Abnormal Uterine Bleeding

JANET R. ALBERS, M.D., SHARON K. HULL, M.D., AND ROBERT M. WESLEY, M.A.

! Am Fam Physician. 2004;69(8):1915-1926

" A more recent article on abnormal uterine bleeding in premenopausal women
is available. (https://www.aafp.org/afp/2019/0401/p435.html)

# A patient information handout on abnormal uterine bleeding, written by the

authors of this article, is provided on page 1931.
(https://www.aafp.org/afp/2004/0415/p1931)

Abnormal uterine bleeding is a common presenting symptom in the

family practice setting. In women of child-bearing age, a methodical
history, physical examination, and laboratory evaluation may enable the
physician to rule out causes such as pregnancy and pregnancy-related
disorders, medications, iatrogenic causes, systemic conditions, and
obvious genital tract pathology. Dysfunctional uterine bleeding
(anovulatory or ovulatory) is diagnosed by exclusion of these causes. In
women of childbearing age who are at high risk for endometrial cancer,
the initial evaluation includes endometrial biopsy; saline-infusion
sonohysterography or diagnostic hysteroscopy is performed if initial
studies are inconclusive or the bleeding continues. Women of
childbearing age who are at low risk for endometrial cancer may be
assessed initially by transvaginal ultrasonography. Post-menopausal
women with abnormal uterine bleeding should be offered dilatation and
curettage; if they are poor candidates for general anesthesia or decline
dilatation and curettage, they may be offered transvaginal
ultrasonography or saline-infusion sonohysterography with directed
endometrial biopsy. Medical management of anovulatory dysfunctional
uterine bleeding may include oral contraceptive pills or cyclic
progestins. Menorrhagia is managed most effectively with nonsteroidal
anti-inflammatory drugs or the levonorgestrel intrauterine contraceptive
device. Surgical management may include hysterectomy or less
invasive, uterus-sparing procedures.

Abnormal uterine bleeding is a common but complicated clinical presentation. One

national study1 found that menstrual disorders were the reason for 19.1 percent of
20.1 million visits to physician offices for gynecologic conditions over a two-year
period. Furthermore, a reported 25 percent of gynecologic surgeries involve
abnormal uterine bleeding.2

Except for self-limited, physiologic withdrawal bleeding that occurs in some

newborns, vaginal bleeding before menarche is abnormal.3 In women of child-
bearing age, abnormal uterine bleeding includes any change in menstrual-period
frequency or duration, or amount of flow, as well as bleeding between cycles.4
(Amenorrhea, or the cessation of menses for six months or more in
nonmenopausal women, is beyond the scope of this article.) In postmenopausal
women, abnormal uterine bleeding includes vaginal bleeding 12 months or more
after the cessation of menses, or unpredictable bleeding in postmenopausal
women who have been receiving hormone therapy for 12 months or more.5

This article presents a practical approach to determining the cause of abnormal

uterine bleeding and briefly reviews medical and surgical management.

Etiology and Evaluation of Abnormal

Uterine Bleeding

BEFORE MENARCHE
 Malignancy, trauma, and sexual abuse or assault are potential causes of abnormal
uterine bleeding before menarche. A pelvic examination (possibly under
anesthesia) should be performed, because a reported 54 percent of cases involve
focal lesions of the genital tract, and 21 percent of these lesions may be
malignant.3

CHILDBEARING YEARS

The menstrual cycle has three phases. During the follicular phase, follicle-
stimulating hormone levels increase, causing a dominant follicle to mature and
produce estrogen in the granulosa cells. With estrogen elevation, menstrual flow
ceases, the endometrium proliferates, and positive feedback is exerted on
luteinizing hormone (LH), resulting in the ovulatory phase. During the luteal phase,
progesterone elevation halts proliferation of the endometrium and promotes its
differentiation; progesterone production by the corpus luteum diminishes, causing
endometrial shedding, or menstruation. A menstrual cycle of fewer than 21 days or
more than 35 days or a menstrual flow of fewer than two days or more than seven
days is considered abnormal.6 (pp201–38)

