Case 4 A 45-year-old woman with heavy periods

 Case 4 A 45-year-old woman with

heavy periods

Mrs Ellen Smith is a 45-year-old woman who presents with

heavy periods. This started about 8 months ago and the

bleeding has become increasingly heavy. She is now quite

distressed about this problem.

What differential diagnoses

immediately come to mind?

• Dysfunctional uterine bleeding (DUB)

• Uterine fibroids

• Endometrial polyp

• Endometrial hyperplasia

• Endometriosis

• Adenomyosis

• Endometrial cancer

What would you like to elicit from

the history?

Presenting complaint and history of

presenting complaint

• Frequency and duration of vaginal bleeding

• Intermenstrual or postcoital bleeding

• Associated pain

Associated symptoms

• Symptoms of anaemia: lethargy, fatigue, palpitations

Menstrual history

• Duration, frequency and regularity of menses prior to

this problem

• Age of menarche

• Contraception, in particular intrauterine device (IUD)

or hormone replacement therapy (HRT)

• Cervical smear history, particularly date and result of

last smear test

Obstetric history

• Parity, type of deliveries, any complications

Medical history

• Thyroid disease, hypertension, diabetes

• Bleeding or clotting disorders

Family history

• History of cancer, particularly endometrial, colon,

breast

• Bleeding or clotting disorders

What aspects of this woman’s social

history are you particularly

interested in?

Heavy menstrual bleeding has a major impact on

a woman ’ s quality of life, and this can help in quantifying

the amount of vaginal loss. For instance, having to take

time off work because the bleeding is too heavy, not

wanting to leave the house for fear of an ‘ accident ’ or not

going on holiday because of the inconvenience of bleeding will give an indication of the effect this problem has

on the patient ’ s life.

The National Institute for Clinical Excellence (NICE)

defines heavy menstrual bleeding as excessive menstrual

blood loss that interferes with the woman ’ s physical,

emotional, social and material quality of life. It is therefore not only useful to enquire about her job, smoking

or alcohol status, but to assess how much this problem

is affecting her day - to - day activities.

Mrs Smith tells you that her periods are lasting longer and it

is sometimes difficult to tell what is her period or bleeding

in between her periods (intermenstrual bleeding). This

haphazard pattern is causing her great distress as she feels

she cannot continue with her outdoor lifestyle which

includes cycling.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.Case 4 43

PART 2: CASES

What would you look for on physical

examination?

General examination

• Body mass index (BMI)

• Pallor and tachycardia may indicate anaemia

• Remember to check mucous membranes for pallor in

dark women

Abdominal examination

This may be completely normal. A pelvic mass may be

palpable in the case of a fibroid uterus. The size of a mass

arising from the pelvis is measured and stated relative to

a pregnant uterus, e.g. a mass felt up to the level of the

umbilicus is 20 – 22 weeks size.

Pelvic examination

Speculum e xamination

The cervix should always be visualized with a Cusco

speculum. Look for polyps or ectopy. A cervix clinically

suspicious of cancer should be referred for an urgent

opinion. You only need to take a vaginal or endocervical

swab if infection is suspected.

Bimanual e xamination

You need to assess the size of the uterus relative to that

of a pregnant uterus and whether it is anteverted or

retroverted. Feel on either side for adnexal masses. An

enlarged uterus may suggest fibroids or adenomyosis.

To summarize your findings so far, Mrs Smith is a

45-year-old para 2+0 (both caesarean sections) with an

8-month history of irregular heavy menstrual bleeding

which is now affecting her quality of life. She is up to date

with cervical smears, and has no past medical history of

note. On examination, her BMI is 35, and there were no

obvious abnormal findings, although it is appreciated that it

was difficult to assess the abdomen and pelvis because of

her size.

What do you do next?

1 An endometrial biopsy should be taken. Although

endometrial cancer is uncommon in women under 40

years, the incidence rises between 40 and 55 years. Risk

factors include obesity, polycystic ovarian syndrome

(PCOS), nulliparity, unopposed oestrogen replacement

therapy, tamoxifen and feminizing ovarian tumours such

as thecomas or granulosa cell tumours.

