Gynaecology Consult

Thank you for referring Sarah Jenkins, a 42-year-old woman whom I assessed in clinic on 24/10/2023 for a gynaecological consultation following referral for menorrhagia and symptomatic uterine fibroids.

History of Current Concern

6-month hx of progressively worsening HMB and pelvic pressure. Floods through super tampons and pads q2h on days 1–3. Passes clots up to 3 cm. Associated fatigue and mild lower abdominal cramping. LMP 10/10/2023.

Gynaecologic History

• Menarche was at age: 12.
• Her cycles are regular, 28 days.
• Dysmenorrhoea: minimal.
• Heavy or abnormal menstrual bleeding: yes.
• Intermenstrual bleeding: no.
• Postcoital bleeding: no.
• Vulvovaginal symptoms: no.
• Vasomotor symptoms: no.
• Bladder function: concerning, reports urinary frequency (voiding q2h daytime) and nocturia x2 secondary to pelvic pressure
• Does deny haematuria
• Bowel function: normal
• Does deny rectal bleeding

Sexual History

• Sexually active: yes, currently sexually active with one male partner
• She does not report safety concerns in her relationship.
• Does not report a history of sexually transmitted infections
• Does require contraception, partner had vasectomy 4 years ago

Cervical Cytology

• Has undergone cervical cytology, NILM in 05/2022
• Does deny a history of abnormal cervical cytology

Obstetrical History

• Previous pregnancy? Yes, G2P2, two uncomplicated SVD at term in 2012 and 2015
• Previously attempted to conceive? Yes

Medical History

• Iron deficiency anaemia
• Mild intermittent asthma

Surgical History

• Laparoscopic appendicectomy (2008)

Medications

1. ferrous fumarate (Palafer®) 300 mg PO OD
2. salbutamol (Ventolin®) 100 mcg INH PRN

External Medications

• Vitamin C 500 mg PO OD

Allergies

• Penicillin (maculopapular rash)

Family History

• She does not have a family history of breast or ovarian malignancy.
• She does not have a family history of uterine cancer.
• She does not have a family history of gastrointestinal malignancy.
• She does not have a family history of bleeding or clotting disorders.
• She does not have a family history of recurrent miscarriage, pregnancy loss, or congenital anomalies.

Social/Lifestyle History

• Cigarettes: No
• Marijuana/THC: No
• Alcohol: Yes, 2–3 standard drinks per week
• Other recreational substances: No
• She currently supports herself through: high school teacher.
• Prescription medication coverage: private extended health benefits via employer
• She lives: with her husband and two children in a two-storey house
• Her current relationship status is: married

Imaging

• Pelvic US (12/09/2023): Bulky uterus measuring 11.2 x 7.5 x 6.8 cm. Multiple intramural and subserosal leiomyomas; largest is a 5.4 cm posterior intramural fibroid distorting the endometrial cavity. Endometrium 6 mm. Bilateral ovaries normal.

Labwork/Investigations

• CBC (15/09/2023): Hb 102 g/L, MCV 76 fL, Plt 310 x 10^9/L. Ferritin 8 ug/L. TSH 1.8 mIU/L. Beta-hCG negative.

Physical Exam

• The abdomen was soft and nontender.
• There was not superficial lymphadenopathy in the inguinal region
• Were the external genitalia normal? Yes
• A medium speculum was inserted, showing normal vaginal mucosa with no blood in the vault
• The cervix was completely visualised and was parous, healthy, with no gross lesions
• On bimanual examination, her uterus was anteverted, mobile, nontender, irregularly enlarged to approximately 12-week size
• Was the uterus difficult to palpate? No
• The adnexa were non-palpable and nontender bilaterally
• Pelvirectal examination was unremarkable, rectovaginal septum intact with no nodularity.
• Normal sphincter tone, no palpable rectal masses, posterior uterine contour confirmed as irregular and mobile.

Impression and Plan

• Sarah Jenkins is a 42-year-old woman with:
  1. Symptomatic uterine fibroids causing HMB and bulk symptoms: Pipelle endometrial biopsy performed today in clinic; counselled on medical vs. surgical options. Pt wishes to avoid major surgery if possible; Rx tranexamic acid (Cyklokapron®) 1,000 mg PO TID PRN during menses, and will arrange levonorgestrel-releasing IUD (Mirena®) insertion once biopsy results return.
  2. Iron deficiency anaemia secondary to HMB: Continue ferrous fumarate 300 mg PO OD; repeat CBC and ferritin in 3 months.

Thank you for including me in her care.