Obstetrics / Women’s Health KFP 1.1 – Amy has heavy periods

by | Feb 13, 2018

Amy, 15, presents to you with heavy and irregular periods over the past 6-12 months and fatigue over the last 1-2 months.  She has no other symptoms, no past medical history.  She has no allergies and does not smoke.

What further history features do you want to ask? List 8

  • Age of menarche
  • Period regularity
  • Period duration and amount – clots, flooding, number of pads/tampons required,
  • Dysmenorrhoea
  • Post coital bleeding
  • Inter menstrual bleeding
  • Contraception and compliance
  • Sexual activity
  • Gravida/parida
  • Impact on daily life
  • Acne
  • Hirsutism
  • Weight gain

Case continued: 

She reports her periods are irregular, occurring sometimes 3 weeks and sometimes 5-6 weeks.  The longer the time in between the heavier they are.  They can cause significant bleeding for the first 2-3 days and she needs to change tampons and pads every 3-4 hours in, after this is slows down and last 6-7 days.  Her periods are not painful.

She started periods around age 12 year and they have always been irregular though they are getting heavier.  She is not sexually active currently.  She is not using any contraception and has no IMB.  There are no symptoms of thyroid disease and no acne or hirsutism.  Examination reveals she her BMI is 29, some pallor but otherwise is NAD.

What investigations do you want to perform? List 6

  • Urine pregnancy test
  • FBE – Hgb
  • Iron studies
  • 21 day progesterone.
  • LH:FSH ratio
  • Androgen Studies
  • TSH
  • Prolactin
  • Pelvic USS

NB – considering her periods are also irregular, ruling out PCOS may be helpful.

Case continued: 

Her Hgb is 100 and ferritin 6. Her 21 day progesterone is low. Her other bloods and USS are normal.

What is the most likely diagnosis? List 1

  • Anovulatory dysfunctional uterine bleeding

What are the first line management options in this case? List 5

  • Oral iron supplements for iron deficiency
  • Mefenamic acid 500mg initial then 250mg qid, use throughout menses
  • Transexamic acid  1gm po QDS at onset of menstruation throughout menses
  • COCP
  • POP
  • IUCD: Mirena, 95% reduction by 1 year

What are the second line management options? List 3

  • Danazol
  • Gestrinone
  • GnRH analogues
  • Surgery – endometrial ablation or hysterectomy