TABLE 1

Differential Diagnosis of Abnormal Uterine Bleeding

Pregnancy and pregnancy-related conditions

Abruptio placentae

Ectopic pregnancy

Miscarriage

Placenta previa

Trophoblastic disease
:
 Medications and iatrogenic causes

Anticoagulants7

Antipsychotics7

Corticosteroids7

Herbal and other supplements: ginseng, ginkgo, soy7

Hormone replacement

Intrauterine devices

Oral contraceptive pills, including progestin-only pills

Selective serotonin reuptake inhibitors7

Tamoxifen (Nolvadex)7

Thyroid hormone replacement

Systemic conditions

Adrenal hyperplasia and Cushing's disease

Blood dyscrasias, including leukemia and thrombocytopenia

Coagulopathies

Hepatic disease

Hypothalamic suppression (from stress, weight loss, excessive exercise)

Pituitary adenoma or hyperprolactinemia

Polycystic ovary syndrome

Renal disease

Thyroid disease

Genital tract pathology

Infections: cervicitis, endometritis, myometritis, salpingitis

:
 Neoplastic entities

Benign anatomic abnormalities: adenomyosis, leiomyomata, polyps of the

cervix or endometrium

Premalignant lesions: cervical dysplasia, endometrial hyperplasia

Malignant lesions: cervical squamous cell carcinoma, endometrial

adenocarcinoma, estrogen-producing ovarian tumors, testosterone-producing
ovarian tumors, leiomyosarcoma

Trauma: foreign body, abrasions, lacerations, sexual abuse or assault

Dysfunctional uterine bleeding (diagnosis of exclusion)

Information from references 7 and 8.

Pregnancy is the first consideration in women of childbearing age who present with
abnormal uterine bleeding (Table 1).7,8 Potential causes of pregnancy-related
bleeding include spontaneous pregnancy loss (miscarriage), ectopic pregnancy,
placenta previa, abruptio placentae, and trophoblastic disease. Patients should be
questioned about cycle patterns, contraception, and sexual activity. A bimanual
pelvic examination (seeking uterine enlargement), a beta-subunit human chorionic
gonadotropin test, and pelvic ultrasonography are useful in establishing or ruling
out pregnancy and pregnancy-related disorders.

Next, iatrogenic causes of abnormal uterine bleeding should be explored. Bleeding

may be induced by medications, including anticoagulants, selective serotonin
reuptake inhibitors, antipsychotics, corticosteroids, hormonal medications, and
tamoxifen (Nolvadex). Herbal substances, including ginseng, ginkgo, and soy
supplements, may cause menstrual irregularities by altering estrogen levels or
clotting parameters.9

TABLE 2

Evaluation of Abnormal Uterine Bleeding

:
 Diagnostic Pertinent signs, symptoms, and
Conditions
step tests

Miscarriage, ectopic pregnancy,

History Pelvic pain PID, trauma, sexual abuse or
assault

Nausea, weight gain, urinary

Pregnancy
frequency, fatigue

Weight gain, cold intolerance,

Hypothyroidism
constipation, fatigue

Weight loss, sweating,

Hyperthyroidism
palpitations

Easy bruising, tendency to bleed Coagulopathy

Jaundice, history of hepatitis Liver disease

Hirsutism, acne, acanthosis

Polycystic ovary syndrome
nigricans, obesity

Cervical dysplasia, endocervical

Postcoital bleeding
polyps

Galactorrhea, headache, visual-

Pituitary adenoma
field disturbance

Weight loss, excessive exercise,

Hypothalamic suppression
stress

Physical
Thyromegaly, weight gain, edema Hypothyroidism
examination

Thyroid tenderness, tachycardia,

Hyperthyroidism
weight loss, velvety skin

Bruising, jaundice, hepatomegaly Liver disease

Pregnancy, leiomyoma, uterine

:
 Enlarged uterus cancer

Firm, fixed uterus Uterine cancer

Ovarian tumor, ectopic

Adnexal mass
pregnancy, cyst

Uterine tenderness, cervical

PID, endometritis
motion tenderness

Laboratory Beta-subunit human chorionic

Pregnancy
tests gonadotropin

Complete blood count with

platelet count and coagulation Coagulopathy
studies

Liver function tests, prothrombin

Liver disease
time

Hypothyroidism,
Thyroid-stimulating hormone
hyperthyroidism

Prolactin Pituitary adenoma

Blood glucose Diabetes mellitus

DHEA-S, free testosterone, 173-

hydroxyprogesterone if Ovarian or adrenal tumor
hyperandrogenic

Papanicolaou smear Cervical dysplasia

Cervical testing for infection Cervicitis, PID

Imaging and
Endometrial biopsy or dilatation Hyperplasia, atypia, or
tissue
and curettage adenocarcinoma
sampling

Pregnancy, ovarian or uterine

Transvaginal ultrasonography
tumors
:
 Saline-infusion Intracavitary lesions, polyps,
sonohysterography submucous fibroids

Intracavitary lesions, polyps,

Hysteroscopy submucous fibroids

PID = pelvic inflammatory disease; DHEA-S = dehydroepiandrosterone sulfate.

