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If bleeding is not controlled with rst-line therapy If expertise is needed for a surgical procedure
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If bleeding is uncontrollable with first-line therapy and the patient is not hemodynamically stable
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Lethaby AE et al Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding Cochrane Database Syst Rev 2005;(4):CD002126 [PMID: 16235297] Marjoribanks J et al Surgery versus medical therapy for heavy menstrual bleeding Cochrane Database Syst Rev 2006 Apr 19;(2):CD003855 [PMID: 16625593]
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Clark TJ et al Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies BJOG 2006 May;113(5):502 10 [PMID: 16637894]
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The premenstrual syndrome is a recurrent, variable cluster of troublesome physical and emotional symptoms that develop during the 7 14 days before the onset of menses and subside when menstruation occurs The syndrome intermittently affects about 40% of all premenopausal women, primarily those 25 40 years of age In about 10 15% of affected women, the syndrome may be severe Although not every woman experiences all the symptoms or signs at one time, many describe bloating, breast pain, ankle swelling, a sense of increased weight, skin disorders, irritability, aggressiveness, depression, inability to concentrate, libido change, lethargy, and food cravings The pathogenesis of premenstrual syndrome is still uncertain Psychosocial factors may play a role Current treatment methods are mainly empiric The clinician should provide the best support possible for the patient s emotional and physical distress This includes the following: 1 Careful evaluation of the patient, with understanding, explanation, and reassurance, is of first importance 2 Advise the patient to keep a daily diary of all symptoms for 2 3 months, to help in evaluating the timing and characteristics of the syndrome If her symptoms occur throughout the month rather than in the 2 weeks before menses, she may be depressed or may have other emotional problems in addition to premenstrual syndrome 3 For mild to moderate symptoms, a program of aerobic exercise; reduction of caffeine, salt, and alcohol intake; and an increase in dietary calcium (to 1200 mg per day), vitamin D (to 400 IU per day), and complex carbohydrates in the diet may be helpful 4 When physical symptoms predominate, spironolactone, 100 mg daily during the luteal phase, is effective for reduction of bloating and breast tenderness Oral contraceptives or injectable progestin medroxyprogesterone acetate (DMPA) will decrease breast pain and cramping NSAIDs, such as 500 mg of mefenamic acid three times a day, will reduce a number of symptoms but not breast pain 5 When mood disorders predominate, serotonin reuptake inhibitors such as 20 mg/d of fluoxetine, either daily or only on symptom days, are effective in relieving tension, irritability, and dysphoria with few side effects 6 When the above regimens are not effective, ovarian function can be suppressed with continuous high-dose progestin (20 30 mg/d of oral medroxyprogesterone acetate [MPA] or 150 mg of DMPA every 3 months or GnRH agonist with add-back therapy if continued for more than 6 months)
ESSENTIALS OF DIAGNOSIS
Vaginal bleeding that occurs 6 months or more following cessation of menstrual function Bleeding is usually painless Bleeding may be a single episode of spotting or profuse bleeding for days or months
General Considerations
Vaginal bleeding that occurs 6 months or more following cessation of menstrual function should be investigated The most common causes are atrophic endometrium, endometrial proliferation or hyperplasia, endometrial or cervical cancer, and administration of estrogens with or without added progestin Other causes include atrophic vaginitis, trauma, endometrial polyps, friction ulcers of the cervix associated with prolapse of the uterus, and blood dyscrasias Uterine bleeding is usually painless, but pain will be present if the cervix is stenotic, if bleeding is severe and rapid, or if infection or torsion or extrusion of a tumor is present The patient may report a single episode of spotting or profuse bleeding for days or months
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