DrVirgo
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In case of abnormal vaginal bleeding, after you have ruled out pregnancy and anatomic causes, you suspect DUB, which could be due to
1. anovulatory cycles and an excessive unopposed estrogen (without the stabilizing effects of progesterone) which causes endometrial hyperplasia and unpredictable bleeding.
OR
2. Hypothyroid/Hyperprolactinoma.
So what do you do FIRST?
1. give a trial of OCP (progestin)
OR
2. Check TSH and Prolactin to rule out those causes.
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| hero
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DUB is diagnosis of exclusion, rule out everything possible
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| DrVirgo
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so do we do a TSH and Prolactin level FIRST always to R/O those causes (even if the patient doesn't have accompanying hypothyroid symp or symp or amenorrhea/galactorrhea) BEFORE giving OCPs?
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| liliaeliz
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i think if you have symp. you do tsh and prl
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| hero
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TSH and prolactin - that's for amenorrhea,
for DUB - PAD (Pregnancy, Anatomic causes - adenomyosis, fibroid, polip, and if not those 2 major causes, we can call it DUB)
it was in one of Kaplan's GYN lectures
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| DrVirgo
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hero wrote:
TSH and prolactin - that's for amenorrhea,
for DUB - PAD (Pregnancy, Anatomic causes - adenomyosis, fibroid, polip, and if not those 2 major causes, we can call it DUB)
it was in one of Kaplan's GYN lectures
Thats right, and then they say the MCC of DUB is
1. Anovulation: treatment: OCP
2. Also caused by Correctable causes: Hypothyroidism, Hyperprolactinemia
3. And third: Endometrial Cancer (if woman is >35, obese, has DM, or chronic HTN, do an Endometrial Biopsy) --> If Negative, treat with Cyclic progestins (OCP).
So I was wondering which one we rule out first 1 or 2?
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| hero
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i think if pt came with bleeding, not amenorrhea, it's better to search causes of bleeding.
Hyperprolactinemia and hypothyroidism usually cause amenorrhea.
Also if there is a hint, like weight gain, slow motion, something - in that case yes, do TSH.
Take a look p 152 obgyn kln (2005-6), there is nothing about TSH and prolactin
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| DrVirgo
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hero wrote:
i think if pt came with bleeding, not amenorrhea, it's better to search causes of bleeding.
Hyperprolactinemia and hypothyroidism usually cause amenorrhea.
Also if there is a hint, like weight gain, slow motion, something - in that case yes, do TSH.
Take a look p 152 obgyn kln (2005-6), there is nothing about TSH and prolactin
I have the 2006-2007 notes.
Under DUB MANAGEMENT on p.153 first paragraph, last couple of sentences it says:
"Correctable causes of anovulation, e.g., hypothyroidism or hyperprolactinemia, should be identified by a TSH and prolactin level. Cases that fail hormonal therapy may be managed by either endometrial ablation (using microwave or thermal methods) or hysterectomy."
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| hero
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yeah, i can see it now, same in older edition. But i think there is scant menses in case of hypothyroidism and hyperprolactinemia (even usually amenorrhea)
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| DrVirgo
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Ok...
Let me rephrase the question:
A 28 year old woman comes in due to abnormal vaginal bleeding (irregular cycles and unpredictable in terms of amount and duration). Physical exam is normal. She is experiencing no other symptoms. Pregnancy is ruled out with a negative B-hcg. Anatomic causes are also ruled out by pelvic ultrasound and imaging studies. She has had regular menses in the past. She has no other PMH. Her BMI is normal.
What is the next best step?
A. Oral Contraceptive Pills
B. Check a TSH
C. Check a Prolactin level
D. Do a hysterosalpingogram
E. Do an Endometrial Biopsy
F. Perform a Hysterectomy
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| hero
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"she is experiencing no other symptoms" - Minus B and C
she is 28 and normal BMI - minus E
anatomic causes are ruled out - minus D
F is not reasonable.
One left. 
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| liliaeliz
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a
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| dr19
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TSH (and if needed Prolactin)should be done as a part of <>,before reaching to DUB diagnosis.
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| dr19
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TSH( and if needed Prolactin) should be done as a part of RULE OUT OTHER CAUSES
step,before reaching to DUB diagnosis.
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