CCS Interactive Case 23

Question 1

16 y/o F, presents to office, irregular and heavy menstrual bleeding. Menses regular since age 13 until 2 months prior to presentation. Sexually active, no systemic symptoms, HDS.

Ddx?

Answer 1

Dysfunctional uterine bleeding (2/2 anovulation, unopposed stimulation of endometrial lining by estrogen, 2/2 immature HPO axis)

DDx - pregnancy, reproductive tract problems (leiomyoma, adenomyosis, endometriosis, PID), endocrine disease (hypothyroid/hyperthyroid, hyperprolactinemia), coagulation disorders

Question 2

Exam

Answer 2

Complete w/pelvic

Question 3

No abnormalities on exam

Orders?

Answer 3

Pregnancy test
TSH
Prolactin
CBC
PT/PTT

[Other tests for select patients - endometrial biopsy if perimenopausal, pelvic ultrasound for suspected PCOS or ovarian tumor, or suboptiaml pelvic exam 2/2 obesity, LFTs if at risk)

Question 4

Mild anemia on CBC

Rx?

Answer 4

Mild DUB (normal Hgb) - iron supplementation alone
Moderate DUB (Hgb = 10-12) - iron supplementation, progestin-only OCPs (preferred if absence of active bleeding), combination OCPs (preferred if active bleeding)
Severe DUB (Hgb <10) - depending on severity, hospitalization and transfusion, hormonal therapy - combination OCPs w/high estrogen if stable; IV estrogen if unstable (D&C and/or surgery are rarely necessary)

Question 5

Sequence?

Answer 5

Complete exam
Order - urinary HCG, CBC, TSH, Prl, PT/INR, PTT
Location - send home, schedule appt in 1 week, labs result WNL except anemia
Patient arrives for f/u
Order - OCP, low estrogen, low progsterone, iron sulfate, counseling (med compliance, safe sex, regular exercise, seat belt use)
Location - send home, schedule appt in 3 months, case ends
Final orders - none
Primary dx - dysfunctional uterine bleeding