Abnormal uterine bleeding: Difference between revisions

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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 endometrial cancer|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
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* Vaginal discharge
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! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Paget's disease]] of vulva to cervix<ref name="van der LindenMeeuwis2016">{{cite journal|last1=van der Linden|first1=M.|last2=Meeuwis|first2=K.A.P.|last3=Bulten|first3=J.|last4=Bosse|first4=T.|last5=van Poelgeest|first5=M.I.E.|last6=de Hullu|first6=J.A.|title=Paget disease of the vulva|journal=Critical Reviews in Oncology/Hematology|volume=101|year=2016|pages=60–74|issn=10408428|doi=10.1016/j.critrevonc.2016.03.008}}</ref><ref name="pmid10605411">{{cite journal |vauthors=Lloyd J, Evans DJ, Flanagan AM |title=Extension of extramammary Paget disease of the vulva to the cervix |journal=J. Clin. Pathol. |volume=52 |issue=7 |pages=538–40 |date=July 1999 |pmid=10605411 |pmc=501500 |doi= |url=}}</ref><ref name="pmid19952933">{{cite journal |vauthors=Shaco-Levy R, Bean SM, Vollmer RT, Papalas JA, Bentley RC, Selim MA, Robboy SJ |title=Paget disease of the vulva: a histologic study of 56 cases correlating pathologic features and disease course |journal=Int. J. Gynecol. Pathol. |volume=29 |issue=1 |pages=69–78 |date=January 2010 |pmid=19952933 |doi=10.1097/PGP.0b013e3181b1cc5e |url=}}</ref><ref name="AsmoukiOumouloud2012">{{cite journal|last1=Asmouki|first1=Hamid|last2=Oumouloud|first2=Rachid|last3=Aboulfalah|first3=Abderrahim|last4=Soummani|first4=Abderraouf|last5=Marrat|first5=Abdelouahed|title=Paget’s Disease of the Vulva in Premenopausal Woman Treated with Only Surgery: A Case Report|journal=Case Reports in Oncological Medicine|volume=2012|year=2012|pages=1–4|issn=2090-6706|doi=10.1155/2012/854827}}</ref>
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Paget's disease]] of vulva to cervix<ref name="van der LindenMeeuwis2016">{{cite journal|last1=van der Linden|first1=M.|last2=Meeuwis|first2=K.A.P.|last3=Bulten|first3=J.|last4=Bosse|first4=T.|last5=van Poelgeest|first5=M.I.E.|last6=de Hullu|first6=J.A.|title=Paget disease of the vulva|journal=Critical Reviews in Oncology/Hematology|volume=101|year=2016|pages=60–74|issn=10408428|doi=10.1016/j.critrevonc.2016.03.008}}</ref><ref name="pmid10605411">{{cite journal |vauthors=Lloyd J, Evans DJ, Flanagan AM |title=Extension of extramammary Paget disease of the vulva to the cervix |journal=J. Clin. Pathol. |volume=52 |issue=7 |pages=538–40 |date=July 1999 |pmid=10605411 |pmc=501500 |doi= |url=}}</ref><ref name="pmid19952933">{{cite journal |vauthors=Shaco-Levy R, Bean SM, Vollmer RT, Papalas JA, Bentley RC, Selim MA, Robboy SJ |title=Paget disease of the vulva: a histologic study of 56 cases correlating pathologic features and disease course |journal=Int. J. Gynecol. Pathol. |volume=29 |issue=1 |pages=69–78 |date=January 2010 |pmid=19952933 |doi=10.1097/PGP.0b013e3181b1cc5e |url=}}</ref><ref name="AsmoukiOumouloud2012">{{cite journal|last1=Asmouki|first1=Hamid|last2=Oumouloud|first2=Rachid|last3=Aboulfalah|first3=Abderrahim|last4=Soummani|first4=Abderraouf|last5=Marrat|first5=Abdelouahed|title=Paget’s Disease of the Vulva in Premenopausal Woman Treated with Only Surgery: A Case Report|journal=Case Reports in Oncological Medicine|volume=2012|year=2012|pages=1–4|issn=2090-6706|doi=10.1155/2012/854827}}</ref>

