To complete this assignment u have to completely read attached case studi before answering the questions below. After completi
To complete this assignment u have to completely read attached case studi before answering the questions below. After completing your Aquifer Case Studi, answer the following questions using the latest evidenced based guidelines:
• Discuss the questions that would be important to include when interviewing a patient with this issue. • Describe the clinical findings that may be present in a patient with this issue. • Are there any diagnostic studes that should be ordered on this patient? Why? • List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each. • Discuss your management plan for this patient, including pharmacologic therapies, texts, patient education, referrals, and follow-ups.
please use apa format style use references no later then 5 years ago.
Family Medicine 32: 33-year-old with painful cycles User: Ralph Marrero Email: [email protected] Date: March 30, 2022 10:44 PM
The student should be able to:
Find and apply diagnostic criteria, risk factors and surveillance strategies for dysmenorrhea. Elicit a focused history that includes information about menstrual history, obstetric history, sexuality and gender identification. Describe appropriate components of a complete physical examination depending on symptoms or risk factors for gynecological problems. Summarize the key features of a patient presenting with dysmenorrhea, capturing the information essential for differentiating between the common and “don’t miss” etiologies. Describe the initial management of common diagnoses that present with dysmenorrhea. Summarize the key features of a patient presenting with menorrhagia, capturing the information essential for differentiating between the common and “don’t miss” etiologies. Develop a health promotion plan for a patient of any age or gender that addresses preconception counseling. Develop a health promotion plan for a patient of any age or gender that addresses family planning. Describe the initial management of common and dangerous diagnoses that present with premenstrual syndrome. Recognize “don’t miss” conditions that may present with PMS. Demonstrate active listening skills and empathy for patients. Demonstrate the ability to elicit and attend to patients’ specific concerns.
Primary Dysmenorrhea Definition, Prevalence, and Risk Factors
Primary dysmenorrhea is defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea is defined as painful menses secondary to some additional pathology. Primary dysmenorrhea is associated with increasing amounts of prostaglandins. The actual prevalence is unknown but ranges from 45% to 97% including teens and older adults. Ten to fifteen percent of people with a uterus feel their symptoms are severe and have to miss school or work. Dysmenorrhea accounts for 1-3 percent of absenteeism or 600 million hours a year. Dysmenorrhea usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours. It can also include symptoms of headache, dizziness, fatigue, diarrhea, and sweating so a broad differential may be helpful. Dysmenorrhea is thought to be secondary to increased prostaglandin synthesis, leading to uterine contractions and decreased blood flow. Risk Factors for Primary Dysmenorrhea
Mood disorders such as depression or anxiety have been associated with dysmenorrhea, especially in adolescents. This may be a complex association as other factors may be comorbid with the mood disorder diagnosis, and the cause and effect is not well-proven. However, there is an association with stress independently as a risk factor for dysmenorrhea. There is also an association between tobacco use and dysmenorrhea. People who give birth to more children are noted to have a decreased incidence of primary dysmenorrhea. Additionally, those who report an overall lower state of health or other social stressors have a tendency for dysmenorrhea. These stressors include social, emotional, psychological, financial, or family stressors. Primary dysmenorrhea most commonly occurs in menstruating patients in their teens and twenties. It is notably associated with ovulatory cycles. Classically, an adolescent will start experiencing dysmenorrhea one or two years after menarche. This is the time it takes naturally for an adolescent to develop regular ovulatory cycles. The earlier the onset of menarche the more likely dysmenorrhea may occur.
This means that a detailed history regarding the nature of menses during adolescence and after children is important. It will also be important to ask about birth control and what types have been used as some can alter the symptoms. The first-line treatment for primary dysmenorrhea is nonsteroidal anti-inflammatory agents, such as ibuprofen. Oral contraceptive pills may also be helpful as a second-line choice. NSAIDs inhibit the production and release of prostaglandins but have long-term side effects, and oral contraceptives inhibit ovulation, reduce endometrial proliferation, and mimic the lower prostaglandin phase of the cycle. Complementary alternatives can include herbs (chamomile, ginger, fennel, cinnamon, aloe vera), yoga, relaxation, psychotherapy, massage, hypnosis, vitamins E, B, and C, calcium, magnesium, and acupuncture/acupressure.
