j.gore.2017.02.008 |url=}}</ref><ref name="pmid5549830">{{cite journal |vauthors=Herbst AL, Ulfelder H, Poskanzer DC |title=Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women |journal=N. Engl. J. Med. |volume=284 |issue=15 |pages=878–81 |date=April 1971 |pmid=5549830 |doi=10.1056/NEJM197104222841604 |url=}}</ref><ref name="pmid9179071">{{cite journal |vauthors=Hanselaar A, van Loosbroek M, Schuurbiers O, Helmerhorst T, Bulten J, Bernhelm J |title=Clear cell adenocarcinoma of the vagina and cervix. An update of the central Netherlands registry showing twin age incidence peaks |journal=Cancer |volume=79 |issue=11 |pages=2229–36 |date=June 1997 |pmid=9179071 |doi= |url=}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |DES exposure (Clear cell adenocarcinoma of vulva and cervix)<ref name="pmid28275694">{{cite journal |vauthors=Tantitamit T, Hamontri S, Rangsiratanakul L |title=Clear cell adenocarcinoma of the cervix in second generation young women who are without maternal exposure to diethylstilbestrol: A case report |journal=Gynecol Oncol Rep |volume=20 |issue= |pages=34–36 |date=May 2017 |pmid=28275694 |pmc=5328756 |doi=10.1016/j.gore.2017.02.008 |url=}}</ref><ref name="pmid5549830">{{cite journal |vauthors=Herbst AL, Ulfelder H, Poskanzer DC |title=Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women |journal=N. Engl. J. Med. |volume=284 |issue=15 |pages=878–81 |date=April 1971 |pmid=5549830 |doi=10.1056/NEJM197104222841604 |url=}}</ref><ref name="pmid9179071">{{cite journal |vauthors=Hanselaar A, van Loosbroek M, Schuurbiers O, Helmerhorst T, Bulten J, Bernhelm J |title=Clear cell adenocarcinoma of the vagina and cervix. An update of the central Netherlands registry showing twin age incidence peaks |journal=Cancer |volume=79 |issue=11 |pages=2229–36 |date=June 1997 |pmid=9179071 |doi= |url=}}</ref>
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* Postcoital bleeding
* Postcoital bleeding
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| style="background: #F5F5F5; padding: 5px;" |±
| style="background: #F5F5F5; padding: 5px;" |−
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* Inguinal lymphadenopathy
* Inguinal lymphadenopathy
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* In case of metastases to internal organs
| style="background: #F5F5F5; padding: 5px;" |−
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! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other symptoms
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other symptoms
|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Von willebrand disease<ref name="CastamanLinari2017">{{cite journal|last1=Castaman|first1=Giancarlo|last2=Linari|first2=Silvia|title=Diagnosis and Treatment of von Willebrand Disease and Rare Bleeding Disorders|journal=Journal of Clinical Medicine|volume=6|issue=4|year=2017|pages=45|issn=2077-0383|doi=10.3390/jcm6040045}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Von willebrand disease<ref name="CardosoLourenço2018">{{cite journal|last1=Cardoso|first1=Mariana Ferreira|last2=Lourenço|first2=Luís Carvalho|last3=Antunes|first3=Margarida|last4=Carvalho e Branco|first4=Joana|last5=Santos|first5=Liliana|last6=Martins|first6=Alexandra|last7=Reis|first7=Jorge A.|title=Recurrent Gastrointestinal Bleeding from Dieulafoy’s Lesions in a Patient with Type 1 von Willebrand Disease: A Rare Association|journal=GE - Portuguese Journal of Gastroenterology|year=2018|pages=1–5|issn=2341-4545|doi=10.1159/000490921}}</ref><ref name="CastamanLinari2017">{{cite journal|last1=Castaman|first1=Giancarlo|last2=Linari|first2=Silvia|title=Diagnosis and Treatment of von Willebrand Disease and Rare Bleeding Disorders|journal=Journal of Clinical Medicine|volume=6|issue=4|year=2017|pages=45|issn=2077-0383|doi=10.3390/jcm6040045}}</ref>
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* Blood in stool
* Blood in stool
* Blood in urine
* Blood in urine
* GI bleeding in rare cases
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* Bruises on skin
* Bruises on skin
* Menorrhagia
* Hematuria
* Melena


