Abnormal Uterine Bleeding: Treatment

Abnormal Uterine Bleeding: Treatment<= /span>

December 13= , 2007

Erin Snyder=

Review of the= Case: A 38 yo AA female comes to you for a routine visit. She has a medical history positive= for substance abuse and domestic violence.&nbs= p; She is G3P3, status post tubal ligation. She complains that her periods hav= e been irregular for the past 2-3 cycles.

The patient te= lls you that her periods have always been heavy, lasting about 7 days, but her main concern is that they are now irregular and erratic.

On further his= tory, the pt tells you that she has been under a lot of stress lately, as her hus= band is ill following an injury. He continues to physically abuse her, she feels very anxious and depressed. Pt denies any menopausal symptoms, recent wt lo= ss, galactorrhea, or other symptoms. She started her period when she was 16 and= has always had regular periods until now. She admits to binge drinking and is smoking. Her family history is negative for any type of cancer

On exam she= 217;s slightly obese but well appearing. BP 110/70, HR 82. HEENT, neck, lungs, abdomen and extremities are normal. Pelvic exam is significant for an abnor= mal contour of the left side of her uterus, suggesting fibroids. No vaginal or cervical lesion seen.

You suspected anovulatory bleeding, and obtained the following lab work:

Pregnancy test= : negative

CBC: Hgb 11.7,= MCV 93, RDW 17.3, platelet ct nl

TSH: normal

Ferritin: 10

In our patient= , who is 38 and obese, you decide to proceed to pelvic ultrasound and endometrial bi= opsy.

Ultrasound con= firms your suspicion of a fibroid. = Her endometrial stripe is 4mm. Her endometrial biopsy shows normal proliferative endometrium. =

The patient is reassured that she doesn’t have endometrial cancer, but she wants to = know what you are going to do about her bleeding.

Commonly used NSAIDS are:

Mefenamic acid: 500mg x1 dose, then 250mg q6hrs x 3 days
Diclofenac
Ibuprofen, Naprosyn
Indomethacin

Cyclic progesterone simulates the luteal phase of the menstrual cycle and stimulates endometrial shedding.&nbs= p; Can use medroxyprogesterone (10mg) or norethindrone (5mg) 10 d= ays, 14 days, or 21 days each month
Continuous progestin orally or via IUD suppresses the unopposed estrogen and thi= ns the lining. Many women become amennorheic with these treatments

OCP with 30-35 mcg EE will su= ppress pts own estrogen production, and placebo week each month will produce withdrawal bleed. = If patient has not had menses in preceding 6 months, should give progestin course to cause withdrawal bleed first.

Agonists overwhelm the usual variation, and receptors become down regulated, and antagonists block the receptors.

How does your management change if you determine that she has ovulatory bleeding?

<= /b>
&nb= sp; More expensive than NSAIDs, may be more effective. Theoretical risk of clot, but= has been shown to confer any increased risk.
Continuous (as in IUD) or at = least 21 day cycles are more effective.

In our patient= , you prescribe OCPs. These are helpful for the first few cycles, but she steadily takes them less and less often. She says that she has difficulty remembering them. She is not interested in having more children, and she asks about a hysterectomy.

What surgical= options does she have?

§ Mo= st women will be sterilized with this procedure, generally by the endometrial damage and tubal occlusion. Sterilization is not 100%, and women who ovulate should have some fo= rm of birth control, because a pregnancy is more likely to be tubal. Tubal ligation can be done concurr= ently with the procedure to achieve sterility if desired.

§<= /p>