Abnormal Uterine Bleeding in A 39 Year Old
Abnormal Uterine Bleeding in A 39 Year Old
Abnormal Uterine Bleeding in A 39 Year Old
Abstract
True uterine bleeding usually results from increased estrogen levels.2,3 In relation
to this, the group reports a case of AUB. Relevant discussion and considerations
of all possible etiologies are presented alongside with approach in its proposed
Gynecology
Introduction
of menses are among the most common health concerns. Bleeding prior to
anovulatory uterine bleeding from HPO axis dysfunction is a frequent finding. 2,3
Case Report
Filipino, Catholic who resides in Arayat, Pampanga and was seen at the
prolonged menstruation from June 13 to July 10, 2016 in which she noted
bleeding to be red and in minimal amount. She consumed an estimated 1-3 pads
per day in a week with accompanying 3/10 dull pain localized in the hypogastric
area which is relieved when blood comes out. There were no accompanying
menstrual bleeding. She sought consultation with a general practitioner and was
given Tranexamic Acid 500 mg capsule three times a day and was also advised
for ultrasound and Pap smear test in which she did not comply because the
general practitioner with unrecalled findings in the ultrasound and a normal Pap
smear result. She was referred to Jose B. Lingad Memorial Regional Hospital
menstrual bleed, which totally soaked 2 white diapers per day with
management done. Foul-smelling vaginal discharge and small clots were also
persistence of bleeding and increasing size of blood clots, she complied with the
side. She doesnt smoke or drink alcohol. She has finished vocational degree
and is a plain housewife. She had her menarche at 12 years old. Her usual
menses are of regular intervals of a 28 day cycle that usually last for 3 days,
consuming 3 sanitary pads per day, fully soaked and with accompanying
first prolonged menstrual bleed was on June 13 - July 10, 2016. First sexual
contact was at 20 years old with only 1 sexual partner. There was no history of
OCP use in the past. In 2004, patient had Pap smear with normal findings. She
and a Body Mass Index (BMI) of 28.7. She has pink palpebral conjunctiva.
genitalia reveals normal looking pubic hair pattern with no scars, warts, and
nodule in the vulva. On speculum examination, vaginal mucosa is pink and has
blood on walls. Cervix is pink, blood-tinged, and has erosion in the 12 oclock
position. Borders are smooth and there were no outgrowths noted. On bimanual
examination, there was neither adnexal mass nor tenderness upon palpation.
3. Multiparous
4. Dysmenorrhea
5. Obese
With all the initial findings noted, the initial impression is Abnormal Uterine
and endometriosis to be the most likely etiologies. This is due to the fact that the
aromatase expression and high tissue estrogen levels. The group primarily
considers endometrial hyperplasia because the patient is older than 35 years old
extended AUB, obesity, and non-smoking status of the patient are present.2
We cannot completely rule out the aforementioned because diagnostic
procedures are necessary to confirm the etiology of the case. This is partly
because the bleeding pattern has limited value in diagnosing the underlying
bleeding cause.2
Discussion
menstrual bleeding. The normal limits for the four main clinical dimensions of
etiologies of AUB. In general, the components of the PALM group are discrete
(structural) entities that can be measured visually with imaging techniques and/or
histopathology, whereas the COEIN group is related to entities that are not
The endometrium consists of two distinct zones, the functionalis layer and
the basalis layer. The basalis layer lies in direct contact with the myometrium,
hormones. During the first part of the cycle, estrogen is made by the ovaries.
Estrogen causes the lining to grow and thicken to prepare the uterus for
does not occur, estrogen and progesterone levels decrease.8 The decrease in
down the stroma and vascular architecture of the functionalis layer. Subsequent
bleeding and sloughing of this layer constitute menstruation. Once the lining is
made and the lining is not shed. The endometrium may continue to grow in
response to estrogen. The cells that make up the lining may crowd together and
blood count (CBC) is indicated to identify anemia and the degree of blood loss.
Wet Prep examination and cervical cultures are used to exclude infectious
into the endometrial cavity. The uterine cavity is distended with saline for
office endometrial biopsy (EMB) or outpatient dilatation and curettage (D&C) are
suitable choices for endometrial sampling. The former is associated with few
women older than 45 years with AUB or those younger than 45 with chronic
type of treatment for abnormal uterine bleeding. These include cause of the
(JOGC) suggests that once malignancy and significant pelvic pathology have
been ruled out, medical treatment should be considered as the first line
protecting the endometrium from unopposed estrogen and the risk of hyperplasia
or carcinoma.10
reducing menstrual blood loss by 33% to 55%. NSAIDs also have the added
including the oral contraceptive pill, contraceptive patch, and vaginal ring provide
breast cancer.10
of women with irregular cycles will achieve menstrual regularity with this regimen
with the added benefit of protecting the endometrium from the effects of
unopposed estrogen. Common side effects from oral progestins include breast
day, inducing endometrial atrophy and reducing mean uterine vascular density. It
has been found to reduce menstrual losses significantly and has recently been
loss of bone density, and hypoestrogenic effects including hot flashes, night
sweats, and vaginal dryness. Add-back therapy with low dose estrogen and
progestins will minimize adverse effects, and should be administered if therapy is
AUB. These include (1) failure to respond to medical therapy, (2) inability to
anemia, (4) impact on quality of life, and (5) concomitant uterine pathology such
Conclusion
with AUB needs further work-ups to determine the etiology of her condition. It is
because not doing so may lead to misdiagnosis and this will affect both the
professors, especially Dra. Malou Mercado and Dr. Angelo Tolentino, who helped
them throughout their journey in making this case report. Through their guidance,
the researchers were able to have the opportunity to examine real gynecological
cases. The knowledge that they gained from this case report will surely be of use
References
2) Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Corton M.
3) Lentz GM, Lobo RA, Gershenson DM, Katz, VL. Comprehensive gynecology.
2009; 4: 179189.
5. Ahuja SP, Hertweck SP. Overview of bleeding disorders in adolescent females
https://www.scribd.com/doc/273678483/POGS-CPG-Abnormal-Uterine-Bleedine.
Available from:
https://www.acog.org/-/media/For-Patients/faq147.pdf?dmc=1&ts=20161015T07
https://sogc.org/wp-content/uploads/2013/07/gui292CPG1305E.pdf. [Accessed:
Appendix
Table 1
Menstrual Cycle
Infrequent > 38
Normal 4.5-8.0
Light < 5