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* Normal PT, Normal or ↑ PTT
* Normal PT, Normal or ↑ PTT
| colspan="2" style="background: #F5F5F5; padding: 5px;" |N/A
| colspan="2" style="background: #F5F5F5; padding: 5px;" |N/A
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| style="background: #F5F5F5; padding: 5px;" |N/A
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* Abdominal pain  
* Abdominal pain  
* Intracranial bleeding signs:
** Headache
** neck stiffness
** Vomiting
** Lethargy
*  
*  


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* Low [[TSH]]
* Low [[TSH]]
* TSH receptor antibodies (TRAb)
| style="background: #F5F5F5; padding: 5px;" |'''Ultrasound''':
| style="background: #F5F5F5; padding: 5px;" |'''Ultrasound''':
* Homogenous hypo-echogenicity
* Homogenous hypo-echogenicity
| style="background: #F5F5F5; padding: 5px;" |Thyroid follicles
| style="background: #F5F5F5; padding: 5px;" |'''Microscopic histology:'''
* Lymphocytic infiltration in follicles
* Enlarged colloids
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* Total T4   
* Total T4   
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* [[Atrial fibrillation]]
* [[Atrial fibrillation]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Hypothyroidism<ref name="DeshmukhBoricha2015">{{cite journal|last1=Deshmukh|first1=Prasad|last2=Boricha|first2=B.|last3=Pandey|first3=Ankita|title=The association of thyroid disorders with abnormal uterine bleeding|journal=International Journal of Reproduction, Contraception, Obstetrics and Gynecology|year=2015|pages=701–708|issn=2320-1770|doi=10.18203/2320-1770.ijrcog20150077}}</ref><ref name="pmid284515762">{{cite journal |vauthors=Pishdad P, Pishdad GR, Tavanaa S, Pishdad R, Jalli R |title=Thyroid Ultrasonography in Differentiation between Graves' Disease and Hashimoto's Thyroiditis |journal=J Biomed Phys Eng |volume=7 |issue=1 |pages=21–26 |date=March 2017 |pmid=28451576 |pmc=5401130 |doi= |url=}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Hypothyroidism<ref name="DeshmukhBoricha2015">{{cite journal|last1=Deshmukh|first1=Prasad|last2=Boricha|first2=B.|last3=Pandey|first3=Ankita|title=The association of thyroid disorders with abnormal uterine bleeding|journal=International Journal of Reproduction, Contraception, Obstetrics and Gynecology|year=2015|pages=701–708|issn=2320-1770|doi=10.18203/2320-1770.ijrcog20150077}}</ref><ref name="pmid284515762">{{cite journal |vauthors=Pishdad P, Pishdad GR, Tavanaa S, Pishdad R, Jalli R |title=Thyroid Ultrasonography in Differentiation between Graves' Disease and Hashimoto's Thyroiditis |journal=J Biomed Phys Eng |volume=7 |issue=1 |pages=21–26 |date=March 2017 |pmid=28451576 |pmc=5401130 |doi= |url=}}</ref><ref name="pmid8432791">{{cite journal |vauthors=Mizukami Y, Michigishi T, Nonomura A, Hashimoto T, Tonami N, Matsubara F, Takazakura E |title=Iodine-induced hypothyroidism: a clinical and histological study of 28 patients |journal=J. Clin. Endocrinol. Metab. |volume=76 |issue=2 |pages=466–71 |date=February 1993 |pmid=8432791 |doi=10.1210/jcem.76.2.8432791 |url=}}</ref>
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| style="background: #F5F5F5; padding: 5px;" |    '''Ultrasound''':
| style="background: #F5F5F5; padding: 5px;" |    '''Ultrasound''':
* Homogenous hypo-echogenicity
* Homogenous hypo-echogenicity
| style="background: #F5F5F5; padding: 5px;" |Thyroid follicles
| style="background: #F5F5F5; padding: 5px;" |'''Microscopic histology:'''
* Follicular atrophy
 