Once pregnancy and iatrogenic causes have been excluded, patients should be
evaluated for systemic disorders, particularly thyroid, hematologic, hepatic, adrenal,
pituitary, and hypothalamic conditions (Table 2). Menstrual irregularities are
associated with both hypothyroidism (23.4 percent of cases) and hyperthyroidism
(21.5 percent of cases).10 [Strength of recommendation (SOR) B. Consistent cohort
studies] Thyroid function tests may help the physician determine the etiology.

Inherited coagulopathy has been shown to be the underlying cause of abnormal

uterine bleeding in 18 percent of white women and 7 percent of black women with
menorrhagia.11 These patients may present in adolescence with severe menstrual
bleeding or frequent bruising. A complete blood count with platelet count should be
obtained. If a coagulation defect is suspected, consultation with a hematologist
may be the most cost-effective option in the absence of reasonable screening tests
for specific abnormalities.11 Because jaundice and hepatomegaly may suggest
underlying acquired coagulopathy, liver function tests should be considered.

Obesity, acne, hirsutism, and acanthosis nigricans may be signs of polycystic ovary
syndrome or diabetes mellitus. Polycystic ovary syndrome is associated with
unopposed estrogen stimulation, elevated androgen lev els, and insulin resistance,
and is a common cause of anovulation.6(p499),12

The presence of galactorrhea, as determined by the history or physical

examination, may indicate underlying hyperprolactinemia, which can cause
oligoovulation or eventual amenorrhea. A prolactin level confirms the diagnosis of
hyperprolactinemia. Hypothalamic suppression secondary to eating disorders,
stress, or excessive exercise may induce anovulation, which sometimes manifests
:
 as irregular and heavy menstrual bleeding or amenorrhea.

Genital tract pathology may be associated with intermenstrual, postcoital, and

heavy menstrual bleeding.4 Any history of abnormal Papanicolaou (Pap) smears,
sexually transmitted disease, gynecologic surgery, trauma, or sexual abuse should
be elicited. Uterine fibroids, endometrial polyps, adenomyosis, endometrial
hyperplasia and atypia, and endometrial cancer should be excluded.13

The evaluation of postmenarchal women who present with abnormal uterine

bleeding includes a pelvic examination, as well as a Pap smear if appropriate, to
look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or dysplasia.
Cervical dysplasia seldom causes abnormal uterine bleeding, but it may be
associated with postcoital bleeding.14 Cervical cultures may be indicated if the
patient is at risk for infection or if symptoms of infection are present. A bimanual
examination in the postmenarchal woman may reveal tenderness associated with
infection, an adnexal mass consistent with an ovarian neoplasm or cyst, or uterine
enlargement consistent with fibroids, pregnancy, or a tumor.

Because endometrial abnormalities are present in 31 percent of patients with a Pap

result of “atypical glandular cells of undetermined significance, favor endometrial
origin,” endometrial biopsy is indicated.15 [SOR B, observational studies]
Transvaginal ultrasonography may be useful in delineating the underlying cause of
abnormal uterine bleeding that is associated with uterine enlargement or an
adnexal mass. Even if the pelvic examination is normal, further evaluation of the
endometrium may be required to eliminate less obvious abnormalities.

Dysfunctional uterine bleeding, with both anovulatory and, less commonly,

ovulatory4 causes, occurs during the childbearing years. It is a diagnosis of
exclusion and is made only after pregnancy, iatrogenic causes, systemic
conditions, and obvious genital tract pathology have been ruled out (Figure 1).2,16

Anovulatory dysfunctional uterine bleeding is a disturbance of the hypothalamic-

pituitary-ovarian axis that results in irregular, prolonged, and sometimes heavy
menstrual bleeding. It may occur immediately after menarche but before
:
 maturation of the hypothalamic-pituitary-ovarian axis, or it may occur during
perimenopause, when declining estrogen levels fail to regularly stimulate the LH
surge and resulting ovulation.

