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Laboratory studies for patients with dysfunctional uterine bleeding include human chorionic gonadotropin (HCG), complete blood

count (CBC), Pap smear, endometrial sampling, thyroid functions and prolactin, liver functions, coagulation studies/factors, and other hormone assays as indicated. Human chorionic gonadotropin is the most common cause of abnormal uterine bleeding during the reproductive years is abnormal pregnancy. Rule out threatened abortion, incomplete abortion, and ectopic pregnancy. Charting the number of menstrual pads used per day or keeping a menstrual calendar is helpful to determine amount of blood loss. Complete blood count is requested for a more accurate documentation of blood loss. Also to obtain a baseline CBC count for hemoglobin and hematocrit and rule out anemia and decreased platelet count if hematologic diseases are suspected. The patient has menorrhagia which may or may not be associated with ovulation therefore it is possible to suspect disorders of coagulation. Coagulation factors and PTT should be measured in case of bleeding secondary to deficiencies. Primary or secondary thrombocytopenia can be factors in the mature patient. Pap smear should be requested because cervical cancer is the most common gynecologic cancer affecting women of reproductive age in the world population. Endometrial sampling via biopsy to rule out endometrial hyperplasia or cancer in high-risk women >35 years and in younger women at extreme risk for endometrial hyperplasia/carcinoma. Most biopsies will confirm the absence of secretory endometrium meaning that the bleeding is pathological. Perform thyroid function tests and prolactin because hyperthyroidism, hypothyroidism, and hyperprolactinemia are associated with ovulatory dysfunction. Women in menopausal transition such as our patient , can be managed without an extensive hormonal evaluation. However a hormonal complete evaluation in women with signs of hyperandrogenism, such as those with polycystic ovarian syndrome, 21 hydroxylase deficiency, or ovarian or adrenal tumors, require full hormonal evaluation. (Hormone assays will include the following: thyroid-stimulating hormone, luteinizing hormone, folliclestimulating hormone, prolactin, total testosterone, free androgen index, sex hormone binding globulin, dehydroepiandrosterone sulfate, 17-OH progesterone.). Imaging Studies The most appropriate imaging to request in suspicion of Adenomyosis is Transvaginal Ultrasonography. Indication for requesting this modality include confirmation of cause of an enlarged uterus, location and extent of the lesion in the uterus, to assess the endometrial lining and the ovaries. Other causes of Dysfunctional Uterine Bleeding and Abdominal pain which can be detected by transvaginal ultrasound are Endometrial hyperplasia, endometrial carcinoma, endometrial polyps, polycystic ovaries and uterine fibroids. Adenomyosis characteristics on ultrasound are heterogenous myometrial echotexture, Ill defined hypoechoic mass, small anechoic lakes, symmetrical uterine enlargement, indistinct myometrial-endometrial borders and posterior wall involvement.

Brosens and Coworkers criteria in assessing ultrasonographic details of adenomyosis include uterine dimensions, symmetry of myometrium and echogenicity of myometrium and according to thisand Ill defined Heterogenous echotexture within the myometrium is the most predictive finding of adenomyosis on TVS. MRI provides better diagnostic capability due to the increased soft tissue differentiation, allowable through higher spatial and contrast resolution. MRI is better able to differentiate adenomyosis from multiple small uterine fibroids. The uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage. MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium. Exact diagnosis of adenomyosis only possible in posthysterectomy specimen. Refrences: Medscape Wikipedia Adenomyosis Case study by brosens