# Clinical Cases: Women's Health in Primary Care

## 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
![Mammography screening](case_01_image.jpg)

*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

2. **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

3. **Workup for AUB:** Pregnancy test, CBC, TSH, pelvic ultrasound. Consider coagulation studies in young women with heavy bleeding since menarche.

4. **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.

---

## Case 2: Menopause Management

### Patient Demographics
- **Age:** 52 years old
- **Sex:** Female
- **Occupation:** High school principal

### Chief Complaint
"I'm having terrible hot flashes and I can't sleep. Is this menopause?"

### History of Present Illness
Mrs. Karen Phillips is a 52-year-old woman presenting with hot flashes, night sweats, and insomnia for 6 months. She experiences 8-10 hot flashes daily, described as sudden warmth spreading from her chest to face, lasting 1-3 minutes, followed by sweating. Night sweats wake her 2-3 times nightly, requiring her to change her pajamas. She has difficulty falling back asleep and feels exhausted during the day, affecting her work performance.

Her last menstrual period was 10 months ago. Prior to that, her periods had become irregular over 2 years (cycles ranging 21-45 days). She reports vaginal dryness causing discomfort during intercourse. She also notes mood swings, irritability, and difficulty concentrating.

### Past Medical History
- Hyperlipidemia (diet-controlled)
- Migraines without aura (infrequent, 1-2/year)
- No thromboembolic disease
- No breast cancer
- No cardiovascular disease

### Family History
- Mother: Osteoporosis, hip fracture at age 78
- Father: Heart disease, died at 72
- No family history of breast cancer, ovarian cancer, or blood clots

### Past Gynecologic History
- G3P3 (three vaginal deliveries)
- Menarche age 13
- No abnormal Pap smears
- Last Pap 1 year ago: Normal
- Last mammogram 8 months ago: Normal

### Social History
- Non-smoker
- Alcohol: 1-2 glasses wine on weekends
- Married, sexually active (diminished due to dyspareunia)
- Exercises regularly (walks 3-4x/week)
- No recreational drugs

### Physical Examination
- **Vital Signs:** BP 128/78 mmHg, HR 74, BMI 26
- **General:** Well-appearing, appears stressed
- **Cardiovascular:** Regular rhythm, no murmurs
- **Breasts:** No masses, no discharge, no axillary lymphadenopathy
- **Abdomen:** Soft, non-tender
- **Pelvic Examination:**
  - External: Normal
  - Vaginal mucosa: Pale, thin, decreased rugae, scant discharge
  - Cervix: Atrophic changes
  - Uterus: Small, non-tender
  - Adnexa: Not palpable

### Assessment and Diagnosis
1. **Perimenopause/Menopause transition** - >12 months since last menses = postmenopausal if confirmed
2. **Vasomotor symptoms (hot flashes, night sweats)** - Moderate-severe, affecting quality of life
3. **Sleep disturbance** - Secondary to night sweats
4. **Genitourinary syndrome of menopause (GSM)** - Vaginal atrophy causing dyspareunia
5. **Hyperlipidemia** - Needs monitoring post-menopause

### Management Plan

**Confirming Menopause:**
- Clinical diagnosis (>12 months amenorrhea in appropriate age group)
- FSH/estradiol levels not routinely needed in women >45 with typical symptoms
- If desired for confirmation: FSH >30 mIU/mL with low estradiol suggests menopause

**For Vasomotor Symptoms - Hormone Therapy Discussion:**

*Patient is a candidate for systemic hormone therapy:*
- Age <60, within 10 years of menopause onset
- No contraindications (no breast cancer, no VTE, no active liver disease, no CVD)
- Moderate-severe symptoms affecting quality of life

*Hormone therapy options:*
- Estrogen + progestogen (required because she has a uterus)
- Transdermal estradiol 0.0375 mg patch twice weekly (lower VTE risk than oral)
- Micronized progesterone 100 mg nightly for 12-14 days/month or continuous
- Alternative: Combined estrogen/progestogen patch

*Benefits discussed:*
- Most effective treatment for hot flashes (reduces by 75-90%)
- Improves sleep
- Helps vaginal symptoms
- Prevents bone loss

*Risks discussed:*
- Small increased risk of breast cancer with >5 years use (combined therapy)
- Small increased risk of VTE (lower with transdermal)
- Individualized risk assessment

**For Genitourinary Syndrome of Menopause:**
- Low-dose vaginal estrogen cream (estradiol 0.01% cream)
  - Minimal systemic absorption
  - Can be used in addition to or instead of systemic therapy
- Vaginal moisturizers (Replens) every 2-3 days
- Lubricants during intercourse

**Non-Hormonal Alternatives (if patient declines HT or contraindicated):**
- SSRIs/SNRIs: Paroxetine 7.5 mg (FDA-approved), venlafaxine
- Gabapentin (especially helpful for night symptoms)
- Cognitive behavioral therapy for hot flashes

**Lifestyle Modifications:**
- Dress in layers
- Keep bedroom cool
- Avoid triggers (alcohol, caffeine, spicy foods)
- Regular exercise
- Stress management

**Preventive Care:**
- Lipid panel (cardiovascular risk increases post-menopause)
- DEXA scan (bone density) at age 65 or earlier given family history of osteoporosis
- Continue mammogram screening
- Cervical cancer screening per guidelines

### Follow-Up
- Return in 6-8 weeks to assess response to therapy
- If HT initiated: Reassess annually, use lowest effective dose, reevaluate need yearly
- Annual well-woman exam with breast and pelvic exam

### Teaching Points
1. **Menopause diagnosis:** Clinical diagnosis based on 12 months of amenorrhea in women over age 45 with typical symptoms. Lab testing (FSH) not usually needed.

2. **Vasomotor symptoms:** Hot flashes affect 75% of menopausal women. Hormone therapy is the most effective treatment (75-90% reduction).

3. **Hormone therapy candidacy:** Consider for symptomatic women <60 years old or within 10 years of menopause without contraindications. Benefits outweigh risks when started in this window.

4. **Genitourinary syndrome of menopause (GSM):** Vaginal dryness, dyspareunia, urinary symptoms. Treated with low-dose vaginal estrogen (safe, minimal systemic absorption) regardless of systemic HT use.

5. **Non-hormonal options:** Paroxetine (Brisdelle) is FDA-approved for hot flashes. Other SSRIs, SNRIs, and gabapentin are also effective alternatives.