Unopposed estrogen stimulation may lead to endometrial proliferation and

hyperplasia. Without sufficient progesterone to stabilize and differentiate the
endometrium, this mucous membrane becomes fragile and sloughs irregularly.
Estrogen also affects uterine vascular tone, angiogenesis, prostaglandin formation,
and endometrial nitric oxide production.4

Ovulatory dysfunctional bleeding may include polymenorrhea, oligomenorrhea,

midcycle spotting, and menorrhagia (Table 3).6 (pp575-9) Polymenorrhea, a presumed
lutealphase dysfunction, results in shortened cycles (less than 21 days), whereas
oligomenorrhea, a prolonged follicular-phase dysfunction, results in lengthened
cycles (more than 35 days). Mid-cycle spotting occurs before ovulation as the
estrogen levels decline.6 Menorrhagia is regularly occurring heavy menstrual
bleeding (more than 80 mL per cycle) and may result from the loss of local
endometrial hemostasis.

FIGURE 1.

Abnormal Uterine Bleeding in Women of Childbearing

Age
:
 Sequential steps through the differential diagnosis of abnormal uterine bleeding in women of
childbearing age.

Information from references 2 and 16.

Further Evaluation Based on Risk

Factors for Endometrial Cancer
Further evaluation of abnormal uterine bleeding depends on the patient's age and
:
 the presence of risk factors for endometrial cancer, which include anovulatory
cycles, obesity, nulliparity, age greater than 35 years, and tamoxifen therapy.17,18
Initially, medical management is recommended for premenopausal women at low
risk for endometrial carcinoma who are diagnosed with presumed dysfunctional
uterine bleeding.

Diabetes is a demonstrated risk factor for endometrial cancer.17 Women with long
or irregular cycles are at risk for developing type 2 diabetes and therefore should
undergo diabetes screening.19

Endometrial cancer is rare in 15- to 18-year-old females.18 Therefore, most

adolescents with dysfunctional uterine bleeding can be treated safely with
hormone therapy and observation, without diagnostic testing.20

The risk of developing endometrial cancer increases with age.18 The overall
incidence of this cancer is 10.2 cases per 100,000 in women aged 19 to 39 years.
The incidence more than doubles from 2.8 cases per 100,000 in those aged 30 to
34 years to 6.1 cases per 100,000 in those aged 35 to 39 years. In women aged 40
to 49 years, the incidence of endometrial carcinoma is 36.5 cases per 100,000.
Thus, the American College of Obstetricians and Gynecologists recommends
endometrial evaluation in women aged 35 years and older who have abnormal
uterine bleeding.21 [SOR C, consensus guideline]

Endometrial evaluation (including imaging and tissue sampling) for subtle genital
tract pathology is recommended in patients who are at high risk for endometrial
cancer and in patients at low risk who continue bleeding abnormally despite
medical management.21

TABLE 3

Terms Used to Describe Abnormal Uterine Bleeding

Term Abnormal uterine bleeding pattern

:
 Oligomenorrhea Bleeding occurs at intervals of > 35 days and usually is
caused by a prolonged follicular phase.

Bleeding occurs at intervals of < 21 days and may be caused

Polymenorrhea
by a lutealphase defect.

Bleeding occurs at normal intervals (21 to 35 days) but with

Menorrhagia
heavy flow (80 mL) or duration (7 days).

Bleeding occurs at irregular, noncyclic intervals and with

Menometrorrhagia
heavy flow (80 mL) or duration (7 days).

Bleeding is absent for 6 months or more in a nonmenopausal

Amenorrhea
woman.

Irregular bleeding occurs between ovulatory cycles; causes

Metrorrhagia or
to consider include cervical disease, intrauterine device,
bleeding
endometritis, polyps, submucous myomas, endometrial
intermenstrual
hyperplasia, and cancer.

Spotting occurs just before ovulation, usually because of a

Midcycle spotting
decline in the estrogen level.

Postmenopausal Bleeding recurs in a menopausal woman at least 1 year after

bleeding cessation of cycles.

Acute emergent Bleeding is characterized by significant blood loss that

abnormal uterine results in hypovolemia (hypotension or tachycardia) or
bleeding shock.