People who are born with a uterus may identify as female or male. We can therefore identify this population as "female assigned at birth," meaning they had a sex assigned at birth as female based on the genitalia seen, or “person with a uterus” to
© 2022 Aquifer, Inc. – Ralph Marrero ([email protected]) – 2022-03-30 22:44 EDT 1/10
acknowledge the biologic presence of a uterus in someone who may identify as anything other than female in their life. Please note that transgender men should not be excluded in this consideration, for which calling periods “cycles” and utilizing terminology of a person with a uterus or exam of the pelvis is more appropriate than “gynecologic.” See below for additional gender Teaching Points.
Gender and Sexual Identity Questions
It is important to know how your patient self-identifies and to not make assumptions. To avoid mis-gendering patients, we recommend asking early in a visit either how they would like to be addressed and/or what pronouns they use. Common answers are he/him, she/her, and they/them, but countless other pronouns exist within the LGBTQ community (lesbian, gay, bisexual, transgender, queer/questioning; this also includes a broad range of sexual, romantic, and gender minorities, and is more inclusively referred to as LGBTQIA with intersex and asexual/ally also represented). Cisgender refers to a person whose sex assigned at birth, based on genitalia, matches their current gender identity. Transgender refers to a person who identifies in a different way than their sex assigned at birth. The terms “assigned female” and “person with a uterus” acknowledge that this population may include people who have a uterus and cycles who do not identify as female. Sex refers to the physical organs present or expected to develop at birth. Gender Identity refers to the patient’s identity as male, female, non-binary or others, and is not the same as sex. Gender Expression refers to the patient’s presentation as male, female or non-binary, and can be different from sex or gender identity. Non-binary, gender-nonconforming, and gender-expansive are all terms some patients use to identify their gender as on a spectrum rather than binary. Sexual orientation refers to the gender that people have sex with. This can be different from romantic orientation as people can be romantically and sexually attracted to different genders or vary based on the person or their own identity. It is also important to consider the anatomy of partners, as a “male” partner may have a uterus and not a penis, and a “female” partner may have a penis. This is important for health risks, screening, and prevention. For example, if a patient with a pelvic problem stated that they actually used he/him pronouns and identified as male, you would want to use he/him pronouns, despite talking about problems related to a uterus. You should not assume based on physical appearance what organs a patient may or may not have, in the same way, that you cannot know without asking if someone has had a hysterectomy.
Questioning About Reproductive History
It is good to start with open-ended questions. Some patients may have had pregnancy outcomes that they are not comfortable talking about, such as miscarriages or abortions (reported as SAB, or spontaneous abortion, or TAB, or therapeutic abortion). This requires sensitivity, as it may bring up trauma for that patient, and it may also require specific questions, such as “Tell me the outcomes of each pregnancy,” or “Any other pregnancies besides those children you mentioned?”
Normal Pelvic Exam Findings
Unless a person is pregnant, a normal uterus is not larger than eight weeks in size, approximately the size of a clenched fist. It is also mostly flat, not round as you see in some pictures. A normal uterus may be mildly tender on exam just prior to or during menses. A normal uterus can be tilted anteriorly (anteverted or anteflexed), midline, or tilted posteriorly (retroverted or retroflexed). An anteflexed or retroflexed uterus may be difficult to assess for size because of its position. The uterus should be smooth in contour around the entire surface area. Serosal fibroids or large mucosal fibroids may cause a "knobby" feel to the uterus. The uterus should be mobile. The uterus is held in the pelvis by a series of ligaments on each side. With endometriosis, the uterus may become non-mobile because of fibrous tissue sticking to the peritoneum along these ligaments. Ovaries are normally 2 cm x 3 cm in size—roughly the size of an oyster. In an obese person, the ovaries may be nonpalpable. During ovulation, the ovaries may be slightly larger secondary to physiologic cysts. Caution should be taken while palpating the ovaries since the patient may have a mild sickening feeling. Mild tenderness on palpation of the ovaries is normal. Nabothian cysts are physiologically normal on the cervix. These are formed during the process of metaplasia where normal columnar glands are covered by squamous epithelium. They are merely inclusion cysts that may come and go and are of no clinical significance. While looking at the cervix white discharge can also normally be seen coming from the os or in the vagina. If there are endometrial growths on the cervix or vagina, these may be bluish. Vaginal discharge can be normal or abnormal. Normal vaginal discharge is termed physiologic leukorrhea. This patient has no symptoms like itching, burning, or foul-smelling discharge. It is normal to have physiologic clear to white vaginal discharge. The volume of discharge may get so heavy that it requires a pad for comfort; the volume may change during the course of a menstrual cycle.
