Abnormal Uterine Bleeding

History of Presenting Complaint (HPC)

• Heavy menstrual bleeding (HMB) and intermenstrual bleeding (IMB) for 6 months, progressively worsening over the last 3 cycles.
• Associated pelvic pain:
  • Site: Suprapubic.
  • Onset: Gradual onset, starting 2 days prior to menses.
  • Character: Dull ache with intermittent cramping.
  • Radiation: Lower back.
  • Associations: Passage of large clots (> 2 cm) and flooding.
  • Time course: Lasts for the first 4 days of bleeding.
  • Exacerbating and relieving factors: Partially relieved by ibuprofen and heat application.
  • Severity: 6/10 at peak.
• Increasing fatigue and mild exertional dyspnoea over the past 2 months.
• No post-coital bleeding (PCB) or dyspareunia.

Past Medical History

• Cervical screening up to date; last smear 14/05/2022 was HPV negative.
• No history of bleeding disorders, easy bruising, or prolonged bleeding after dental extraction.
• Hypothyroidism, diagnosed in 2019.
• Laparoscopic appendicectomy in 2014.

Medications and Allergies

• Levothyroxine 75 mcg PO OD (taken for 5 years).
• Ibuprofen 400 mg PO TID PRN during menses.
• Evening primrose oil 1,000 mg PO OD (self-started 3 months ago).
• Penicillin: widespread maculopapular rash.

Family History

• Mother had uterine fibroids and underwent a total abdominal hysterectomy aged 46.
• Maternal aunt diagnosed with endometrial carcinoma aged 62.
• No family history of inherited bleeding disorders.

Screening Questions

Menstruation

• Currently Day 12 of cycle; experiencing light brown spotting today.
• Regular 28-day cycle (range 27–30 days).
• Bleeding lasts 7–8 days (previously 4–5 days); heavy flow requiring double protection (super tampons and heavy pads) changed every 1–2 hours on days 1–3.
• Menarche aged 12 years.

Possibility of Pregnancy

• Unlikely; partner had a vasectomy, though no formal clearance test was documented.

Previous Pregnancies

• G2P2: Two spontaneous vaginal deliveries at term (2015, 2018), no obstetric complications.
• Family complete; no desire for future pregnancies.

Contraception

• Male partner vasectomy.
• Relied upon for 4 years.
• Not applicable (not taking oral contraceptive pills).

Menopause Status

• Pre-menopausal (aged 42); no vasomotor symptoms.
• No hormone replacement therapy (HRT) use.

Sexual History

• In a mutually monogamous relationship with male partner for 10 years; low STI risk.

Review of Systems (ROS)

• Mild urinary frequency over the past 2 months; no dysuria or haematuria.
• Feeling of lower abdominal fullness/pressure.
• Bowels normal, no change in habit or dyschezia.
• No unintentional weight loss or night sweats.

Examination

General Examination

• Mild conjunctival pallor.
• Observations: BP 118/74 mmHg, HR 82 bpm, Temp 36.7 °C, BMI 26.4 kg/m².
• Abdomen soft, non-tender; firm, smooth mass palpable arising from the pelvis, equivalent to a 12-week size gravid uterus.

Pelvic Examination

• Vulva and vagina normal.
• Bimanual examination: Uterus bulky (approx. 12-week size), mobile, irregular contour, mildly tender on palpation.
• Adnexa non-tender, no discrete adnexal masses palpable; no cervical motion tenderness.

Speculum Examination

• Cervix appears healthy, parous os, no polyps, ectropion, or lesions seen.
• Small amount of old brown blood in the vaginal vault; no offensive discharge.

Investigations

• Urine pregnancy test (UPT): Negative in clinic.
• Bloods requested: FBC, ferritin, TFTs, and coagulation screen.
• High vaginal swab (HVS) and endocervical NAAT (chlamydia/gonorrhoea) taken.
• Referred for urgent pelvic ultrasound scan (transvaginal and transabdominal).

Assessment and Plan

• 42-year-old pre-menopausal female presenting with HMB, IMB, and pressure symptoms; examination findings suggestive of uterine fibroids (leiomyoma) and likely secondary iron deficiency anaemia.
• Differential diagnoses: Adenomyosis, endometrial polyp, endometrial hyperplasia.
• Prescribed tranexamic acid 1 g PO TID for up to 4 days during heavy menses to reduce blood loss.
• Advised to continue ibuprofen 400 mg PO TID with food during menses for dysmenorrhoea.
• Discussed long-term management options including the levonorgestrel intrauterine system (LNG-IUS, Mirena®) once structural pathology is delineated on ultrasound.
• Follow-up appointment arranged in 3 weeks to review blood results, swab results, and pelvic ultrasound findings (consider endometrial biopsy or gynaecology referral depending on endometrial thickness and cavity distortion).
• Safety netting provided: advised to seek urgent medical attention if experiencing severe acute pain, dizziness, syncope, or soaking through > 1 pad per hour for 2 consecutive hours.