Revision as of 04:26, 6 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:[1]
  • 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[2][3][4][5][6][7][8][9]
  • 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[10]
  • 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[11][12][13][14][15][16][17][18][19]
  • Heavy/prolonged menstrual bleeding
  • Intermenstrual bleeding
 + + −
  • Large,irregular pelvic mass
 ±
−
  • Erythrocytosis
  • 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[20][21][22]
  • Difficulty urinating
  • Post-coital pain
 + + +
  • Larrge uterine/cervix mass
  • Irregularity
 + Pap smear:
  • Small round blue cells
  • High nuclear/cytoplasm ratio,
  • Scant cytoplasm
 Immunohistochemistry markers:
  • Well-defined, solid, concentric, hypoechoic mass
 MRI:
  • Intramyometrial infiltrative nodules
  • Small tumor cells with large nuclei
  • High mitoses and proliferation
  • Biopsy
  • diffuse large B-Cell lymphoma (DLBCL) most frequent type.
Cervical sarcoma[23][24][25][26]
  • Post-coital pain
  • Fullness in pelvic
  • Vaginal discharge
 + + ±
  • Cervical mass
  • Lump protruding from vagina/vulva
 + −
  • Endometrial mass with heterogeneous echogenicity
 MRI:
  • Endometrial polypoid mass
  • Hypointense hypervascular solid components
  • Biopsy
Cervical erosion(Ectropion)[27][28][29][30][31]
  • 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
 − − N/A N/A N/A
  • Vascular ectasia
  • Lymphocytic infiltration
Cervicitis[32][33][34][35]
  • Intermenstrual bleeding
  • Postcoital
  • Bleeding after pelvic exam
  • Pain during urination
 + +
  • May have fever only
  • Red,inflammed swollen cervix
  • Inflammation/irritation of vulva/vagina
 − STI panel:
  • ↑ WBC
  • + NAAT for chlamydia, gonorrhea
Endometrial carcinoma[36][37][38]

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[39][40][41]
  • +
 + N/A
  • Normal or thickened endometrium
 ± −
  • Thickened endometrium
  • Complex hyperplasia
  • Simple hyperplasia with atypia
  • Complex hyperplasia with atypia (glands are highly irregular in size and shape)
  • Biopsy
Endometriosis[42][43][44][45][46][47]
  • 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
 + −
  • ↑ IL-6
  • ↑ TNF-α
  • ↑ CA-125

(limited value)

  • Ground glass echogenicity of the cyst fluid (Endonetrioma)
  • Cysts are unilocular
  • Visual inspection by laparascopy
IUD use[48]
  • Heavy bleeidng
  • Painful menstruation
  • ±Vaginal discharge
 + −
  • Normal
 − −
Pelvic inflammatory diseases[49][50]
  • Bleeding after sex
  • Intermenstrual bleeding
  • Pelvic pain
 ± +
  • Oral temperature >101F
  • Vaginal/vulvar tender lesion depending on microbial causes
 − STI panel: Non-specific lab values:
  • ↑ WBC
  • Oral temperature >101F
 Ultrasound:
  • Thickened, fluid-filled tubes with or without free pelvic or tuboovarian complex
  • Clinical diagnosis is gold standard for diagnosing PID
  • Laparascopy is confirmatory in acute salpengitis
Adenemyosis[51][52][53][54][55]
  • Abnormal uterine bleeding
  • Painful menstruation
 + + −
  • Polypoid mass protruding into the endocervical canal.
  • Enlarged uterus may present as abdominal mass
 −
  • Subendometrial striations
  • Myometrial cysts
  • Asymetrical thickness in myometrium walls
  • Heterogenous exhotexture of myometrum
 MRI:
  • Thickened junctional zone
Cervical ectopic pregnancy[56][57] + − −
  • 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
Paget's disease of vulva to cervix[58][59][60][61]
  • 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.
 − −
  • Thick vulvar skin
  • "Cake-icing effect", pathognomic for vulvar paget's disease
  • Intraepidermal adenocarcinoma which involves epidermis
  • Biopsy of lesion
Vaginal cancer[62][63][64][65]
  • Postcoital bleeding
 + + ±
  • Ill-defined vaginal ulcer
  • In case of metastases to internal organs
 Ultrasound:
  • Hydronephrosis in case of pelvic metastases
  • Multiple liver metastases
 MRI:
  • Isointense on T1-weighted images
  • Soft-tissue mass with intermediate-to-high signal intensity on T2-weighted images
 Biopsy findings:
  • Biopsy
Nabothian cyst[66][67][68]
  • Postcoital bleeding
 − − − − 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[69][70] +
  • Pelvic/back pain
  • Spotting
  • Nausea
  • Vomiting
  • Enlarged uterus
  • Blood clot in cervical os.
 Ultrasound:
  • ‘Sliding sign’ on transvaginal ultrasound
  • Embryo with increase in crown-rump length without visible embryo heart activity
  • Absence of embryo heart activity
Abruptio placenta[71][72] +
  • Pelvic/back pain
  • Abdominal pain
  • Vaginal bleeding
  • Painful uterine contractions
  • Uterine tenderness
  • ↓ Fetal heart rate
  • ↓ Fetal movement

Ultrasound:

  • Uterine hypertonicity
  • Non-reassuring fetal heart
  • Villous infarctions
  • Decidual destruction, hemorrhage
Placenta previa[73][74][75] +
  • Dilated cervix
  • ↑ Uterine contraction
  • Blood clot or spotting
 Ultrasound:
  • Low lying placenta, less than 1cm from cervical os.
  • Trophoblastic giant cell migration into decidua
  • Hemorrhage into decidua and myometrium
Ectopic pregnancy[76][77] +
  • Pelvic pain which is worse on one side
  • ↑ β-HCG
 Ultrasound:
  • Absence of "Sliding sign" on gentle pressure of cervix
  • Tubal rupture
Molar pregnancy[78][79][80] +
  • Heavy vaginal bleeding
  • Nausea
  • Vomiting
  • Uterine size larger than date
 Ultrasound:
  • Complex and echogenic intrauterine mass
  • Containing many small cystic spaces
  • Classical "snow storm" appearance
  • Hydropic villi
  • Empty uterus
  • Fetal tissue in partial hydatiform mole.
  • Histological confirmation post-curettage
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[81][82][83] +
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
  • Fatigue
  • Blood in stool
  • Blood in urine
  • GI bleeding in rare cases
 N/A N/A
  • Current gold standard diagnostic testing includes:
Factors deficiencies[84][85] +
  • Heavy bleeding since the menarche
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
  • Fatigue
  • Blood in stool
  • Blood in urine
  • Intramuscular hematoma
  • Abdominal pain
  • Intracranial bleeding signs:
    • Headache
    • Neck stiffness
    • Vomiting
    • Lethargy
  • `↓ Factors νιιι, ιx, xι
  • ↑ PTT , Normal PT
  • Normal VWF
  • ↓ RBC count
 N/A N/A
  • Factor VIII , IX, XI assay
Platelet dysfunction[86][87] ±
  • Skin bruises
  • Epistaxis
  • Excessive bleeding after surgery
  • Menorrhagia
  • Bruises on skin
 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[88][89] +
  • 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
 Associated conditions:
Hypothyroidism[90][91][92][93][94] +
  • 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
 Associated conditions with Hashimoto thyroiditis:
Adrenal hyperplasia[95][96][97][98][99] +
  • Irregular menses
  • Percocious puberty
  • Muscle weakness
  • Fatigue
 Depending upon deficient enzyme:

Depending upon enzyme deficiencies may include the following:

CT-Scan:
  • Enlargement of glands
  • Cosyntropin stimulation test (250 μg cosyntropin intravenously):
Cushing's disease[100][101] +
  • Weight gain
  • Moon facies
  • Skin bruising
  • Abdominal striae
  • Facial plethora
  • Ecchymosis
  • Violacious striae
  • Muscle weakness
  • Kyphosis
  • Slow deep tendon reflex relaxation
  • Emotional lability
 T1-weighted MRI:
  • Pituitary macro/micro adenoma
  • Testing urinary free cortisol over 24 hours (UFC)
  • Overnight Dexamethasone 8 mg, distinguishes Cushing’s syndrome from the ectopic ACTH secretion
Polycystic ovarian syndrome[102][103][104][105][106] +
  • ↑ Prolactin in some women
  • ↑ LH/ Normal or ↓ FSH
  • ↑ Serum Anti-mullerian hormone
 Ultrasound:
  • ↑ Number of follicles
  • ↑ Ovarian volume
  • Fluid filled ovaries
  • Multiple cysts in ovaries bilaterally.
  • Clinical,biochemical and ultrasound
 Associated conditions:
  • Insulin resistance
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[107][108][109]
  • +
  • Heavy menstrual bleeding
  • Pallor
  • Heavy menstrual bleeding
 N/A N/A
  • Complete medication history
  • History of venous thromboembolism or pulmonary embolism
Antipsychotics[110] +
  • Sexual dysfunction
 N/A N/A
  • Complete medication history
  • Serum prolactin test
Oral contraceptive pills[111]
  • Break through bleeding
  • Amenorrhea
  • Menstrual irregularity
  • Mood swings
  • Heavy bleeding
  • Depressed mood
Herbal supplements[112] + Ultrasound:

References

  1. ↑ Munro, Malcolm G.; Critchley, Hilary O.D.; Broder, Michael S.; Fraser, Ian S. (2011). "FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age". International Journal of Gynecology & Obstetrics. 113 (1): 3–13. doi:10.1016/j.ijgo.2010.11.011. ISSN 0020-7292.
  2. ↑ Hippisley-Cox J, Coupland C (January 2013). "Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm". Br J Gen Pract. 63 (606): e11–21. doi:10.3399/bjgp13X660733. PMC 3529288. PMID 23336450.
  3. ↑ Dunyo, Priscilla; Effah, Kofi; Udofia, Emilia Asuquo (2018). "Factors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study". BMC Public Health. 18 (1). doi:10.1186/s12889-018-6065-6. ISSN 1471-2458.
  4. ↑ Khalife D, El Housheimi A, Khalil A, Saba C S, Seoud M, Rammal R, Abdallah IE, Abdallah R (February 2019). "Treatment of cervical cancer metastatic to the abdominal wall with reconstruction using a composite myocutaneous flap: A case report". Gynecol Oncol Rep. 27: 38–41. doi:10.1016/j.gore.2018.12.006. PMC 6302027. PMID 30603660. Vancouver style error: name (help)
  5. ↑ . doi:10.1097/PAS.0000000000000498. Check |doi= value (help). Missing or empty |title= (help)
  6. ↑ Brenner PF (September 1996). "Differential diagnosis of abnormal uterine bleeding". Am. J. Obstet. Gynecol. 175 (3 Pt 2): 766–9. PMID 8828559.
  7. ↑ Alcázar, Juan Luis; Arribas, Sara; Mínguez, José Angel; Jurado, Matías (2014). "The Role of Ultrasound in the Assessment of Uterine Cervical Cancer". The Journal of Obstetrics and Gynecology of India. 64 (5): 311–316. doi:10.1007/s13224-014-0622-4. ISSN 0971-9202.
  8. ↑ Qing L, Xiang T, Guofu Z, Weiwei F (September 2014). "Leukemoid reaction in cervical cancer: a case report and review of the literature". BMC Cancer. 14: 670. doi:10.1186/1471-2407-14-670. PMC 4174654. PMID 25223869.
  9. ↑ Qing L, Xiang T, Guofu Z, Weiwei F (September 2014). "Leukemoid reaction in cervical cancer: a case report and review of the literature". BMC Cancer. 14: 670. doi:10.1186/1471-2407-14-670. PMC 4174654. PMID 25223869.
  10. ↑ Mitchell H (May 2004). "Vaginal discharge--causes, diagnosis, and treatment". BMJ. 328 (7451): 1306–8. doi:10.1136/bmj.328.7451.1306. PMC 420177. PMID 15166070.
  11. ↑ Al-Habib A, Elgamal EA, Aldhahri S, Alokaili R, AlShamrani R, Abobotain A, AlRaddadi K, Alkhalidi H (November 2016). "Large primary leiomyoma causing progressive cervical deformity". J Surg Case Rep. 2016 (11). doi:10.1093/jscr/rjw190. PMC 5159177. PMID 27887011.
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  107. ↑ Munro, Malcolm G.; Critchley, Hilary O.D.; Broder, Michael S.; Fraser, Ian S. (2011). "FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age". International Journal of Gynecology & Obstetrics. 113 (1): 3–13. doi:10.1016/j.ijgo.2010.11.011. ISSN 0020-7292.
  108. ↑ James, A. H. (2016). "Heavy menstrual bleeding: work-up and management". Hematology. 2016 (1): 236–242. doi:10.1182/asheducation-2016.1.236. ISSN 1520-4391.
  109. ↑ Bryk AH, Piróg M, Plens K, Undas A (December 2016). "Heavy menstrual bleeding in women treated with rivaroxaban and vitamin K antagonists and the risk of recurrent venous thromboembolism". Vascul. Pharmacol. 87: 242–247. doi:10.1016/j.vph.2016.11.003. PMID 27865826.
  110. ↑ Adra, Abdallah; El Zibdeh, Mazen Yousef; Abdul Malek, Abdul Malek Mohammed; Hamrahian, Amir H.; Abdelhamid, Amr Mohamed Salaheldin; Colao, Annamaria; Anastasiades, Elie; Ahmed, Essam Moustafa Aboul Fetooh; Ezzeddine, Jihad Ibrahim; El Sattar, Mahmoud Ibrahim Abd; Dabit, Suleiman Tawfiq; Ghanameh, Wadih; Nedjatian, Navid; El-Kak, Faysal (2016). "Differential diagnosis and management of abnormal uterine bleeding due to hyperprolactinemia". Middle East Fertility Society Journal. 21 (3): 137–147. doi:10.1016/j.mefs.2016.02.001. ISSN 1110-5690.
  111. ↑ Shakerinejad, Ghodratollah; Hidarnia, Alireza; Motlagh, Mohammad Esmaeil; Karami, Khodabakhsh; Niknami, Shamsoddin; Montazeri, Ali (2013). "Factors predicting mood changes in oral contraceptive pill users". Reproductive Health. 10 (1). doi:10.1186/1742-4755-10-45. ISSN 1742-4755.
  112. ↑ van Hunsel FP, Kampschöer P (2012). "[Postmenopausal bleeding and dietary supplements: a possible causal relationship with hop- and soy-containing preparations]". Ned Tijdschr Geneeskd (in Dutch; Flemish). 156 (41): A5095. PMID 23062258.

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