Menorrhagia is very difficult to define precisely and is only one of the terms associated with abnormal uterine bleeding. The absolute criterion for menorrhagia is blood loss of more than 80 milliliters. Some providers try to use pad or tampon count.
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However, there is variability in the absorption of different pads and how much blood one has on the pad prior to changing. Asking about clots may help, but again not easy to quantify. In fact, many women either overestimate or underestimate the blood loss. Another important criterion is the length of menses. Anything longer than seven days is most likely menorrhagia.
Metrorrhagia is irregular frequent bleeding but it doesn't have to be heavy. Menometrorrhagia is irregular, frequent, and heavy bleeding.
Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria
Premenstrual syndrome (PMS) is characterized by physical and behavioral symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms must not be present at other times through the cycle, and must also cause significant impairment. Premenstrual Dysphoric Disorder (PMDD), the more severe form of the disorder, is classified in the DSM-5 as a mental health diagnosis. The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess. The patient must also have one of the following: food cravings, changes in sleep, a sense of being overwhelmed or out of control, decreased energy, anhedonia, and some physical symptoms. The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms. It may be helpful to get the perspective of other close contacts of the patient.
Never lose a chance to bring up preconception considerations. 1. Vitamin supplementation: Daily supplementation with 400 to 800 micrograms of folic acid is recommended, as many
pregnancies are unplanned. This lowers the risk for neural tube defects by over 70%. Patients with a history of miscarriage or fetuses affected by neural tube defects should be counseled to take a higher dose.
2. Substance use: Substances such as alcohol, tobacco, caffeine, or other substances (marijuana, opioids, stimulants, etc.) should be discontinued and/or cut back as much as possible. Having shared decision making and readiness to assist with this process is important. Evidence is growing that marijuana can have detrimental effects on the fetus, even though it is more widely accepted. We recommend a sensitive approach to help patients with addiction cut down on substances when they are ready. Primary care treatment options for opioid use may include buprenorphine which can lower withdrawal symptoms in the neonate.
3. Immunizations: Check for live-attenuated immunizations that must be given prior to pregnancy, such as MMR and chickenpox. Guidelines suggest giving Tdap during the third trimester of each pregnancy, influenza if indicated by the time of year, and testing for rubella immunity if there is not clear evidence of vaccination with the MMR vaccine. SARS-CoV2 vaccines should be considered given the higher risk of complications if one who is pregnant develops COVID-19. There is emerging data demonstrating the safety of the mRNA vaccines in pregnancy.
4. Chronic conditions: Get any chronic medical problems—such diabetes, depression, asthma/COPD, or thyroid disorders— under control prior to pregnancy.
Safety and Mental Health
Premenstrual syndrome or premenstrual dysphoric disorder may coexist with additional Axis 1 and Axis 2 mental health diagnoses. Depression, anxiety, bipolar disorder, and additional psychiatric diagnoses should be considered, and if concerned, asking about thoughts or plans to harm oneself or another (suicidal ideation, homicidal ideation, and/or self-harm or intent) is important.
Primary Dysmenorrhea: Presentation and Treatment
In a family physician's office, primary dysmenorrhea in an adolescent is a common diagnosis. In a person with a uterus who is under 20 and not sexually active with the classic history of suprapubic pain the first two days of menses, non-steroidal anti-inflammatory medications can be started without a pelvic exam. Ibuprofen is the gold-standard anti-inflammatory, but many other anti-inflammatories have also been proven equally efficacious when taken cyclically starting a day or two prior to the onset of menses and continuing into the first days of menses. Studies have noted improvement with diclofenac, vaginal sildenafil, celecoxib, and naproxen. Choice of the specific anti-inflammatory to use should be based on cost and side effects the patient experiences. If anti- inflammatories are not effective, combination birth control pills (monophasic or triphasic) with medium-dose estrogen are effective. Hormonal implants, inserts, intrauterine devices, patches, and rings may also be considered. Some people will prefer to avoid hormonal options if possible. Other treatments shown to be effective include acupressure, acupuncture, and superficial needling. Medicinal plant remedies may include fennel, vitamin E, chamomile and thyme, but other side effects should be considered. A pregnancy test should be performed in an adolescent or anyone with a uterus who is sexually active with someone who has a penis. Other testing should be added if the patient has any type of dysfunctional uterine bleeding or pelvic pain outside of the typical pattern. For instance, consideration of polycystic ovary syndrome may be considered for irregular menstruation.
