Family Medicine · Year 3 · from Family Medicine

Case 1: Abnormal Uterine Bleeding

Patient Demographics

  • Age: 38 years old
  • Sex: Female
  • Occupation: Marketing director

Chief Complaint

"My periods have become so heavy I'm soaking through a super tampon every hour. I'm exhausted."

History of Present Illness

Ms. Rachel Morrison is a 38-year-old woman presenting with heavy menstrual bleeding for the past 8 months. Her periods have always been regular (28-30 day cycles) but previously lasted 5 days with moderate flow. Now her periods last 8-9 days with very heavy flow for the first 4 days. She is soaking through a super tampon and pad every 1-2 hours on heavy days and has passed blood clots the size of quarters. She has had to miss work several times due to her periods.

She reports fatigue, dizziness when standing quickly, and feeling short of breath with exertion (climbing stairs). No intermenstrual bleeding or postcoital bleeding. No dysmenorrhea beyond mild cramping. Sexually active with husband, using condoms for contraception.

Past Medical History

  • Hypothyroidism on levothyroxine
  • No prior surgeries
  • G2P2, vaginal deliveries at ages 28 and 32

Past Obstetric/Gynecologic History

  • Menarche age 12
  • Previously regular cycles
  • No history of abnormal Pap smears
  • Last Pap smear 2 years ago: Normal
  • No STI history

Family History

  • Mother: Fibroids, hysterectomy at age 45
  • Maternal aunt: Uterine cancer at age 58
  • No bleeding disorders in family

Social History

  • Non-smoker
  • Social drinker (1-2 glasses wine on weekends)
  • Married, two children
  • High-stress job

Physical Examination

  • Vital Signs: BP 108/68 mmHg, HR 94, orthostatic hypotension present (BP drops 20 mmHg on standing)
  • General: Pale-appearing, fatigued
  • HEENT: Pale conjunctivae
  • Cardiovascular: Tachycardia, systolic flow murmur
  • Abdomen: Soft, non-tender, no masses
  • Pelvic Examination:
  • External genitalia: Normal
  • Vagina: No lesions
  • Cervix: Nulliparous appearance, no lesions, no cervical motion tenderness
  • Uterus: Mildly enlarged (8-week size), irregular contour, non-tender
  • Adnexa: No masses, non-tender

Clinical Image

Image: Mammography examination, an important component of women's health screening. While this case focuses on abnormal uterine bleeding, comprehensive women's health includes breast health surveillance.

Image Source: Wikimedia Commons Attribution: National Cancer Institute, Public Domain URL: https://commons.wikimedia.org/wiki/File:Mammography.jpg

Outpatient Workup

  • CBC: Hemoglobin 9.2 g/dL (low), MCV 74 fL (microcytic), Platelets 320 (normal)
  • Iron studies: Ferritin 8 ng/mL (low), TIBC elevated
  • TSH: 2.1 mIU/L (normal on replacement)
  • Pregnancy test: Negative
  • Coagulation studies: PT/INR, PTT normal
  • Pelvic ultrasound:
  • Uterus: 10 x 8 x 6 cm (enlarged)
  • Multiple intramural fibroids, largest 4 cm
  • Submucosal fibroid 2 cm distorting endometrial cavity
  • Endometrial thickness: 8 mm
  • Ovaries: Normal

Assessment and Diagnosis

  1. Abnormal uterine bleeding (AUB-L) - Leiomyoma (fibroids) as etiology
  2. Submucosal fibroid - Most likely cause of heavy bleeding
  3. Iron deficiency anemia - Secondary to chronic blood loss
  4. Symptomatic fibroids - Causing quality of life impairment

Management Plan

For Iron Deficiency Anemia (Urgent):

  • Ferrous sulfate 325 mg twice daily with vitamin C to enhance absorption
  • Take on empty stomach if tolerated, with food if GI upset
  • Recheck CBC in 4-6 weeks
  • Consider IV iron if oral not tolerated or hemoglobin very low

For Heavy Menstrual Bleeding - Immediate:

  • Tranexamic acid 1300 mg three times daily during menses (reduces bleeding by 30-50%)
  • NSAIDs: Ibuprofen 600 mg every 8 hours during menses (reduces bleeding and cramping)

For Heavy Menstrual Bleeding - Ongoing Management:

  • First-line option discussed: Levonorgestrel IUD (Mirena)
  • Reduces menstrual blood loss by 90%
  • Effective contraception
  • May shrink small fibroids
  • Trial for 3-6 months
  • Alternative hormonal options:
  • Combined oral contraceptives (if no contraindications)
  • Oral progestins (norethindrone acetate)
  • GnRH agonists (short-term for severe symptoms or presurgical)

Referral Considerations:

  • Gynecology referral for discussion of procedural options:
  • Hysteroscopic myomectomy: For submucosal fibroid
  • Uterine artery embolization
  • Endometrial ablation (if family complete)
  • Hysterectomy (definitive, if family complete and other options failed)

Patient Preferences Discussed:

  • Desires to preserve fertility (possible future pregnancy)
  • Prefers to try medical management first
  • Will consider IUD

Follow-Up

  • Return in 4-6 weeks to reassess symptoms and hemoglobin
  • IUD placement scheduled
  • Gynecology referral placed for surgical consultation
  • Repeat ultrasound in 6 months to monitor fibroid size

Teaching Points

  1. PALM-COEIN classification of AUB:
  • Structural (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy
  • Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified
  1. Fibroid types and bleeding risk:
  • Submucosal (distorts endometrial cavity): Most likely to cause heavy bleeding
  • Intramural: May cause heavy bleeding if large
  • Subserosal: Least likely to affect bleeding
  1. Workup for AUB: Pregnancy test, CBC, TSH, pelvic ultrasound. Consider coagulation studies in young women with heavy bleeding since menarche.
  1. Levonorgestrel IUD: First-line medical treatment for heavy menstrual bleeding. Reduces blood loss by 90% and provides contraception. May be used even with fibroids if cavity not severely distorted.

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