This ovulatory or anovulatory bleeding is diagnosed after the

Dysfunctional exclusion of pregnancy or pregnancy-related disorders,
uterine bleeding medications, iatrogenic causes, obvious genital tract
pathology, and systemic conditions.

Information from reference 6.

Imaging and Tissue Sampling

:
 The sensitivity of endometrial biopsy for the detection of endometrial abnormalities
has been reported to be as high as 96 percent.22 However, this office-based
procedure may miss up to 18 percent of focal lesions,23 including polyps and
fibroids, because only a small part of the endometrium may be sampled at any one
time. Although endometrial biopsy has high sensitivity for endometrial
carcinoma,24,25 its sensitivity for detecting atypical endometrial hyperplasia may be
as low as 81 percent.25 [Reference 25: SOR B, meta-analysis of lower
quality/inconsistent studies]

Transvaginal ultrasonography may reveal leiomyoma, endometrial thickening, or

focal masses. Although this imaging modality may miss endometrial polyps and
submucous fibroids, it is highly sensitive for the detection of endometrial cancer
(96 percent) and endometrial abnormality (92 percent).26 [SOR A, meta-analysis of
consistent, good-quality studies] Compared with dilatation and curettage,
endometrial evaluation with transvaginal ultrasonography misses 4 percent more
cancers,26,27 but it may be the most cost-effective initial test in women at low risk
for endometrial cancer who have abnormal uterine bleeding that does not respond
to medical management.28

Saline-infusion sonohysterography bolsters the diagnostic power of transvaginal

ultrasonography. This technique entails ultrasound visualization after 5 to 10 mL of
sterile saline has been instilled in the endometrial cavity. Its sensitivity and
specificity for endometrial cancer are comparable with the high sensitivity and
specificity of diagnostic hysteroscopy.29 [SOR B, meta-analysis with significant
heterogeneity] Saline-infusion sonohysterography is more accurate than
transvaginal ultrasonography in diagnosing intracavitary lesions30,31 and is more
accurate than hysteroscopy in diagnosing endometrial hyperplasia.32 The
ombination of directed endometrial biopsy and saline-infusion sonohysterography
results in a sensitivity of 95 to 97 percent and a specificity of 70 to 98 percent for
the identification of endometrial abnormality.33,34 [References 33 and 34: SOR B,
diagnostic cohort studies]

Although dilatation and curettage has been the gold standard for diagnosing

35
:
 endometrial cancer,35 it no longer is considered to be therapeutic for abnormal
uterine bleeding; furthermore, it is limited in its ability to access the tubal cornua of
the uterus.36 Hysteroscopy with biopsy provides more information than dilatation
and curettage alone37 and rivals the combination of saline-infusion
sonohysterography and endometrial biopsy in its ability to diagnose polyps,
submucous fibroids, and other sources of abnormal uterine bleeding.31

Postmenopausal women with abnormal uterine bleeding, including those who have
been receiving hormone therapy for more than 12 months, should be offered
dilatation and curettage for evaluation of the endometrium (96 percent sensitivity
for the detection of cancer, with a 2 to 6 percent false-negative rate).26
Postmenopausal women who are poor candidates for general anesthesia and
those who decline dilatation and curettage may be offered transvaginal
ultrasonography or saline-infusion sonohysterography with endometrial biopsy.

Further research is necessary to determine the best method for evaluating the
endometrium in patients with abnormal uterine bleeding. However, based on
current evidence, saline-infusion sonohysterography with endometrial biopsy
appears to provide the most complete evaluation with the least risk33,34 (Figures
223,26,38 and 3).

Medical Management

ANOVULATORY DYSFUNCTIONAL UTERINE BLEEDING

Oral contraceptive pills (OCPs) are used for cycle regulation and contraception. In
patients with irregular cycles secondary to chronic anovulation or oligoovulation,
OCPs help to prevent the risks associated with prolonged unopposed estrogen
stimulation of the endometrium. OCPs effectively manage anovulatory bleeding in
premenopausal and perimenopausal women. Treatment with cyclic progestins for
five to 12 days per month is preferred when OCP use is contraindicated, such as in
21 16,39,40
:
 smokers over age 35 and women at risk for thromboembolism21 (Table 4).16,39,40

FIGURE 2.

Presumed Dysfunctional Uterine Bleeding in Women of

Childbearing Age: Evaluation Based on Risk Factors for
Endometrial Cancer
:
 Evaluation of women of childbearing age with presumed dysfunctional uterine bleeding, based
on risk for endometrial cancer.

