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Formal Case Presentation: Abnormal Uterine Bleeding

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Rachel Hein

on 14 August 2013

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Transcript of Formal Case Presentation: Abnormal Uterine Bleeding

Formal Case Presentation: Abnormal Uterine Bleeding
CC: Abnormal Uterine Bleeding
S.M. is a 39 y/o sexually active African American female with a PMH of a b/l tubal ligation and no systemic illness who presented for a f/u on 8/2 with complaints of abnormal vaginal bleeding.
Bleeding began July 21 and lasted seven days. Bleeding was heavier than her normal period with more associated cramping and back pain. Patient also reported passing several large clots
LMP was on July 7 and lasted for 6 days
Usually has a period every 26-28 days

Differential Diagnosis
Pregnancy
Medications:
OCPs/IUD; psychopharmacologic drugs
HPO axis abnormalities:
Hypo/hyperthyroidism
Elevated prolactin
Anorexia/increased exercise or weight changes
Increased stress
Infection
Ovarian granulosa cell tumor
Cervical polyps
Abnormal uterine growth
Endometrial hyperplasia/ carcinoma
Leiomyoma/sarcoma
Uterine polpys
Adenomyosis
Perimenopause
Assessment:
39 y/o AAF w/ PMH of b/l tubal ligation and ovarian cyst who presented with abnormal uterine bleeding
History and physical exam points to pre or perimenopausal anovulatory cycles
CBC was not done
Pregnancy test was negative
Cycles were determined to be most likely anovulatory in etiology by HPI
TSH was normal
Prolactin was not measured but breast exam was normal
No anorexia or wt loss, but pt is under a lot of stress
No signs of PCOS on physical exam
Transvaginal ultrasound showed a normal sized uterus (9.7cm) with normal thickness (3.0 cm)
Results of pap smear came back negative for cervical lesions but positive for trichomonas vaginalis
GAD7 was completed with a high score
Patient Education and Prevention
Patient education about menstrual cycles and abnormal uterine bleeding
Article from ACOG: http://www.acog.org/~/media/For%20Patients/faq095.pdf?dmc=1&ts=20130813T0830045349
Benefits of counseling
Protected sexual intercourse
Potential causes discussed with patient:
Hormonal changes
Stress
Treatment options discussed
Plan
Continue to monitor menstrual cycles; f/u in 3 months
Treat infection with metronidazole 500mg BID for 7 days; discuss treating partner
OCPs if bleeding continues to be irregular
Consider endometrial biopsy, prolactin levels
Discuss options of counseling, relaxation techniques, pharmacologic therapy for stress and anxiety

Rachel Hein, MS3
CC: Abnormal Uterine Bleeding
At time of appointment, patient denied any bleeding
Still some intermittent lower midline abdominal cramping that is consistent with the cramping she normal gets on her period
Bleeding and cramping are not associated with coitus

HEENT: positive for increased frequency of headaches
Cardiac: No new chest pain, palpitations
Respiratory: No SOB
GI: No N/V
GU: crampy abdominal pain that localizes to the lower midline
Endocrine: positive for tiredness, heat intolerance, increased sweatiness

Review of Systems
Psych: On further questioning, pt became tearful and admitted to increased amount of stress in her life from her ex boyfriend, her hospitalized brother, work, and strained family relationships
Pt also states that because of the stress she has not been able to work out and has been gaining weight

Past Medical History
Tubal ligation in 2007
Ovarian mass in 2005- dx as hemorrhagic cyst that had since resolved
Abnormal pap smear in 2006
Panic attacks (per patient)
No history of depression or hypo/hyperthyroidism

Negative for breast, ovarian, or endometrial cancer
Negative for thyroid disorders and other autoimmune diseases
No family history of early menopause
No history of bleeding disorders

Pt is a single mom with 3 children currently on summer break
Pt reports increased stress due to caring for a brother that is currently hospitalized, an ex-boyfriend, work problems at the pharmacy, and strained family relationships
Also has hx of recent unprotected sexual intercourse with a new partner
Pt reports recent weight gain and cessation of physical activity
Denies smoking, alcohol use, illicit drugs

Current Medications
Budesonide, Nasal 32 Mcg/act
Polytrim 10,000-.01 unit/mL OP solution
Zyrtec 10mg

Family History
Review of Systems
Social History
Physical Exam
Vitals:
BP: 112/73
Pulse: 84
BMI: 26.6
Non obese female in NAD, tearful
No hirsutism or acanthosis nigricans noted
Pelvic exam confirmed that the bleeding source was uterine
No cervical polyps or tenderness noted, exam otherwise unremarkable
No visible vaginal pathology or uterine enlargement
Breast exam was unremarkable- mild tenderness and no milk production

Diagnostic Tests
CBC
Pregnancy Test
Pap smear
GAD7; PHQ9
Gonorrhea/Chlamydia test
Transvaginal ultrasound
TSH and prolactin levels
Endometrial Biopsy
Abnormal Uterine Bleeding
Premenopausal
10-30% prevalence
Perimenopausal
Postmenopausal
Abnormal Uterine Bleeding
Premenopausal
Obtain history, Physical Exam, CBC
Genital tract lesion - perform biopsy
Uterine enlargement - exclude pregnancy
Is the patient pregnant?
What is the patient’s ovulatory status?
Ovulatory: menorrhagia, polymenorrhea, olighomenorrhea, intermenstrual bleeding
Anovulatory: Hypothalamic/pituitary dysfunction
TSH, prolactin, stress, eating disorders, exercise
Consider PCOS
Obesity
Perimenopausal
Cycles tend to shorten and become intermittently anovulatory

Prevelance estimated 3.1%
More commonly affects women than men
Can range from asymptomatic to dysuria, foul smelling discharge and lower abdominal pain

Trichomonas
Risk Factors
Adolescence
Perimenopausal
PCOS
Obesity
References
Up to date
http://www.uptodate.com.foyer.swmed.edu/contents/initial-approach-to-the-premenopausal-woman-with-abnormal-uterine-bleeding?detectedLanguage=en&source=search_result&search=abnormal+uterine+bleeding&selectedTitle=1%7E150&provider=noProvider
ACOG
http://www.acog.org/~/media/For%20Patients/faq095.pdf?dmc=1&ts=20130813T0830045349
Clinical Key
https://www.clinicalkey.com/topics/obstetrics-gynecology/dysfunctional-uterine-bleeding.html
AAFP
http://www.aafp.org/afp/1999/1001/p1371.html
Full transcript