You’re a junior physician working in Basic Apply. Your subsequent affected person, Mrs Sarah Peters, is a 28-year-old nulliparous lady who’s struggling to manage with heavy menstrual bleeding and needs one thing to be accomplished to assist scale back the quantity of blood loss.
“Doctor, I’m really struggling with how heavy my periods are. It’s reached a point where I can’t even leave the house for the first 2 days, and I can’t afford to be taking so much time off work! And worse yet, the rest of the time I feel like I have no energy.”
What questions would you wish to ask Mrs Peters concerning the bleeding?
How lengthy has this been happening for? Have been your durations beforehand regular?
“This has been going on since I first started my periods – but it’s just been getting worse and worse. I can’t cope with this anymore.”
What number of pads/tampons do you employ in a day? Do you put on each on the similar time?
“I’m using 35 sanitary towels for each period.”
What color is the blood? Have you ever observed any clots? Any flooding or leaking?
“The blood is of a normal colour, and I have noticed clots during the first 3 days of getting my period.”
What triggered you to return in about this at present?
“I feel that my heavy periods have caused me to have no energy and it’s really getting me down!”
ICE – How is it affecting your life? Your job? Time without work work? Is something regarding you particularly?
“I’m worried about leaking into my clothes and so I take 2 days off work when the period first begins, so that I can deal with it safely at home.”
The solutions to the primary set of questions type the idea of the analysis, as though menorrhagia is outlined as >80ml of blood loss (1), that is not often measured – thus, menorrhagia is recognized when each the affected person and physician agree the quantity of blood loss is critical sufficient to have an effect on the lady’s life.
What additional questions would you wish to ask Mrs Peters?
Take a full menstrual historical past
At what age did you start to have your durations? (Menarche)
“I started my periods when I was 14.”
Do you keep in mind the primary day of your final menstrual interval (LMP)?
“I’ve just finished my period, so probably about 7 days ago.”
Are your cycles common? After what number of days do you get your subsequent interval? How lengthy does the bleeding final?
“My menstrual cycle occurs every 29 days and my periods last for 6 days, with the presence of clots during the first 3 days.”
Different issues to think about asking about, relying on the historical past given to date, comparable to:
- Painful durations (dysmenorrhoea)?
- Bleeding between cycles (intermenstrual bleeding)?
- Bleeding after intercourse (postcoital bleeding)?
- Ever not had durations for a while (amenorrhoea)?
- “I wouldn’t say my periods are painful, nor do I have bleeding between cycles or after sex.”
What else do you have to ask in a gynaecological historical past?
Sexual and contraception historical past:
- Are you sexually lively? Do you’ve got a daily associate?
- Any issues with intercourse (e.g. dyspareunia)?
- Have you ever ever been handled for an STI?
- Another sexual companions up to now three, 6 or 12 months?
- Are you utilizing contraception in the meanwhile? What contraception did you final use? OR Any issues with your present contraception?
- When was your final cervical smear?
- Have you ever been attending repeatedly?
- Any irregular smears?
- Any remedy required?
- Any issues with your waterworks?
- Are you passing urine extra typically (frequency)?
- Ache on passing urine (dysuria)?
- Any dragging sensation or mass in/on the vagina (prolapse)?
Temporary obstetric historical past:
- Do you’ve got any youngsters? Are you at present making an attempt for a kid?
- Confirm lady’s want for contraception or if making an attempt for a kid (determines subsequent administration)
- Have you ever ever been pregnant? Any miscarriages or terminations?
“I am married to my husband of 3 years. I am sexually active and have not had any other partners since I was married. I’ve never been treated for an STI. I stopped using the oral contraceptive pill about 9 months ago as I wanted to fall pregnant. My most recent cervical smear was 2 and a half years ago, and this was normal but I do have a reminder letter that I’m due another shortly as part of the 3-yearly screening. I have no problems with my waterworks. I do not have any children and really would like to fall pregnant in the next few months if possible.”
What questions can be helpful for a methods evaluation to finish your historical past?
Methods evaluation (to rule out any pathology which will trigger menorrhagia):
- And the way are you in any other case? Are you in good well being?
- Any fever, lethargy, weight reduction, night time sweats? (malignancy)
- Are you extra drained than normal, in need of breath, noticeable heartbeats/palpitations, pale? (anaemia)
- Any extreme tiredness, weight achieve, dry hair/hair loss, feeling chilly when others will not be? (hypothyroidism)
“Apart from feeling tired all the time, my husband does say I look quite pale. My weight hasn’t changed, and I haven’t had any fevers or night sweats. I wouldn’t say I’m particularly sensitive to the cold. I am otherwise well and haven’t had to see a doctor for any reason. I’m not on any medications, and I have no allergies. My family are well. I don’t smoke or drink alcohol.”
