Subjective Data

CC: fatigue for the past 6 months

HPI: Jessica is a 38-year-old female with complaints of fatigue for the past 6 months. She reports regular menstrual periods, with bleeding lasting 7-9 days. She typically uses super absorbent tampons and changes them every 2 hours during the first couple of days of her period. She uses pads as backup during her heavier flow days. She has noticed passing quarter-sized clots. She states she has had heavy periods during her reproductive life but has never sought medical attention. She denies intermenstrual or postcoital bleeding. Denies history of abnormal Pap tests or positive STI screening.

PMH: HTN-HCTZ 25mg po daily, obesity

Surgical History: C-section, tubal ligation

OB/GYN History: G4P3013, 2 vaginal deliveries and 1 cesarean section. Denies abnormal pap tests or positive STI screening

Allergies: NKDA

Medications: HCTZ 25mg po daily, Multivitamin daily

Social History: Married-monogamous relationship, has 3 children, denies smoking, occasionally drinks alcohol socially.

Family History: Denies family history of breast, ovarian, colon, or uterine/endometrial cancers.

Review of Systems

Constitutional: Fatigue x 6 months, denies recent illness or changes to physical or emotional health.

Cardiovascular: Reports HTN

Gynecological: Reports regular menstrual periods with bleeding lasting 7-9 days. Reports passing quarter-size clots.

Psychiatric: Denies depression or significant stress

Objective Data

HR: 78 BP: 138/87 Temp: 98.9 Ht: 5’6” Wt: 267# BMI: 43.09 Age: 38

General Appearance: Well-developed obese female in no apparent distress.

Gynecological: No vulvar or vaginal lesions. Small amount of dark blood present in vault. No cervical motion tenderness or cervical lesions. Uterus and adnexal structures difficult to palpate due to abdominal girth. Uterus does not appear to be enlarged. No pelvic masses palpated.

What is your assessment of this patient?

This patient is experiencing iron deficiency anemia due to her abnormal uterine bleeding (AUB). AUB is frequently encountered in primary care. Although estimates vary, it is believed that between 20%-35% of non-pregnant women of reproductive age worldwide experience this condition (McGregor et al., 2022). Iron deficiency is the most prevalent micronutrient deficiency globally, affecting up to 60% of women who experience heavy menstrual bleeding (McGregor et al., 2022).

What are your thoughts on the treatment plan of this patient?

Beginning with the most conservative treatment, I would encourage this patient to eat an iron-rich diet (red meat, leafy green vegetables, and iron-fortified cereals). This patient should also start oral iron supplements, such as ferrous sulfate 325mg po daily. Given the patient’s history, hormonal therapy might also be effective, such as combined oral contraceptives (COCs). While taking COCs, bleeding should slow or stop within 24-48 hours, but treatment should continue for 5-7 days (Alexander et al., 2023). According to MacGregor et al. (2023), NSAIDs, such as mefenamic acid, naproxen, ibuprofen, and diclofenac may be an option for reducing prostaglandin levels by inhibiting the cyclooxygenase enzyme. Tranexamic acid is an antifibrinolytic used during menstruation to reduce blood loss. It comes in various oral formulations, with doses ranging from 1000 to 1300 mg taken 3–4 times daily. Tranexamic acid can be used alone or alongside an NSAID during the first 5 days of the menstrual cycle if there are no contraindications. It has been shown to reduce menstrual blood loss by 26%–50% and is more effective than NSAIDs alone. The patient must return in 4 weeks to assess her response to treatment. There are several medical treatments available to this patient. If medical treatments do not work or further testing shows a need, then surgical intervention, such as an ablation, uterine artery embolization, or hysterectomy, is the next step.

Is there any other information that you would obtain to assist you in determining treatment options?

According to Alexander et al. (2023), a pregnancy test should be performed as the first step in evaluating this patient with AUB, despite her history of tubal ligation. Cervical cytology and cervical cultures should also be considered to evaluate for cervical neoplasia and rule out STIs. A transvaginal ultrasound is the first-line imaging modality for patients presenting with AUB. The patient’s PT/INR and PTT should be assessed. Additionally, it is recommended to test all patients with excessive bleeding for von Willebrand disease.

Which guidelines would you consult?

I would consult the American College of Obstetricians and Gynecologists (ACOG) because their guidelines are based on the latest research and clinical evidence and provide a thorough approach to diagnosing and treating AUB.

Another guideline to consult is the National Institute for Health and Care Excellence (NICE). NICE guidelines provide clear structured pathways to help evaluate AUB, identify the underlying cause, and determine the most appropriate interventions.

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