* Chronic lymphocytic infiltration
* Hyperplastic change in the follicles
* Presence of [[Hurthle cells|Hurthle cell]] metaplasia
| style="background: #F5F5F5; padding: 5px;" |
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* TSH
* TSH
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|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Adrenal hyperplasia<ref name="pmid22270556">{{cite journal |vauthors=Vigliani MB, Buster JE |title=Nonclassic 21-hydroxylase deficiency presenting as endometrial hyperplasia with uterine bleeding in a 67-year-old woman |journal=Fertil. Steril. |volume=97 |issue=4 |pages=950–2 |date=April 2012 |pmid=22270556 |doi=10.1016/j.fertnstert.2012.01.089 |url=}}</ref><ref>{{cite journal|doi=10.1515/jpem-2017-0235.}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Adrenal hyperplasia<ref name="pmid22270556">{{cite journal |vauthors=Vigliani MB, Buster JE |title=Nonclassic 21-hydroxylase deficiency presenting as endometrial hyperplasia with uterine bleeding in a 67-year-old woman |journal=Fertil. Steril. |volume=97 |issue=4 |pages=950–2 |date=April 2012 |pmid=22270556 |doi=10.1016/j.fertnstert.2012.01.089 |url=}}</ref><ref name="pmid26238443">{{cite journal |vauthors=Gioco F, Seccia TM, Gomez-Sanchez EP, Rossi GP, Gomez-Sanchez CE |title=Adrenal histopathology in primary aldosteronism: is it time for a change? |journal=Hypertension |volume=66 |issue=4 |pages=724–30 |date=October 2015 |pmid=26238443 |doi=10.1161/HYPERTENSIONAHA.115.05873 |url=}}</ref><ref>{{cite journal|doi=10.1515/jpem-2017-0235.}}</ref>
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Revision as of 19:23, 1 February 2019


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Farman Khan, MD, MRCP [2]

Causes

Common Causes


Causes by Organ System

Cardiovascular No underlying causes
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect Blood thinners, breakthrough bleeding in women using hormonal birth control, copper intrauterine device , depo-Provera

hormone replacement therapy, tamoxifen, corticosteroids, chemotherapy, clomiphene, dilantin, antipsychotic drugs , antibiotics ( due to toxic epidermal necrolysis or Stevens-Johnson syndrome )

Ear Nose Throat No underlying causes
Endocrine Diabetes, hyperthyroidism, hypothyroidism, Cushing's syndrome, Hormone secreting adrenal and ovarian tumors
Environmental No underlying causes
Gastroenterologic Liver disease
Genetic No underlying causes
Hematologic Clotting disorders, Von Willebrand disease, thrombocytopenia or platelet dysfunction,

acute leukemia ,Some factor deficiencies, Advanced liver disease

Iatrogenic Radiation therapy
Infectious Disease Chlamydia, gonorrhea, uterine infection, genitourinary tract infection, bacterial vaginosis

sexually transmitted diseases, atrophic vaginitis

Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic Adenomyosis, atrophy of the tissue lining the vagina and uterus, cervicitis, ectopic pregnancy, endometrial hyperplasia, endometritis, uterine sarcoma, first few months after the first menstrual period, first few weeks after abortion, first few weeks after delivery, intrauterine device, miscarriage, ovarian cysts, placenta previa, polycystic ovarian syndrome, retained products of conception, uterine fibroids, uterine polyps, diseases involving the vulva for example Crohn's disease, Behcet's syndrome , pemphigoid , pemphigus , erosive lichen planus , lymphoma, skin tags, sebaceous cysts, condylomata, angiokerataoma
Oncologic Cancer or precancer of the cervix , cancer or precancer of the endometrium, ovarian cancer, uterine cancer, uterine sarcoma
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte Chronic renal disease
Rheum / Immune / Allergy No underlying causes
Sexual Sexual abuse
Trauma Sexual intercourse , sexual abuse , foreign bodies (including IUD) , pelvic trauma, Straddle injuries
Urologic Genitourinary tract infection
Dental No underlying causes
Miscellaneous Foreign body, irritation of the genital area due to bubble baths, soaps, lotions or infection, smoking,

Excessive exercise

Causes in Alphabetical Order


Treatment

Contraindicated medications


Template:Abnormal uterine bleeding Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[4]

