I. Workup a. Transvaginal Ultrasound (TV-US) i. Good for detecting structural problems (e.g. fibroids) that might be missed by EMB. ii. Endometrial thickness measurement of <4-7 cm rarely cancer; EMB not needed. b. Endometrial biopsy (EMB) i. Most commonly used test for DUB. 1. Good: Can diagnose endometrial problems 90-100% 2. Bad: Fails to detect polyps, fibroids. 3. Indication: a. (female) with DUB >35 since risk of cancer is so high. b. (female) with amenorrhea for >1 year who then has uterine bleeding. 4. Note: do it late in the cycle to determine if ovulation has taken place. c. D&C i. Good: allows more extensive sampling of the uterine cavity; diagnostic AND therapeutic. If D&C + EMB ~100% detection rate. Detects dysplasia and malignancy. ii. Used if EMB is inadequate, the cervical os is stenotic, or DUB treatment fails iii. Bad: Asherman’s, damage to uterus/cervix. 1. So, never used for young people who are unlikely to have endometrial cancer. d. Hysteroscopy i. Good: More sensitive. Can be used in place of D&C for diagnosis (meaning no Asherman’s); allows direct visualization. Much better than anything else at diagnosing polyps + submucosal fibroids. ii. Bad: Often misses endometritis (inflammation of the lining of uterus). 1. Complications: entering the uterus via cervix will increase risk of developing endometritis D&C, hysteroscopy, placement of IUD. II. Treatment – treatment of choice depends on the cause, severity, fertility status, need for contraception. a. IV (E) – intravenous estrogen is for acute, heavy, uncontrolled bleeds; use until bleeding stops. b. OCPs – moderately heavy DUB. i. Conjugated 1. Good: Will stabilize epithelium, slough excessive buildup, provide contraception. 2. If already on OCPs, then get DUB increase dosage. ii. POP – progesterone only 1. Better at contraception, doesn’t help as well with bleeds. iii. SE – nausea/vomiting c. D&C i. Treatment of choice if bleeding is severe and/or requires blood transfusions. d. Ablation i. Thermasure – thermal uterine balloon. 1. Water balloon filled with D5 raise to 87C for 8 minutes. 2. Fits contours well. ii. Novasure 1. Insert coil on fan shaped device electrical induced heat burning. Faster. Probably not as good as thermal balloon. e. Hysterectomy i. Good – 100% curative, better sexual functioning than other treatments overall. ii. Bad – 6/10,000 die, longer heal times than ablation.