Dysmenorrhoea/Menorrhagia

Primary Concern

The patient presents today with worsening dysmenorrhoea and menorrhagia.

Presenting Issue

Symptoms: The patient reports severe lower abdominal cramping radiating to the lumbar region during menstruation. She also experiences heavy menstrual bleeding with passage of small clots, accompanied by mild nausea and marked fatigue during the first three days of her cycle. She denies intermenstrual bleeding, postcoital bleeding, or deep dyspareunia.

Duration: These symptoms have been present for approximately 8 months and have progressively increased in severity over the past 3 cycles.

Menstrual History: Menarche occurred at age 12. Her cycles are regular, occurring every 28 days, with bleeding lasting 6 to 7 days. Her last menstrual period commenced on 02/10/2023.

Impact on Daily Life: The pain and heavy bleeding have required her to take 1 to 2 days off work per month over the past quarter. Over-the-counter analgesia provides only partial, temporary relief, and she reports needing to change sanitary pads every 2 hours on her heaviest days.

Past Medical History

Gynaecological History: There is no prior history of pelvic inflammatory disease, sexually transmitted infections, endometriosis, or ovarian cysts. Her last cervical screening was completed in May 2022 and was negative.

Chronic Conditions: She has a history of mild intermittent asthma and iron-deficiency anaemia diagnosed two years ago, which previously resolved with oral supplementation.

Medications:

• Ibuprofen 400 mg PO TID PRN
• Paracetamol 1,000 mg PO QID PRN
• Salbutamol 100 mcg INH PRN

Relevant Obstetric History

Pregnancies: The patient is G2P2, having had two uncomplicated spontaneous vaginal deliveries in 2018 and 2020.

Previous Gynaecological Procedures: She had a copper intrauterine device (IUD) inserted in 2020 and subsequently removed in early 2022. She has had no other surgical gynaecological procedures.

Physical Examination

General Appearance: The patient is alert, oriented, and appears comfortable at rest with no acute distress. Mild conjunctival pallor is noted. Vital signs are stable with BP 118/74 mmHg, HR 76 bpm, and Temp 36.7 °C.

Abdominal Examination: The abdomen is soft and non-distended with mild suprapubic tenderness on deep palpation. No guarding, rebound tenderness, organomegaly, or palpable masses are identified.

Pelvic Examination: External genitalia and vaginal walls appear normal with no lesions or abnormal discharge. Speculum examination reveals a healthy, multiparous cervix with no ectropion or contact bleeding; high vaginal and endocervical swabs were taken. Bimanual examination demonstrates a normal-sized, anteverted, mobile uterus with mild uterine tenderness, no cervical motion tenderness, and no palpable adnexal masses or uterosacral nodularity.

Assessment

Working Diagnosis: The working diagnosis is secondary dysmenorrhoea with menorrhagia.

Differential Diagnosis: Differential diagnoses under consideration include uterine fibroids, adenomyosis, and endometriosis.

Investigations Ordered

Imaging: A transvaginal and pelvic ultrasound has been requested to evaluate for structural abnormalities, specifically uterine fibroids, adenomyosis, or ovarian pathology.

Additional Tests: Venous blood tests have been ordered, including a full blood count (FBC), serum ferritin, thyroid function tests (TFTs), and a coagulation profile. Chlamydia and gonorrhoea NAAT swabs and a high vaginal swab for microscopy and culture have also been sent.

Treatment Plan

Pain Relief: Prescribed mefenamic acid (Ponstan®) 500 mg PO TID and tranexamic acid (Cyklokapron®) 1,000 mg PO TID, both to be taken during menstruation for up to 4 days. We also discussed the future option of a levonorgestrel intrauterine system (Mirena®) pending investigation results.

Supplementation: Recommended commencing over-the-counter magnesium glycinate 300 mg PO daily and vitamin B6 50 mg PO daily to assist with menstrual symptoms, alongside awaiting ferritin results before restarting therapeutic iron.

Exercise: Advised engaging in regular low-impact aerobic exercise, such as brisk walking or swimming, and gentle pelvic stretching throughout the cycle to help reduce cramping severity.

Diet: Advised increasing dietary intake of iron-rich foods (such as leafy greens and lean red meat) while reducing caffeine, alcohol, and refined sugars during the luteal phase and menses.

Alternative Therapies: Recommended applying a local heat pack or hot water bottle to the lower abdomen and lower back during acute cramping episodes.

Follow-Up: Arranged for a review in 6 weeks to assess treatment efficacy and discuss ultrasound and blood results, with strict safety-netting to return sooner or seek urgent care if she develops severe acute pelvic pain, fever, foul-smelling discharge, or dizziness with heavy bleeding soaking through a pad every hour for two consecutive hours.

Next Steps

Follow-Up Appointment: A routine GP appointment has been scheduled in 6 weeks (after two menstrual cycles on the new regimen) to review her symptom diary, blood test results, and pelvic ultrasound findings.

Referral: No specialist referral has been made at this stage; a referral to Gynaecology will be initiated if imaging reveals significant structural pathology or if symptoms remain refractory to first-line medical management.

Date: 18/10/2023