OVULATORY DYSFUNCTIONAL UTERINE BLEEDING

Medical therapy for menorrhagia primarily includes nonsteroidal anti-inflammatory

:
 drugs (NSAIDs) and the levonorgestrel releasing intrauterine system (Mirena). The
U.S. Food and Drug Administration has approved the use of mefenamic acid
(Ponstel), an NSAID, for the treatment for menorrhagia; this agent is well
tolerated.41 [SOR A, meta-analysis] The levonorgestrel contraceptive device has
been shown to decrease menstrual blood loss significantly and to be superior to
cyclic progestins for this purpose.42 [SOR A, meta-analysis]

FIGURE 3.

Abnormal Uterine Bleeding in Postmenopausal Women

Evaluation of abnormal uterine bleeding in postmenopausal women.

:
 TABLE 4

Medical Management of Anovulatory Dysfunctional

Uterine Bleeding

The rightsholder did not grant rights to reproduce this item in electronic media. For the
missing item, see the original print version of this publication.

Although the effect of OCPs on menorrhagia has not been well studied, one small
randomized trial comparing OCPs, mefenamic acid, naproxen, and danazol showed
no significant difference in their effectiveness in treating menorrhagia.43 [SOR B,
single randomized controlled trial] Side effects and cost limit the use of androgens
such as danazol and gonadotropin-releasing hormone agonists in the treatment of
menorrhagia, but these agents may be used for short-term endometrial thinning
before ablation is performed.44 [SOR A, meta-analysis]

TABLE 5

Surgical Management of Abnormal Uterine Bleeding

Surgical procedure Reason for surgery

Operative hysteroscopy Intracavitary structural abnormalities

Myomectomy (abdominal,
Leiomyoma
laparoscopic, hysteroscopic)

Transcervical endometrial Treatment-resistant menorrhagia or

resection menometrorrhagia

Endometrial ablation (using Treatment-resistant menorrhagia or

various energy systems, menometrorrhagia; secondarily for
principally thermal balloon or management of treatment-resistant acute
rollerball) uterine hemorrhage

Uterine artery embolization Leiomyoma

:
 Atypical hyperplasia, endometrial cancer, or
Hysterectomy bleeding that does not respond to less invasive
uterus-sparing surgeries

Antifibrinolytics significantly reduce heavy menstrual bleeding. However, these

agents are used infrequently because of concerns about safety (i.e., potential for
thromboembolism).45

Intravenous administration of conjugated estrogens (Premarin) may be required in

women with acute uterine hemorrhage.40 [SOR B, single randomized controlled
study]

Surgical Management
When medical therapy fails or is contraindicated, surgical intervention may be
required. Hysterectomy is the treatment of choice when adenocarcinoma is
diagnosed, and this procedure also should be considered when biopsy specimens
contain atypia.13 Hysterectomy and various uterus-sparing surgical procedures for
the treatment of abnormal uterine bleeding are beyond the scope of this article but
are listed in Table 5.

Author Information
JANET R. ALBERS, M.D., is associate professor and associate chair in the
Department of Family and Community Medicine at Southern Illinois University (SIU)
School of Medicine, Springfield, where she is also director of the family practice
residency program. Dr. Albers received her medical degree from SIU School of
Medicine and completed a family practice residency at Mayo Graduate School of
Medicine, Rochester, Minn.

SHARON K. HULL, M.D., currently is on professional development leave from SIU

School of Medicine, where she is assistant professor in the Department of Family
:
 and Community Medicine and clinical assistant professor in the Department of
Medical Education. Dr. Hull earned her medical degree at SIU School of Medicine
and completed a family practice residency at Union Hospital Family Practice
Center, Terre Haute, Ind.

ROBERT M. WESLEY, M.A., is director of research and program development in the

Department of Family and Community Medicine at SIU School of Medicine. He
received a master's degree in sociology/anthropology from Sangamon State
University, Springfield, Ill.

The authors indicate that they do not have any conflicts of interest. Sources of funding:
none reported.

Address correspondence to Janet R. Albers, M.D., Southern Illinois University School of

Medicine, Springfield Family Practice Residency Program, 520 N. 4th St., Springfield, IL
62702 (e-mail:[email protected] (mailto:[email protected])). Reprints are not
available from the authors.

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