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Treatment for Leiomyomas and Associated Symptoms
A Progesterone-releasing intrauterine device (IUD) is an effective option for reducing menstrual blood flow in those with menorrhagia secondary to fibroids. Another advantage is that it can be left in for five to seven years (potentially longer but not yet widely accepted). There are potential complications, particularly during the procedure to place the device, but after appropriately discussing these with a patient it is a viable option. In studies, the progesterone-releasing IUD (levonorgestrel-releasing intrauterine system) has clearly demonstrated decreased menstrual flow in those with fibroids. In one smaller study, the device decreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Through decreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In people who hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with the fewest side effects. Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potential side effects are lower abdominal pain and breast tenderness. The risk of uterine perforation is more likely at the time of insertion. The risk of infection is within the first 20 days of insertion. Routine STI testing may be performed prior to or during insertion with immediate treatment if any infection is found. Good patient instructions to monitor for foul-smelling discharge and signs of systemic infection or perforation are key. Acupuncture has been used for many pain conditions. Some studies demonstrate effectiveness for dysmenorrhea without uterine pathology when compared to sham or placebo treatments. In further studies, acupuncture improves the quality of life but may be associated with higher health costs for the patient. Combined hormonal contraceptives would be an effective option if the patient has not experienced side effects from these in the past. Oral contraceptive pills (OCPs) have been proven effective when used for dysmenorrhea related to anovulation only without a structural problem, especially in a patient who needs birth control. In those with isolated dysmenorrhea, small trials have demonstrated benefit. However, a meta-analysis of these found insufficient evidence that oral combined hormonal pills are effective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause both menorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and may decrease dysmenorrhea by thinning the endometrial lining. OCPs are commonly known to patients and providers making them often the initial step in management. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, such as the vaginal ring and the hormonal patch, are worth considering. These may cause less nausea and vomiting as they bypass the gastrointestinal system altogether. All types of combined hormonal contraceptives have a slightly increased risk of venous thromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35 years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The vaginal ring has risks of leukorrhea and vaginitis in approximately 5% of patients; the other types do not. None of these worsen cervical dysplasia or have been proven to increase the risk of breast cancer. Injectable medroxyprogesterone is another potential treatment for leiomyomas and the symptoms associated with them. However, recent literature does demonstrate that there is bone density loss after several years of use. Other side effects may include weight gain, irregular menses for weeks to months, and potential mood changes. However, there is no risk of venous thromboembolism and this can be used in a smoker older than 35. This is a great choice for transgender men as it can help decrease periods without additional estrogen or a traumatizing procedure. Hysterectomy is the definitive surgical option for those with secondary dysmenorrhea and those with menorrhagia who no longer desire to bear children. In a meta-analysis, surgery has been proven to reduce bleeding more at one year than any other medical treatment. However, medical treatments may have less morbidity depending on the exact etiology of menorrhagia. Some surgeons will offer hysterectomy to a person with a uterus 14 to 16 weeks in size or greater whether or not the patient has symptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication for hysterectomy. For a patient who has failed other management, hysterectomy may be an option. Myomectomy, in which the clinician removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient's future reproductive plans are important in distinguishing these two options. Other procedural options for dysmenorrhea unrelated to uterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy, though there is insufficient evidence to recommend those in most cases. The copper IUD is another effective form of birth control. This device may stay inside the uterus for up to 10 years. For those who are not planning any children in the near future, this may be a viable option for birth control. An advantage of the copper IUD is that it has no hormones. However, in people using this, there is an increased risk of dysmenorrhea and menorrhagia just from the IUD. It is not a treatment for leiomyomas at all. In this case, it could potentially make the symptoms worse. Since all patients undergoing uterine artery embolization must understand the potential for urgent hysterectomy, consideration of future fertility is imperative. Some consider this a relative contraindication. Post-procedure, the patient usually has pelvic pain for at least 24 hours, sometimes lasting up to 14 days. "Post-embolization syndrome" is a group of signs and symptoms that include pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure to consider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis of fibroids, and vaginal discharge, and bleeding for up to two weeks. This treatment is usually reserved for those who cannot tolerate other hormonal treatments or who do not want those treatments for other reasons. This procedure is usually performed by an interventional radiologist. It is not an option for dysmenorrhea alone or for menorrhagia without uterine fibroids.
