Menstrual Disorders (Abnormal Vaginal Bleeding)

Front 1

Case 1
15 year old patient presents to primary care physician with c/o regular menses for 3 years, but cycling monthly pelvic lower abdominal pain. Pain is described episodic, central, deep in pelvis. She is getting worse over time, now missing school and restricting activity prior to onset of menses.

Questions (history only, exam next) -

Back 1

Amount of menstrual flow, length of menstrual cycle and menstrual period, length of intermenstrual bleeding, pregnant?

Flow is normal, not pregnant, pain a day or two prior to menses, constant pain, turns off quickly, takes tylenol and helps a little bit, mother complains of similar symptoms or has in the past.

Make sure each question connects to a disease mechanism or process.

Front 2

All additional “significant history” is negative

Exam:
Afebrile, BP 92/58, P 78, R16
WDWN, normal height and weight. Breasts Tanner 3, normal hair distribution. Pelvic exam is requested by patient and parent to be deferred (they just want her started on birth control pills).

Labs requested (if any)?

Back 2

Normal height and weight throws out chromosomal defects

Tanner 3 = have not gone through adolescence yet (but still normal)

Labs = hematocrit, CBC, TSH

Ultrasound, historosalpinogram

Front 3

Lab values reveal normal FSH, serum progesterone and TSH.

Differential?

Any other testing?

Back 3

Differential =

1. Pelvic inflammatory disease (probably not with no sexual activity and being cyclical) = chlamydia, gonorrhea

2. Endometriosis = lining of uterus moves to other areas (uterine wall, on the colon, ovaries,

3. Dysmenorrhea

Front 4

What type of imaging is this?

Back 4

Hystrosalpinogram

(injection of dye into uterus via cervix)

Abnormal = should not look like a banana shaped = essentially shows

Front 5

Diagnosis?

Back 5

Bicornate uterus

Front 6

Identify uterus, colon, and left ovary, pouch of Douglas, oviduct

Back 6

Front 7

Notice the abnormalities.

Back 7

Flat then bulging up, has had this condition since she was born.

Front 8

Squeezing incision, push out mass with blood.

What is it?

Back 8

Non-communicating uterine horn.

Front 9

Case 2
38 yo woman G2 P2, normal deliveries. In usual state of good health until 6 months ago when she started missing monthly menses. Presents to gyn requesting evaluation. Home pregnancy tests have been negative.

Additional history?

Back 9

Height and weight

No contraceptives

No significant stress

Some changes in weight

Mother went through menopause at 50

Front 10

No breast leakage
No headaches
No weight change
No other medications
No change exercise habits (minimal)
Contraceptive use – husband vasectomy

Differential Dx?

Back 10

Breast = PROLACTING

Headaches = PITUITARY LESIONS, CRANIOPHARYNGIOMA

Weight = OBESITY OR THYROID

Medication = ANTI-DEPRESSANTS

Exercise = intense exercise can have effects

No hormonal contraception

Front 11

Exam
Afebrile; BP 112/78; P 68; R 18

General exam negative
Pelvic exam – NEFG; vagina normal; uterus small, non-tender; adnexa – negative masses/ tenderness

Differential?
Labs?

Back 11

Thyroid, polycystic ovarian syndrome, etc.

NORMAL EXAM

Order FSH, LH, TSH,

Front 12

Back 12

Hypothyroidism

Weight gain, reflexes, hair loss, skin changes, etc.

Front 13

Case 3

55 yo woman presents on referral from primary care for vaginal bleeding. Other than CBC, which was normal, no other eval has been undertaken. Healthy, no medications except daily aspirin for heart health.

Additional history?

Back 13

When was your last normal menstrual period?

When were they last normal and regular?

How much aspirin is she taking?

Any risk factors?

Any HRT? Smoke?

Family history of cancer?

Abnormal PAP smear?

Front 14

3 children, all C/S, last with tubal ligation at age 34. No other gyn surgeries. No pain. Regular menses q 28 d, lasting 4 d, until uneventful menopause age 48 (smoker). She is quite sure this is vaginal bleeding, not GI. Starting age 17 and between C/S she used OCPs. Never obese, breastfed each child 6 months.

VS normal; General exam is negative, pelvic exam is negative.

Differential?

Lab tests?

Back 14

Birth control pills have elevated protection for OVARIAN cancer.

Lack of children, lack of breast feeding = ENDOMETRIAL CANCER?

Post-menopausal bleeding = always do endometrial biopsy (it was negative)

Front 15

What does patient have?

What are the chances this is cancer?

Back 15

Uterine polyp = bleeding

1/50 chance of being cancer

Front 16

Case 4.
62 yo old woman, G1 P1, (vag del) presents with vaginal bleeding of 6 months duration. She underwent a surgical menopause age 42 because of bilateral ovarian “cysts” that had a solid component (uterus remains in situ). Has not been on hormonal therapy other than OCPs between ages 25 and 35. Otherwise healthy, no medications. Has hot flashes but is afraid to take HRT

Additional history?

Back 16

Continue

Front 17

Pathology on ovaries – bilateral dermoid cysts (benign teratomas are 15% bilateral).

Spotting is not cyclic or predictable, occasionally heavy. No pain

CBC – not anemic, normal

Exam – very thin, NAD. NEFG, thin, pale vaginal mucosa. Scant blood per cervical os. Uterus small. No adnexal masses.

Lab tests?

Back 17

Thin woman reduces risk of ovarian cancer

Front 18

Ultrasound – very thin to absent endometrial stripe.

EMB – scant tissue, no hyperplasia or cancer

Diagnosis?

Recommended treatment?

Back 18

Scant tissue = uterine atrophy => bleeding in post menopausal patient

Mechanism = no estrogen (lack of estrogen for 20 years)

Front 19

Case 5
24 yo woman, G0 P0, presents for evaluation of primary infertility. Onset of menses age 13, but has had only infrequent menses to present (about 3 per year). Has been attempting pregnancy for a year.

Husband eval has been done – normal sperm motility, normal count.

Back 19

Diagnosis of infertility because they have been trying.

Husband is normal (not the cause).

Front 20

Exam
Afebrile, BP 136/88; P 78; R 20
Wgt 205 lbs (no change)
Heart/lung exam negative. Obese. Hair distribution over mid chest – abdomen. Thick dark skin over back of neck. Breasts negative, no leakage.
Pelvic – NEFG, vaginal well estrogenized, Cervix – normal appearance, non-tender. Uterus – normal size, non-tender. Adenxae cannot be appreciated well because of obesity, but no large masses.

Differential? Labs?

Back 20

Hair distribution, acanthosis nigricans = PCOS

Other unlikely options = primary adrenal tumor, diabetes, craniopharyngioma, etc.

Labs = FSH, LH (probably not important because it is too expensive) = neither of these will help in diagnosis

Need to look for androgens (testosterone and DHEA, prolactin sometimes but rarely)

Front 21

TSH 2.2
hCG negative
Prolactin 34 (4 to 25)
DHEA-S – 605 (12 – 520 mcg/dl)
Testosterone – 99 (15 – 70 ng/ml)
FSH – 3.3

Other test needed?

Back 21

Ultrasound! Look for the "string of pearls."

Front 22

What are the hormonal issues here?

Back 22

We don't really know

Possibility:

Overactive CYP 450 (17-alpha --OH)