A 26-year-old P0 with PCOS presents to the emergency department with a chief complaint of prolonged, heavy vaginal bleeding. She was taking oral contraceptives to regulate her periods until 4 months ago, when she stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. Her bleeding has been very heavy, requiring her to double up on her sanitary napkins and change them five to six times daily since the bleeding began. In the emergency department, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her blood pressure while standing is 108/66 mm Hg with an increase in her pulse to 126 beats per minute. While you wait for laboratory work to come back, you order intravenous hydration. After 2 hours, she is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. A transvaginal ultrasound showed an atrophic appearing endometrial stripe.
Which of the following is the best next step in the management of this patient?
This patient is having bleeding due to ovulatory dysfunction related to PCOS. The transvaginal ultrasound helps direct the next step in the care of this patient. Her endometrial stripe is thin, suggesting that she has shed her endometrium to its basalis layer. Women who have experienced acute heavy bleeding and have an atrophic endometrium should be treated with 25 mg of conjugated estrogen every 4 hours until the bleeding subsides. Estrogen will help stop the bleeding by rebuilding the endometrium and stimulating clotting at the capillary level. Since this patient’s bleeding is due to an atrophic endometrium, estrogen therapy is the preferred treatment. Had the transvaginal ultrasound shown a thickened endometrial stripe, hysteroscopy and D&C would be an option to stop the bleeding more rapidly than medical treatment. In older women, a D&C might be helpful in obtaining tissue for pathology to rule out endometrial hyperplasia or cancer. In this young patient who is resuscitated and stabilized with intravenous fluids, there is no indication for a blood transfusion as long as the bleeding abates. Iron therapy alone would not be adequate for this patient; the bleeding must be stopped first. Antiprostaglandins have no role in curtailing hemorrhage in a woman bleeding due to anovulation. They have been used with some success in ovulatory women who have heavy cycles, or in women with menorrhagia caused by use of the IUD. It is thought that prostaglandin synthetase inhibitors reduce the amount of bleeding by promoting vasoconstriction and platelet aggregation.
A 29-year-old P0 presents to your office with a chief complaint of symptoms of premenstrual syndrome (PMS). A detailed history reveals that she experiences emotional lability and depression for about 10 days prior to her menses. Once her period starts, she feels “back to normal.” She also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous physician prescribed oral contraceptives to treat her PMS 6 months ago, and she reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms.
Which of the following is the best next step in the treatment of this patient’s problem?
PMS is a constellation of physical, emotional, and behavioral symptoms that occur in a cyclic pattern, always in the same phase of the menstrual cycle. These symptoms usually occur 7 to 10 days before the onset of menses, and are relieved at some point following the onset of menses. Examples of symptoms include edema, mood swings, depression, irritability, breast tenderness, increased appetite, and cravings for sweets. The etiology is unclear. Selective serotonin reuptake inhibitors (SSRIs) are safe, well tolerated, and are considered first line therapy for PMS. For those who don’t respond or cannot tolerate SSRIs, other therapies include oral contraceptives, GnRH agonists (with add-back estrogen/progesterone therapy), alprazolam, and aerobic exercise. Progesterone, diet modification, and vitamins have not been proven to be beneficial. The only medications that have been shown in randomized, double-blind, placebo-controlled trials to be consistently effective in treating the emotional symptoms of PMS are the SSRIs such as fluoxetine. Some women can be effectively treated by limiting use of the medication to the luteal phase.
A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; and she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning HRT, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She has no medical problems, and the only medication she takes are calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb.
In counseling this patient regarding the risks and benefits of HRT, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?
The Women’s Health Initiative helped establish that the use of ERT/HRT increases the user’s risk of a thromboembolic event two to threefold. The use of combined HRT does not increase the risk of uterine cancer, colon cancer, melanoma, or Alzheimer disease. There is much literature that indicates that HRT reduces the risk of both colon cancer and Alzheimer disease. Estrogen use has a proven beneficial effect on serum lipid concentration. It decreases total cholesterol and LDL and increases HDL and triglycerides.
The hot flush is the first physical symptom of declining ovarian function. More than 95% of perimenopausal/menopausal women experience these vasomotor symptoms. Hot flushes may begin several years before the cessation of menstruation. When a woman experiences a hot flush, she typically feels a sudden sensation of heat over the chest and face that lasts between 1 and 2 minutes, followed by a sensation of cooling or a cold sweat. The entire hot flush lasts about 3 minutes total. Estrogen therapy will usually cause resolution of the hot flush within 3 to 6 weeks. Without estrogen therapy, hot flushes on average resolve spontaneously within 2 to 3 years after cessation of menstruation. Although hot flushes are normal, they may interfere with a woman’s sleep, causing significant interference with her sense of well-being. Psychological symptoms during the climacteric occur at a time when much is changing in a woman’s life. Steroid hormone levels are dropping, and the menses is stopping. However, studies show these two factors to be unrelated to emotional symptoms in most women. Many factors, such as hormonal, environmental, and psychiatric elements, combine to cause the symptoms of the climacteric such as insomnia; vasomotor instability (hot flushes, hot flashes); emotional lability; and genital tract atrophy with vulvar, vaginal, and urinary symptoms.
She tells you she is worried about how HRT might impact her lipid panel. You should counsel her to expect which of the following?
The patient asks you what she should expect in regard to her hot flushes if she does not take hormone replacement. How should you counsel her?
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