Overview

Abnormal uterine bleeding differential diagnosis

  • Abnormal uterine bleeding differential diagnosis include:
  • Endometrial hyperplasia
  • Cervical polyp
  • Cervical leiomyoma
  • Cervical lymphoma
  • Cervical sarcoma
  • Metastases to the cervix
  • Cervical ectopic pregnancy
  • Cervicitis
  • Cervical erosion ( Ectropion )
  • IUD use
  • Pelvic inflammatory disease
  • Endometriosis
  • Adenomyosis
  • Postcoital bleeding
  • Clear cell adenocarcinoma
  • Hematologic causes:
    • Von willebrand disease
    • Thrombocytopenia
    • Clotting disorder
    • Platelet dysfunction
    • Factors deficiency
Abnormal Uterine bleeidng differential diagnosis
Ob-Gyn neoplasm and diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical exam Lab Findings Imaging Histopathology
Abnormal

vaginal bleeding

Other Genitourinary/ Gastrointestinal symptoms Abdominal pain Pelvic

pain

B symptoms Gynecological examinations Abdominal

mass

HPV

Pap smear

STI panel

Other labs Ultrasound Other

imagings

Cervical cancer[1][2][3][4][5][6][7][8]
  • Postmenopausal
  • Intermenstrual
  • Postcoital
  • Bleeding after pelvic exam
  • Dysuria
  • Urinary hesitancy
  • Dyspareunia
  • Vaginal discharge
  • Itching or burning of the vulva

+

+ +
  • Cervical mass on exam
+ ± HPV
  • Atypical cells on Pap smear
  • STI: ±Chlamydia
  • ↑ CA-125
  • Leukomoid reaction
  • Large cervical cancer
  • Angiogenesis on Doppler sonography
  • Bladder involvement
  • Lymph node involvement
T2-weighted MRI :
  • Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement. PET/CT scan:
    • Detect tumor size
    • Lymph node involvement,
    • Metastases to bladder or rectum
  • CIN1: mild dysplasia
  • CIN2: moderate dysplasia
  • CIN3: high degree of dysplasia/metastases
  • Colposcopy/biopsy
Cervical polyp[9]
  • Postcoital
  • Intermenstrual
  • Postmenopausal
  • Bleeding after exam
  • Vaginal discharge
  • Dyspareunia
  • Mass on exam
  • ↓ RBC count
  • ↓ Hb, ↓ Hct
  • ↓ Serum Iron
  • Hyper/hypoechogenic masses with or without cysts
  • Filling the endocervical or vaginal canal
  • Epithelial cells with no nuclear atypia/mitoses
  • Hysteroscopy /Biopsy
Cervical leiomyoma[10][11][12][13][14][15][16][17]
  • Heavy/prolonged menstrual bleeding
  • Intermenstrual bleeding
  • Urinary retention
  • Constipation
  • Infertility
  • Bowel obstruction
  • Increase in pregnancy/labor complications
  • Vaginal discharge
+ +
  • Large,irregular pelvic mass
±
  • Well circumscribed hyperechoic mass
T2-weighted MRI:
  • Hypointense masses
  • Homogeneous

enhancement

  • Red degeneration
  • Spindle shaped smooth muscle cells
  • Mature adipocytes
  • Extracellular matrix consist of collagen,fibronectin.
  • Clinical diagnosis/ and
  • Ultrasound
Cervical lymphoma[18][19]
  • Postmenopausal bleeding
  • Difficulty urinating
  • Post-coital pain
+ + +
  • Larrge uterine/cervix mass
  • Irregularity
+
  • Well-defined, solid, concentric, hypoechoic mass
  • Small tumor cells with large nuclei
  • High mitoses and proliferation
  • Biopsy
Cervical sarcoma[20]
  • Intermentrual
  • Postmenopausal
  • Post-coital pain
  • Fullness in pelvic
  • ± Vaginal discharge
+ + ±
  • Cervical mass
  • Lump protruding from vagina/vulva
+
  • Biopsy
Cervical erosion(Ectropion)[21][22][23]
  • Light bleeding after pelvic exam
  • Spotting
  • Post-coital pain
  • Painful cramps
  • Dyspareunia
  • Vaginal discharge
  • Itching of vulvovaginal area
+ +
  • Red, glandular area around os of cervix
Cervicitis[24][25][26]
  • Intermenstrual bleeding
  • Postcoital
  • Bleeding after pelvic exam
  • Pain during urination
  • Pain during sex
  • Painful menstruation
  • Vaginal discharge
  • Itching of vulva
+ +
  • May have fever only
  • Red,inflammed swollen cervix
  • Inflammation/irritation of vulva/vagina
STI panel:
  • Chlamydia
  • Gonorrhea
  • Herpes simplex
  • Trichomonas vaginalis
Endometrial carcinoma[27][28][29]
  • Postmenopausal bleeding
  • Intermesntrual

