Heavy Menstrual Bleeding, Its Treatment and Risk - Case Study Example

of Faculty of …….. Heavy Menstrual Bleeding, its treatment and risk Case Study of the patient of patient: Diagnosis of patient: Multiple fibroids in the intramural and sub serous walls. Differential Diagnosis: Dysfunctional Uterine Bleeding, Chronic PID, Hypothyroidism Complications: Anaemia, Uterine Obstructions ( hydronephrosis) Name of Student: Group No: Date: Heavy Menstrual Bleeding The case history of the patient indicates many details that are very useful in diagnosing and providing the adequate medical assistance to the patient. To begin with, the subject of the study is a woman who is in her late 30s, 38 years old to be precise, who has been diagnosed with fibroids located on the uterine walls mainly the intra-uterine wall having a diameter of 1x1cm and are 2 in numbers and another one located on the sub-serosal wall once again with the same diameter of 1x1 cm. Her main complaints dated two years already since she started having heavy menstrual bleeding (HMB) which is a painful in character and surged much in quantity although it still lasted for an interval of 6-8 days with a normal 28 cycles days. However, she stated that she has been making use of extra sanitary pads. She noticed no inter-menstrual bleeding, no post coital bleeding and none during sexual intercourse or after the act. She felt constantly tired and was irritated as well as stressed by some ordeals at university. Moreover, she has a family background of fibroids. There are some important factors that make her more susceptible to be attained with fibroids which are first of all her age, sex, weight, general constitution and genetics. It was noted that she has a BMI of 30.2 while in average should be in the range of 18- 25. Also the patient has a past history of thyroid disease which can also influence her general state in case that she does not take the proper dose of thyroxine as well. The fact that she smokes and takes NSAIDs at the same time can be another factor predisposed to her condition. There are several treatment options that are available for her but firstly, it would be advisable that she can visit her endocrinologist and confirm that she is on the normal dosage or alter the one in case it is not sufficient as it is also a factor. Then she should be administered with Vitamin B12 to regulate her haemoglobin level along with iron tablets. She can also follow the growth of the myomas as it can also be that it is not the fibroids that are causing the HMB even though the sub mucosal tumors contribute the most in the menorrhagia. Primary surgical procedures are normally conducted when all the conservative treatments fail to be efficient on the health of the patient and in this case, she can undergo two types of surgery either a myomectomy or a hysterectomy but laparoscopically in order to minimise the amount of infections and other risks. But since the patient is para 4 and has a normal family life, she can undergo either a complete or a partial hysterectomy as she still has the choice of keeping the reproductive functions. A myomectomy is good in cases that the person has still not procreated her family. Recently there has been another ways of effective treatment of the fibroids and it includes the destruction of the endometrium wall and the ablation of the endometrium along with embolisation of the uterine artery. There is also the hormone therapy that the patient should be administered in addition to many other drugs after her surgery. The fact remains that she is adamant that she should do it since her aunt did it and she should be informed of other methods as well and a regular follow up for the confirmation that the aetilogy of the HMB is the leiomyomas. The patient has already reached the conclusion that she would like to have an outpatient resection of the sub mucosal leiomyomas and opt for the Mirena Intra Uterine System- IUS. But she should be well advised as, while removing that one, the sub serosal ones can also be excised at the same time but the use of IUS is not a sensible decision to take as she is at the danger of undergoing a perforation of the walls of the uterine. The UK Medical Eligibility Criteria for Contraceptive Use, counsels that women who have an abnormal uterine cavity and even she will have to abide by this rule (distorted, mobile and bulky uterus). The lady was at first consulted by a general practitioner whose main responsibility consists in detecting , providing the patient about the existing methods to that would treat her.Nonetheless, she should be ausculted by a gynecologist instead of a GP as the former is a specialist in the field. She went to the GP thinking that she would have an emergent treatment and everything will be attended to within shorter time, remaining unaware of the further by a non consultant. But since she needs to file a case against her university and the hospital may delay in providing the surgery to her, she opted for the GP to carry out with the necessary. Since the patient already has made up her mind, there