Abnormal Menstrual Bleeding Consultation Note

Thank you for your referral of Sarah Jenkins, a pleasant 44 year old woman referred for abnormal uterine bleeding (AUB) and symptomatic anemia.

Reason for Consultation

• Evaluation and surgical management of heavy menstrual bleeding (HMB) secondary to uterine fibroids, refractory to medical therapy.

History of Present Illness

• Onset of HMB 18 months ago, progressively worsening over the past 6 months.
• Regular 28-day cycles with 8–9 days of bleeding, up from her baseline of 4–5 days.
• Passes clots up to 3 cm on days 1–3; experiences frequent flooding requiring double protection and pad/tampon changes q1–2h during peak flow.
• Denies intermenstrual or postcoital bleeding/spotting.
• Endorses mild dysmenorrhea, pelvic pressure, and significant fatigue with exertional dyspnea.
• Previously trialled tranexamic acid (Cyklokapron®) 1,000 mg PO TID during menses with minimal reduction in flow. Trialled combined oral contraceptives 8 months ago, discontinued after 2 months due to intractable migraines.

Past Medical History

• Iron deficiency anemia, hypertension, migraines without aura. No prior hospitalizations.

Medications

• amlodipine (Norvasc®) 5 mg PO daily
• ferrous fumarate (Palafer®) 300 mg PO daily
• naproxen (Aleve®) 250 mg PO BID PRN for dysmenorrhea

Allergies

• Penicillin (maculopapular rash); no known food or environmental allergies.

Surgical History

• Laparoscopic appendectomy (12/05/2012) and bilateral tubal ligation (18/09/2016); no surgical or anesthetic complications.

Gynecological History

• Menarche at age 12. Last Pap test 14/11/2023 (NILM). Negative STI history. Premenopausal; denies vasomotor symptoms.

Obstetrical History

• G2T2P0A0L2. Two uncomplicated spontaneous vaginal deliveries at term in 2013 and 2016.

Social History

• Non-smoker, 2–3 standard alcoholic drinks per week. Works full-time as an elementary school teacher.

Family History

• Mother had hysterectomy at age 48 for fibroids; father has HTN and T2DM. Negative for gynecologic, breast, or colorectal malignancies, and negative for bleeding disorders.

Review of Systems

• Positive for fatigue, mild orthostasis, and pelvic bulk symptoms (urinary frequency). Negative for fever, weight loss, GI changes, or easy bruising/epistaxis.

Physical Examination

• Vitals (10:15 America/Edmonton): BP 126/78 mmHg, HR 82 bpm, Temp 36.8 °C, BMI 26.4 kg/m². Alert, NAD, mild conjunctival pallor. Abdomen soft, non-tender, palpable firm fundus at the pubic symphysis. Vulva and vagina unremarkable on speculum exam; cervix parous without lesions, minimal dark blood in vault.
• Bimanual examination performed: uterus anteverted, mobile, non-tender, irregularly enlarged to approximately 12-week size; adnexa unremarkable and non-tender bilaterally.
• Pap test was not taken as screening is up to date.
• Endometrial biopsy performed in clinic: cervix cleaned with povidone-iodine, anterior lip grasped with a single-tooth tenaculum, uterine sounding depth 10 cm, 2 passes completed with Pipelle yielding a moderate amount of tissue.

Investigations

• Labs (02/03/2025): Hb 98 g/L, MCV 74 fL, Ferritin 8 ug/L, Platelets 245 x 10^9/L, TSH 1.8 mIU/L, beta-hCG negative.
• Pelvic US (04/03/2025): Uterus enlarged at 11.5 x 7.2 x 6.8 cm. Multiple intramural and subserosal leiomyomas; largest is a 4.5 cm posterior intramural fibroid distorting the endometrial cavity (FIGO type 2-5). Endometrium 7 mm. Bilateral ovaries normal.
• Endometrial biopsy (today): Pending histopathology.

Assessment

• 44yo G2P2 with AUB-L (leiomyoma) causing iron deficiency anemia and bulk symptoms, refractory to tranexamic acid. DDx includes adenomyosis or endometrial polyp.
• Low baseline risk of endometrial cancer, though biopsy performed today given age > 40 with persistent AUB to rule out hyperplasia/malignancy prior to definitive surgical management.

Plan

• Continue ferrous fumarate 300 mg PO daily. Hold further hormonal trials given history of migraines.
• Patient prefers definitive surgical management and has completed childbearing. Booked for total laparoscopic hysterectomy and bilateral salpingectomy (TLH-BS) pending benign endometrial biopsy results. Pre-operative anesthesia consult ordered to optimize anemia.
• Counselled extensively on alternatives including levonorgestrel IUD, uterine artery embolization, and myomectomy. Discussed surgical risks of TLH-BS including bleeding, infection, visceral injury (bladder, bowel, ureter), VTE, and conversion to laparotomy. Printed educational materials provided; RTC in 4 weeks to review pathology and finalize OR booking.

Once again, thank you for involving me in her care.