The indications for taking an endometrial biopsy in

women with menorrhagia are:

• age 45 years and above

• persistent intermenstrual bleeding

• treatment failure

An endometrial biopsy is a safe and simple procedure

which is usually well - tolerated as an outpatient procedure and should be performed at this first visit.

2 Full blood count (FBC) to check for iron deficiency

anaemia secondary to blood loss.

3 Pelvic ultrasound scan. This will identify structural

abnormalities and detect endometrial polyps, uterine

fibroids and uterine malformations (Box 4.1 ). It may

show unusual appearances suggestive of malignancy.

However, an ultrasound performed showed a slightly

bulky uterus, no fibroids and no endometrial polyps. Both

ovaries appeared normal. An FBC reports a haemoglobin

level at the lower limit of normal at 110g/L. You had

difficulty performing a Pipelle endometrial biopsy, which is

common when a woman has not had any vaginal deliveries,

as in this case.

What would you do next?

If available, an outpatient hysteroscopy may be attempted

under local anaesthetic. Alternatively, a diagnostic hysteroscopy can be performed in theatre under a general

anaesthetic. This should be carried out as an inpatient

with an anaesthetic assessment for this patient because of

her high BMI. A hysteroscopy is the gold standard for

evaluating the uterine cavity and could show endometrial

polyps, submucosal fibroids, fibroid polyps, as well as

endometrial cancer and can allow a biopsy to be taken.

A dilatation and curettage is no longer a recommended

investigation as pathology may be missed without inspection of the uterine cavity.

Following the results of all investigations, including

a diagnostic hysteroscopy, there are no significant

Box 4.1 Uterine fibroids (leiomyomas)

• Most common benign tumour of the female genital

tract

• Found particularly in black/African/Afro-Caribbean

women

• Oestrogen-dependent

• Can be intramural, subserosal, submucosal or

pedunculated44 Part 2: Cases

PART 2: CASES

structural abnormalities detected and an

endometrial biopsy shows no hyperplasia, atypia or

malignancy.

Now, review all your differential

diagnoses

• Uterine fibroids: none seen on ultrasound scan or

hysteroscopy, so unlikely

• Dysfunctional uterine bleeding: most likely cause so far

as no structural abnormality detected (Box 4.2 )

• Endometrial polyp: although initially plausible, none

seen on ultrasound scan or hysteroscopy, so unlikely

• Endometrial hyperplasia: not detected on biopsy of

endometrium

• Endometriosis: somewhat unlikely in this age group

and usually accompanied with pelvic pain and

dysmenorrhoea

• Adenomyosis: possible as bulky uterus noted on ultrasound scan, but cannot be definitively diagnosed other

than histopathological examination of the uterus following hysterectomy (Box 4.3 )

• Endometrial cancer: not detected on biopsy of

endometrium

Box 4.2 Dysfunctional uterine bleeding

• DUB is a very common cause of abnormal vaginal

bleeding

• This diagnosis should only be made after ruling out

organic and structural causes for abnormal vaginal

bleeding

• About 90% of DUB results from anovulation and 10%

occurs with ovulatory cycles

• During an anovulatory cycle, the corpus luteum fails to

form, which causes failure of normal cyclical

progesterone secretion

• This results in continuous unopposed production of

oestradiol, stimulating overgrowth of the endometrium.

Without progesterone, the endometrium proliferates

and eventually outgrows its blood supply, leading to

necrosis. The end result is overproduction of uterine

blood flow

• In ovulatory DUB, prolonged progesterone secretion

causes irregular shedding of the endometrium

• DUB is common at the extremes of a woman’s

reproductive years. In this patient, who may be

peri-menopausal, DUB could be an early manifestation

of ovarian failure What treatment options would you

offer this patient?

It is important to note that any intervention should aim

to improve the woman ’ s quality of life rather than focusing on menstrual blood loss. NICE recommends that

treatment and care should take into account the woman ’ s

needs and preferences and good communication is

essential in allowing women to make informed decisions

about their care (Tables 4.1 & 4.2 ).