bleeding

  • Vaginal discharge
  • Pain during urination
  • Pain during sex
  • Fulness in pelvic
  • Difficulty emptying bladder
+ +
  • Often normal
  • Vaginal lump
  • Pelvic mass
+
  • ↑ CA-125
Endometrial hyperplasia[30][31][32]
  • Postmenopausal bleeding
  • Intermenstrual bleeding
  • Amenorrhea
  • Dysmenorrhea
  • Amenorrhea
  • Dyspareunia
  • Heavy menstrual bleeding
  • +
+
  • Normal or thickened endometrium
±
  • Thickened endometrium
  • Simple(cystic) hyperplasia
  • Complex hyperplasia
  • Simple hyperplasia with atypia
  • Complex hyperplasia with atypia (glands are highly irregular in size and shape)
  • Biopsy
Endometriosis[33][34][35][36]
  • Heavy mentrual bleeding
  • Painful menstruation
  • Burning/painful urination
  • Painful bowel movement
  • Pain during or after sex
  • Infertility
  • Watery vaginal discharge
+
  • Pelvic pain
  • Back pain
  • Tender uterosacral nodularity
  • Immobile uterus
  • Cervical motion tenderness
  • Retroverted uterus
+
  • Visual inspection by laparascopy
IUD use[37]
  • Heavy bleeidng
  • Painful menstruation ±Vaginal discharge
+
  • Normal
Pelvic inflammatory diseases[38]
  • Bleeding after sex
  • Intermenstrual bleeding
  • Fever
  • Pelvic pain
  • Dyspareunia
  • Dysmenorrhea
  • Dysuria
  • Dyscchezia
  • Smelly grey/white/yellow vaginal discharge
  • Itching and burning of vulvovaginal area
± +
  • Vaginal/vulvar tender lesion depending on microbial cause
STI panel:
  • Chlamydia
  • Gonorrhea
Adnemyosis[39][40][41]
  • Abnormal uterine bleeding
  • Painful menstruation
+ +
  • Polypoid mass protruding into the endocervical canal.
  • Enlarged uterus may present as abdominal mass
Cervical ectopic pregnancy[42]
  • Amennorhea
  • Bleeding after pelvic exam
  • Pelvic pain
+
  • Soft and disporportionally enlarged uterus.
±
  • Empty uterine
  • Thickened endometrium
T2-weighted MRI:
  • Hypointense large mass

T1-weighted MRI:

  • Partially hyperintense mass
  • Necrotic hemorrhagic mass with chorionic villus
  • Hysterectomy and biopsy
DES exposure (Clear cell adenocarcinoma of vulva and cervix)[43][44][45]
  • Postcoital bleeding
  • Vaginal discharge
+ ±
Paget's disease of vulva to cervix[46][47][48]
  • Bleeding from lesion
  • Oozing
  • ±Vaginal discharge
  • Pain in vulva
  • Itching or burning sensation in vulva
  • Scaly eczematoid lesion in vulva.
  • Erythematous plaques with white scaling.
  • Inguinal lymphadenopathy in case of metastases.
  • Intraepidermal adenocarcinoma which involves epidermis
  • Biopsy of lesion
Vaginal cancer[49]
  • Postcoital bleeding
  • Tenesmus
  • Dysuria
  • Urinary frequency
  • Constipation
  • Pelvic pain
  • Vaginal discharge
  • Vaginal lump
  • Inguinal lymphadenopathy
  • In case of metastases to internal organs
Nabothian cyst[50][51][52]
  • Postcoital bleeding
  • Pain during sex
  • Vaginal discharge
  • Cystic mass on exam
T1-weighted
  • Intermediate or slightly high signal intensity T2-weighted
  • High signal intensity on T2-weighted images


Pregnancy and pregnancy related conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Miscarriage +
  • Pelvic/back pain
  • ↑ β-HCG
  • ↓ RBC
Abruptio placenta +
  • Pelvic/back pain
  • Abdominal pain
  • Uterine tenderness
  • ↓ Fetal heart rate
  • ↓ Fetal movement

Ultrasound:

  • Uterine hypertonicity
  • Non-reassuring fetal heart
Placenta previa +
  • Transvaginal sonography
Ectopic pregnancy +
  • ↑ β-HCG
Molar pregnancy[53] +
  • ↑↑ β-HCG
  • ↑ Inhibin-A
  • ↑ Activin-A
Ultrasound:
  • Complex and echogenic intrauterine mass
  • Containing many small cystic spaces
  • Classical "snow storm" appearance
  • Hydropic villi
  • Empty uterus
Hematologic conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab findings Imaging Histopathology
Abnormal uterine

bleeding

Other symptoms
Von willebrand disease[54][55] +
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
  • Fatigue
  • Blood in stool
  • Blood in urine
  • GI bleeding in rare cases
  • Bruises on skin
  • Menorrhagia
  • Hematuria
  • Melena
  • ↓ RBC
  • ↓ Serum Iron
  • + FOBT
  • RBC in Urinalysis
  • ↓ VWF
  • Normal PT, Normal or ↑ PTT
N/A N/A
Factors deficiencies[56] +
  • Easy bleeding
  • Epistaxis
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
  • Fatigue
  • Blood in stool
  • Blood in urine
  • Petechia on skin
  • Intramuscular hematoma
  • Hematemesis
  • Melena
  • Hematuria
  • Abdominal pain
  • Intracranial bleeding signs:
    • Headache
    • neck stiffness
    • Vomiting
    • Lethargy
  • `↓ Factors νιιι, ιx, xι
  • ↑ PTT , Normal PT
  • Normal VWF
N/A
Platelet dysfunction[57] ±
  • Skin bruises
  • Nosee bleed
  • Menorrhagia
  • Thrombocytopenia
  • Normal PT , Normal PTT
N/A
Metabolic conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Hyperthyroidism[58][59] +
  • Wet skin/hair thinning
  • Low TSH
  • TSH receptor antibodies (TRAb)
Ultrasound:
  • Homogenous hypo-echogenicity
Microscopic histology:
  • Lymphocytic infiltration in follicles
  • Enlarged colloids
  • Total T4

For Grave's disease:

  • TSH receptor antibody
Hypothyroidism[60][61][62] +
  • Dry skin
  • Hair loss
  • Normal/ low TSH
  • ↑ Total cholesterol
  • ↑ LDL
  • ↑ VLDL
Ultrasound:
  • Homogenous hypo-echogenicity
Microscopic histology:
  • Follicular atrophy
  • Chronic lymphocytic infiltration
  • Hyperplastic change in the follicles
  • Presence of Hurthle cell metaplasia
  • TSH
Adrenal hyperplasia[63][64][65] +
  • Acne
  • Virilization
  • Irregular menses
  • Percocious puberty
  • Muscle weakness
  • Fatigue
Depending upon deficient enzyme:

Depending upon enzyme deficiencies may include the following:

  • Androstenedione
  • Testosterone
  • 11-deoxycortisol
  • Dehydroepiandrosterone sulfate (DHEAS)
  • 17-hydroxypregnenolone
  • Pregnenolone
  • Renin/Aldosterone
CT-Scan:
  • Enlargement of glands
  • Diffuse cortical hyperplasia
Cushing's disease[66] +
  • Acne
  • Hirsutism/hair loss
  • Weight gain
  • Moon facies
  • Skin bruising
  • Abdominal striae
  • Insomnia,
  • Amenorrhea
  • Decrease libido
  • Facial plethora
  • Acanthosis nigricans
  • Ecchymosis
  • Violacious striae
  • Muscle weakness
  • Kyphosis
  • Hypertension
  • Edema
  • Slow deep tendon reflex relaxation
  • Emotional lability
  • Depression
  • Lipodystrophy
  • Glucose intolerance or diabetes mellitus
  • Low/Normal ACTH
  • High cortisol
T1-weighted MRI:
  • Pituitary macroadenoma
Polycystic ovarian syndrome[67][68] +
  • Prolactin in some women
  • LH/ Normal or ↓ FSH
  • ↑ Serum Anti-mullerian hormone
Ultrasound:
  • ↑ number of follicles
  • Large ovaries
  • ↑ Ovarian volume
  • Fluid filled ovaries
Hepatic disease +
Medication side effects/ Iatrogenic Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Anticoagulants +
Antipsychotics +
Corticosteroids +
Oral contraceptive pills Break through bleeding
Herbal supplements

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