Don’t overlook the standard previous medical, drug, household and social historical past.
Based mostly on the findings within the historical past, what’s your prime differential analysis?
Dysfunctional uterine bleeding (DUB):
- No histological abnormality
- The menorrhagia is probably going because of delicate abnormalities of endometrial haemostasis and/or uterine prostaglandin ranges.
What are some native causes of menorrhagia?
- Uterine fibroids
- Cervical or endometrial polyps
- Pelvic inflammatory illness (PID)
- Endometrial hyperplasia or carcinoma
What are some systemic causes of menorrhagia?
- Bleeding issues (e.g. von Willebrand’s illness)
- Anticoagulant remedy (unusual)
- Climacteric (perimenopausal ladies)
Examination and Investigations
You could have now carried out a pelvic examination on Mrs Sarah Peters and the findings are proven under.
- No uterine tenderness or plenty, with a traditional anteverted uterus that isn’t enlarged.
- No adnexal plenty or tenderness famous.
- Cervix feels regular on palpation.
- No plenty obvious on the cervix.
- No discharge or bleeding is famous from the cervical os.
What additional investigations would you wish to carry out?
- Examine FBC and ferritin ranges for iron deficiency anaemia.
- Mrs Peters has a low Hb of 10.5 g/dL and in addition a low ferritin degree.
- Refer for a transvaginal ultrasound (TVUS) to exclude native natural causes (e.g. fibroids, polyps or adnexal plenty).
- Mrs Peters TVUS outcomes present a traditional endometrial thickness and no irregular plenty.
Think about if applicable based mostly on the historical past (these investigations weren’t carried out on this case):
- Clotting checks (bleeding dysfunction e.g. vWD)
- TFTs (hypothyroidism)
- Endometrial biopsy for histological examination (if worrying options e.g. endometrial thickness > 10mm on TVUS if premenopausal or intermenstrual bleeding)
- Triple swabs (if contemplating STI)
Analysis and Administration
The examination and investigations affirm your analysis of dysfunctional uterine bleeding (DUB).
What administration choices can be found for Mrs Peters?
Dysfunctional uterine bleeding could be managed in main care if there are not any regarding options within the historical past, medical examination and preliminary investigations (e.g. FBC, USS). Referral to secondary care can be suggested if two varieties of remedy have been to fail in main care.
First line remedy
- Tranexamic acid (anti-fibrinolytic) – ~50% discount in blood loss and is used throughout or simply earlier than the interval.
- Mefenamic acid (NSAID) – ~30% discount in blood loss and is used throughout or simply earlier than the interval; it’s notably helpful if dysmenorrhea can also be current (not on this case), and it might be taken with the tranexamic acid.
What administration choices can be found if a lady with menorrhagia was not planning to fall pregnant within the subsequent 12 months?
First line remedy
- Levonorgestrel intrauterine system (e.g. Mirena coil) offered long-term (at the very least 12 months) use is anticipated (this might not be applicable for Mrs Peters as she is making an attempt to conceive).
- Mixed oral contraceptive (COCP) is usually used for ladies who’re unable to take an NSAID (this might not be applicable for Mrs Peters as she is making an attempt to conceive).
- Norethisterone (15 mg) every day from days 5 to 26 of the menstrual cycle (impacts ovulation and has a contraceptive impact, so not applicable for Mrs Peters)
What surgical administration choices can be found to handle DUB?
Surgical remedy of DUB
Not one of the following remedies can be applicable for Mrs Peters, as she needs to take care of her fertility.
- Transcervical resection of the endometrium (TCRE): makes use of monopolar diathermy or microwave balloons to ablate the endometrium and superficial myometrium of the uterus, permitting amenorrhoea or lighter durations to comply with.
- Uterine artery embolisation (UAE): appropriate for ladies who need to retain their uterus and keep away from surgical procedure.
- Hysterectomy: typically a final resort used for ladies who don’t need additional youngsters.
1. Munro, Malcolm G.; Critchley, Hilary O. D.; Broder, Michael S.; Fraser, Ian S. (2011-04-01). “FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age”. Worldwide Journal of Gynecology & Obstetrics.
2. CG44 Heavy menstrual bleeding: Understanding NICE steerage” (PDF). Nationwide Institute for Well being and Clinical Excellence (UK). 24 January 2007.