Hormonal Birth Control Therapies
Progesterone-Only Intrauterine Device (IUD)
The progesterone-only IUD can stay in place for three to seven years, depending on which device is used. There may be some irregular bleeding at the beginning for up to six months. Some women will stop bleeding altogether, and others continue having periods with less bleeding. The IUD is just taken out if the patient decides to try to get pregnant again. If, after five years, they decide they do not want to get pregnant, it can be replaced at the same visit for another five years. Progestin Implants
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These are put under the skin and last for three years. They can cause unpredictable spotting and can also be removed earlier if desired. Hormone Patch
The patch is left in place for one week, then the person uses a new patch weekly for three weeks. No patch is placed during the fourth week, during which time the person has a period. This option contains ethinyl estradiol in addition to a progestin. Caution should be used to ensure proper placement for absorption and consideration of the amount of subcutaneous tissue in the area of placement. Medroxyprogesterone Shot
The shot is given every 12 weeks. If a patient on this decides to get pregnant, it may take a little longer to get pregnant after stopping the shots than if they used the IUD. It also has a higher rate of irregular bleeding at the beginning. Vaginal Ring
The vaginal ring is placed inside the vagina and left for three weeks. It is removed the fourth week to have a period.
Premenstrual Syndrome Treatment
Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high-density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular. Oral contraceptives are an effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. While not always effective for premenstrual syndrome, they are a good place to start. It would be appropriate to try this in a person also needing birth control. One study demonstrates potential improved effectiveness by decreasing the placebo pills to four days from seven. Additionally, pills can be taken for sequential cycles, skipping the placebo week, to reduce the frequency of menstruation and, theoretically, the rate of PMS/PMDD. Selective serotonin reuptake inhibitors (SSRI) during menses are an effective treatment of PMS, especially if severe mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as a daily treatment for decreasing both psychological and physical symptoms during menses. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a patient has symptoms and continue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine can be used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior to considering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost. Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in people with a uterus. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in those done with childbearing. Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies, the effectiveness for treating these symptoms is inconsistent. It has anti-androgenic effects but offers less control than hormonal options. If this were to be tried on a patient, the dosing would be during the luteal phase. One must be cautious about causing potential electrolyte abnormalities, such as hyperkalemia, with this medication. Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity. Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been studied and shown some efficacy. These are all worth discussing with patients, although true efficacy is not proven.
Progesterone-Releasing IUD Placement: Contraindications / Complications
Contraindications: Infection or active gynecologic cancer, allergy to levonorgestrel (uncommon) Cautions: History of headache or vascular disease, history of perforation with prior IUD placement, allergy to iodine or shellfish (often used to clean the cervix, other methods could be used). Complications:
During the actual procedure, the patient can have pain or bleeding. There is also a risk of uterine infection or perforation which are rare with appropriate technique. If a patient were to get pregnant, they have a higher risk of an ectopic pregnancy and this is an emergency. Patients may also experience vasovagal symptoms with placement. They should also be reminded that it is not effective for protection from sexually transmitted infections. After the procedure is done, the patient may have some bleeding or cramping for a few days, but this usually responds to ibuprofen. There may be foul-smelling vaginal discharge from an infection. Once the IUD is in place, there is a risk the uterus can expel it, or the patient may have pain with intercourse or experience irregular bleeding. Some partners can feel the string. After the patient's next period, she should come back to have the string checked and make sure it is still in place. It is a good idea for the patient to check for the IUD strings after every menses to ensure it stays inside the uterus but to use caution that it is not inadvertently removed. The strings can be trimmed at follow-up visits if needed. The patient should return to the clinic for any fever associated with lower abdominal pain, with or without abnormal vaginal
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discharge. These signs would be concerning for uterine infection.
Evaluation of Differential of Secondary Dysmenorrhea / Menorrhagia
A complete blood count is always a consideration when a person seems to be bleeding more heavily than usual. Iron deficiency anemia is common in patients of reproductive age, affecting between 21% and 67% of those with menorrhagia. It can add to the fatigue a person feels. This type of anemia is responsive to therapy, which initially is oral iron supplementation, and could progress to iron infusions if indicated. A pregnancy test should be done on every person with a uterus of reproductive age with any changes in bleeding pattern or amount. Ectopic pregnancy can present with irregular bleeding and is life-threatening. Additionally, unusual forms of pregnancy— such as molar pregnancies—can cause heavy bleeding, abdominal pain, and uterine enlargement. Although it is acknowledged that pregnancy most commonly causes amenorrhea, these are diagnoses not to be missed. Ultrasound is the study of choice for pelvic pathology. The sensitivity is 60% and specificity is 93% for detecting intracavitary issues. The sensitivity for detecting intramural pathology is also high, but not as high as it is for detecting intracavitary issues. Ultrasound has a high positive pre
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