At a subsequent visit, you suggest the option of a Mirena

coil to Mrs Smith, but she does not seem to

be keen as she has had a coil in the past, but ‘it did not

agree with her’. You explain that unlike other contraceptive

IUDs, this is an intrauterine system

(IUS) which works differently and may improve her

symptoms. However, she would prefer not to try it and,

following further detailed discussion, a microwave

endometrial ablation (MEA) is chosen. She seems happy

about this option.

Three months following the MEA, you review Mrs Smith.

She is much happier with the vaginal bleeding, which she

says is very much reduced. She does complain of occasional

cramping abdominal pain, but can otherwise continue with

her active lifestyle.

Box 4.3 Adenomyosis

• Adenomyosis is the presence of endometrial tissue

within the muscle of the uterus (myometrium) where it

is not normally found

• When the endometrial tissue grows during the

menstrual cycle and then at menses tries to slough off,

the old tissue and blood cannot escape the uterine

muscle and flow out of the cervix as part of normal

menses. This trapping of the blood and tissue causes

uterine pain in the form of monthly menstrual cramps

(dysmenorrhoea)

• It also produces abnormal uterine bleeding when some

of the blood finally escapes the muscle, resulting in

prolonged spotting

• The uterus is uniform in outline and may be minimally

enlarged

• Adenomyosis is difficult to diagnose and is usually only

detected on histopathological examination of the uterus

following hysterectomyCase 4 45

PART 2: CASES

Table 4.1 Medical (pharmaceutical) treatment.

Treatment How does it work Side-effects

LNG-IUS, Mirena A hormonal intrauterine device that slowly

releases progestogen and prevents

proliferation of the endometrium. It also

thickens the cervical mucus and acts as a

contraceptive

Irregular spotting, bleeding for first 3–6 months. Breast

tenderness, acne, headaches. Small risk of uterine

perforation at insertion

Not useful with large fibroids distorting the uterine cavity

Tranexamic acid

NSAIDs

Combined oral

contraceptive

A non-hormonal oral antifibrinolytic

Reduce prostaglandin production

Stops ovulation, prevents proliferation of

endometrium

Uncommon side-effects, occasionally indigestion, headache

Indigestion, diarrhoea. Not for use with peptic ulcer disease

Breast tenderness, nausea, mood changes. Rarely, deep vein

thrombosis. Therefore not for use in those with past history

of thrombotic events

GnRH analogues Monthly injection that stops oestrogen and

progesterone production

A temporary measure to shrink fibroids prior

to surgery, or to ‘buy time’ if peri-menopausal

Causes menopausal-like symptoms such as hot flushes,

night sweats and vaginal dryness

Cannot be used for more than 6 months, as can be

associated with osteoporosis

GnRH, gonadotrophin releasing hormone; LNG-IUS, levonorgestrel-releasing intrauterine system; NSAID, non-steroidal antiinflammatory drug.

an additional challenge which may be frequently

encountered.

All treatment options, both medical and surgical,

should be fully discussed with the patient and a decision

made depending on expected results and possible side -

effects. In this case, medical therapy may not have been

the best selection, while a hysterectomy can be considered

to be extreme as the first option for treatment.

Hysterectomy is the most invasive form of treatment and

risks such as haemorrhage, thrombosis and infection are

greater than for less invasive techniques such as the

Mirena IUS or endometrial ablation. However, it is

essential that women are aware that endometrial ablation

can reduce menstrual loss, but may not cause

amenorrhoea.

CASE REVIEW

This woman presented with heavy menstrual bleeding, one

of the most common gynaecological complaints. It is

important to assess the quantity of menstrual blood loss

particularly in relation to how this influences her daily

life.

There were no obvious abnormalities detected on

examination and investigations including an ultrasound

scan and hysteroscopy similarly were negative. Heavy

menstrual bleeding can be caused by DUB which occurs in

the absence of structural abnormalities. However, it is

recommended that an endometrial biopsy is performed in

women over the age of 40 years who complain of any change

in menstrual pattern. This should also be performed prior

to any form of endometrial ablation. Obesity, as well as the

inability to perform a Pipelle sample in this case, provided