456 Emergency Medicine
on the first day of menses and continues until ovulation whereupon the
luteal, or secretory, phase begins. During the follicular phase, endometrial
glands form under the influences of estrogen, primarily estradiol. In the
luteal phase, estrogen is still present but progesterone takes over and is
mainly responsible for endometrial secretion and prepares the lining of the
uterus for implantation. The luteal phase is characterized by an elevated
body temperature and stromal edema. When implantation does not occur,
menses ensues as a result of falling hormonal levels, which cause coiling
and constrict the endometrial arteries. An elevated β-hCG maintains the
corpus luteum. Dysfunctional uterine bleeding (DUB)is any abnormality in
the regular bleeding pattern of the menstrual cycle and anovulation is the usual
cause. This is the ovaries’ failure to secrete an ovum, which thereby prevents
luteinization from occurring. Without progesterone, the endometrium prolif-
erates.This can lead to endometrial hyperplasia, which increases the risk
for carcinoma. Other causes of symptoms of DUB include uterine fibroids,
uterine polyps, genital tract trauma, exogenous estrogens, endocrine axis
dysfunction, and bleeding disorders. Menopause occurs on average at the
age of 51.5 years. Given that this woman is close to this age, this could also
be perimenopausal symptoms. Hormone levels may be checked to see if
they are falling. However, endometrial carcinoma may present in a similar
way and needs to be ruled out with an endometrial biopsy.
Hormonal therapy (b)should not be used in this patient given that she
is older and this can increase her chances of endometrial hyperplasia. Dilation
and curettage (d)is not warranted given that she does not have a diagnosis
yet. Any surgical intervention, (c and e)should be held until a biopsy is
performed.
411.The answer is c.(Rosen, pp 226-231.)It is very important to stress
the possibility that any fertile female is pregnant until proven otherwise.
Obtaining a urine β-hCG along with an ultrasound could save your
patient’s life, as other essential tests and consults are being acquired. In this
case of a ruptured ectopic pregnancy,the presentation is atypical but it
may be said that it is essentially typical of ectopics. These are, by very nature,
implantations that can occur anywhere in the abdominal cavity. It is therefore
imperative to keep this life-threatening diagnosis at the top of your differential.
Appendicitis(a)is unlikely given this patient’s examination and temper-
ature.This patient does not have any of the signs for PID (b)or any changes
in bowel habits that would suggest diverticulitis (e).This clinical scenario
is challenging in the sense that the ectopic pregnancy mimics a verypainful
albeit not life-threatening illness like a ureteral stone (d).It is important to take