Abnormal Menstrual Bleeding

Age: ‍ years old

Gender: female



HISTORY:

Presents with a ‍-‍day history of abnormal vaginal bleeding

Type: ‍excessive menstrual bleeding, ‍intermenstrual bleeding, ‍spotting, ‍frequent menstrual periods (cycles < 21 days, ‍postcoital bleeding

Described as ‍spottinglightmoderateheavy, ‍with smallwith largewithout clots, changing pads/tampons every ‍ hours

Bleeding is ‍constantintermittent

Episodes lasts for ‍ days, recurs ‍ times per ‍weeksmonths

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍abnormal vaginal discharge, ‍clear, ‍thin, ‍withwithout fishy odor

‍pelvic pain

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍vaginal pruritus

‍vulvovaginal rash

‍urinary Sx

‍fatigue



Gynecological history:

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

Menarche: ‍ years old

G‍01234 P‍01234 A‍01234

Last Pap smear: ‍ ‍monthsyears ago

Coitarche: ‍ years old ‍never

Contraception: ‍yesno ‍oral contraceptives

Condom use: ‍alwayssometimesnever

STI risk factors: ‍



Contributing factors:

‍obesity

‍smoking

‍unprotected sex

‍multiple sexual partners

‍delayed Pap smear

‍unvaccinated against HPV

‍adherent to contraceptives

no history of: ‍uterine fibroids, ‍endometriosis, ‍polycystic ovary syndrome, ‍abnormal Pap smears, ‍pregnancy, ‍bleeding disorders

no use of: ‍hormone therapy, ‍anticoagulants, ‍NSAIDs, ‍iron supplements





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Pelvic:

- External genitalia: ‍normal, ‍rashlesions, ‍inguinal lymphadenopathy

- Vagina: ‍normal, ‍lesions, discharge ‍normal, ‍foul-smelling

- Cervix: ‍normal, ‍, ‍IUD strings visualized

- Bimanual exam: ‍normal, uterus ‍tendernessmass, adnexa ‍tendernessmass ‍on righton left, ‍cervical motion tenderness

- Tests performed: ‍Pap smearHPV test, ‍vaginal culturechlamydia/gonorrhea screeningHSV sample, pH ‍< 4.5 (normal)> 4.5, KOH sniff test ‍negative

- ‍Pelvic exam performed with chaperone 





ASSESSMENT:

‍Abnormal uterine bleeding ‍likelysuspectedpossible

DDx: uterine fibroids, endometrial polyps, endometrial cancer, cervical cancer, cervical polyps, hormone therapy side effects, contraceptive side effects, vaginitis, atrophic vaginitis, coagulopathy, pelvic inflammatory disease, endometritis, trauma, foreign body, intrauterine contraceptive device, anticoagulant medication side effect, thyroid dysfunction, bleeding disorders, sexual assault, iatrogenic causes, STI, ectopic pregnancy, miscarriage





PLAN:

Investigations:

- Blood work: ‍CBC, ‍ferritin, ‍coagulation profile, ‍TSH, ‍FSH, ‍PRL, ‍β-hCG

- STI screening for chlamydia and gonorrhea

- Pap smear

- Pelvic ultrasound

Treatments:

- ‍NSAIDs

- ‍Oral contraceptives

- ‍Tranexamic acid

- Oral contraceptives adherence counseling

- Change of progestin in oral contraceptives

- Increase dose of estrogen in oral contraceptives

- Smoking cessation counseling

Further care:

- Referral to gynecologist

- Follow-up in ‍ ‍weeksmonths

- Return if bleeding worsens or if symptoms do not improve with treatment