are several things she should bear in mind about the consequences of hysterectomy for people in her age group and category. There are short terms as well as long term risks of having undergone a hysterectomy. The short term risks include: anaemia, fever, pain at urinating, prolonged bleeding for some time, change in sexual function, and decrease in libido, infections, thrombophlebitis, pulmonary embolism and hematomas among many other diseases. Fibroids being the most common tumors among tumors do not really lead to death and its main characteristic feature is that it rarely changes from being a benign tumor to a malignant one. This means that the long term risks should exclude most probable consequences of death or malignisation. Among the prolonged effects of hysterectomy are cardiovascular diseases, it increases the risk of having cancer of other types if surgically removed in comparison to those women who have not undergone one. There can also be long term pain syndrome especially in the pelvic region and may cause a dysfunction in the motility system of the bowel without excluding a prolapse of the vagina. Thus all of them are contributing factors which may directly be lethal to the health of the patient. There is a threat to be endangered by infections and also in case that the surgeon or the GP in this case makes a mistake, he can injure the kidney which comes along with its own dangers too. Recommendations to the patient: She should have another blood test and she should not be in a rush to take such a decision about excising the fibroids as it might be that there are some other causative factors like the fact that she had hypothyroidism. She can also seek help to another doctor who will help her in confirming the fibroids and a biopsy should be done in order to know whether they are of cancerous origin or not. Also it would be better that she establish her university matters and consider them as an ordinary matter even if they are stressful as in her case, additional stress can be bad for her health. She should try to resolve the issues on very friendly ground. In case the patient has an endeavour to have another kid, then she should discuss the matter with her husband and come to a conclusion as the IUS is an indicative sign that she would definitely want to live a normal sexual life as well as be healthy. So her husband can share his point of view as well as advise her. In this era though, it is uncommon to have many kids no matter from where one comes from. Prognosis: This particular case is a bit confusing as the patient has only some signs and symptoms which mimic fibroids as well there are the confirmation from the ultrasound that they are indeed present. But it is not a reason to believe that they are those fibroids that are the real cause. She should visit a gynecologist for further advice as a GP is not in a good position to do this surgery or even prescribe her further drugs. The fact that in her aunt had had a hysterectomy does not mean that she should have one too. There are other conservative means that she should be informed about. The patient should undergo a CT scan and see that she does not have any other diseases or tumors just for differential diagnosis purposes. But in case that the fibroids diagnosis is maintained, she can have the whole uterine removed as she already has her own children. And then using the IUS comes with its own side effects mostly as compared to the benefits. After the surgery, she should also have regular check ups and see that there is a regular maintenance of all her systems. References: 1. Schwartz, S. I., & Brunicardi, F. C. (2007). Schwartzs principles of Surgery. New York: McGraw-Hill Medical. 2. Trimble, E (2006, July 1). Hysterectomy. Retrieved April 11, 2009, from http://womenshealth.gov/faq/hysterectomy.cfm 3. Wicker, P., & ONeill, J. (2006). Caring for the perioperative patient. Oxford: Blackwell Pub. 4. World Health Organization (1999). Men Ageing And Health: Achieving health across the life span. Retrieved April 12, 2009 from http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.2.pdf 5. Cuschieri, A. (2003). Clinical surgery. Malden, Mass: Blackwell Science 6. Elsevier B.V.(2007). No analgesic effect of ibuprofen or paracetamol vs placebo linkinghub.elsevier.com/retrieve/pii/S1090380197900501 7. The Mayo Clinic(2005). Uterine fibroids - www.mayoclinic.com/health/uterine- fibroids/DS00078 8. Merck Manuals Online Medical Library: The Merck Manual for Healthcare Professionals.(2009) Latest Updates: Merck Manual Home Edition   9. WHO. Medical eligibility criteria for contraceptive use(2004) www.who.int/reproductive-health/publications/mec/iuds.html 10. D Kritz-Silverstein, E Barrett-Connor, and D L Wingard (2007)- Hysterectomy, oophorectomy, and heart disease risk factor www.pubmedcentral.nih.gov/articlerender.fcgi?artid 11. Woeber K.(2007) The Effects of Hypothyroidism and Hyperthyroidism on Menstruation -www.thyroid-info.com/articles/menstruation.htm 12. Markert, R.J. (1993) The role of UK general practitioners- www.ncbi.nlm.nih.gov/pubmed Read More