NUR 656 Module 5 Case Study Example

Case Study: Evaluating and Managing Heavy Menstrual Bleeding in a 44-Year-Old Using PALM-COEIN

[Student Name]

Southern New Hampshire University

NUR 656: Primary Care of Women

Module Five Case Study

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Case Study: Evaluating and Managing Heavy Menstrual Bleeding in a 44-Year-Old Using PALM-COEIN

Heavy menstrual bleeding is common in women in their forties and is often dismissed as a normal part of approaching menopause. It can, however, reflect conditions ranging from fibroids and polyps to endometrial hyperplasia or cancer, and it frequently causes iron deficiency anemia that affects energy and quality of life. A systematic approach protects against both missing serious disease and overtreating benign causes. Renee, 44, came to the composite community health center because of heavy periods. This case study documents her evaluation and management using the FIGO classification system. It argues that organizing the evaluation by structural and nonstructural causes, sampling the endometrium when risk warrants and choosing treatment based on trial evidence and the patient's goals provides safe, effective care.

Presentation

Renee reports that over the past year her periods have become heavier and longer, lasting eight days, with clots the size of a quarter and flooding through a pad and tampon within an hour on the heaviest two days. She has missed work twice. Her cycles remain regular at 26 to 28 days, with no bleeding between periods or after intercourse. She feels tired and short of breath on stairs. She has no history of easy bruising, nosebleeds or bleeding after dental work, and no family history of bleeding disorders. She had two vaginal births, has had a tubal ligation and takes no medications. Her body mass index is 34. She has no symptoms of thyroid disease. She wants her bleeding controlled and prefers to avoid surgery if possible.

On examination her blood pressure is 128/80 and heart rate 94. Her conjunctivae are pale. Pelvic examination shows a normal cervix and a slightly enlarged, regular uterus without tenderness.

Organizing the Differential With PALM-COEIN

Munro et al. (2011) described the FIGO classification system for abnormal uterine bleeding in nonpregnant women of reproductive age. Its first four categories, forming PALM, are structural causes that can be seen on imaging or histology: polyps, adenomyosis, leiomyomas and malignancy or hyperplasia. The remaining five, forming COEIN, are nonstructural: coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes and causes not yet classified. The system also standardized terminology, replacing vague terms such as menorrhagia with descriptions of frequency, regularity, duration and volume, and allows more than one cause to be recorded, since many women have several.

Applied to Renee: her regular cycles make ovulatory dysfunction less likely; her negative bleeding history makes coagulopathy unlikely, though not impossible; she takes no medications that cause bleeding; and her enlarged uterus raises the possibility of leiomyomas or adenomyosis. Her age and obesity, which increases estrogen exposure, make it necessary to exclude hyperplasia or malignancy.

Evaluation

ACOG guidance on abnormal uterine bleeding in reproductive-aged women recommends a pregnancy test, a complete blood count and, depending on history, thyroid testing and screening for coagulation disorders; transvaginal ultrasound as the first imaging test when a structural cause is suspected; and a biopsy of the uterine lining as an initial step for anyone 45 or older, and for those under 45 whose estrogen has gone unopposed by progesterone for long periods, as with obesity or polycystic ovary syndrome, or whose bleeding persists or fails to respond to medical treatment (American College of Obstetricians and Gynecologists, 2012). Although Renee is 44, her obesity and persistent heavy bleeding meet criteria for sampling.

Her urine pregnancy test was negative. Her hemoglobin came back at 10.1 g/dL, her red cells were small at an MCV of 76, and ferritin was 8 ng/mL, confirming iron deficiency anemia. Thyroid-stimulating hormone was normal. Transvaginal ultrasound showed a 3 cm intramural fibroid that did not distort the uterine cavity and a normal endometrial thickness. An office endometrial biopsy showed benign proliferative endometrium without hyperplasia.

Assessment

Heavy menstrual bleeding classified as AUB-L, associated with a 3 cm intramural leiomyoma that does not distort the cavity, with possible contribution from an endometrial cause, and iron deficiency anemia. Malignancy and hyperplasia have been excluded by biopsy. The fibroid's size and location make it an unlikely sole cause, and the treatment chosen should address heavy bleeding regardless of which contributes more.

Choosing Treatment

Options discussed included the levonorgestrel IUD, tranexamic acid during menses, nonsteroidal anti-inflammatory drugs, combined hormonal contraception and progestin therapy, with referral for procedures such as endometrial ablation or hysterectomy if medical treatment fails. Combined hormonal contraception was less attractive because of her age and obesity, which raise thrombotic risk. Gupta et al. (2013) randomized 571 women with heavy menstrual bleeding in primary care to the levonorgestrel intrauterine system or usual medical treatment, including tranexamic acid, mefenamic acid, combined hormonal contraception or progestogen. Over two years, women with the IUD reported greater improvement in the effect of bleeding on their daily lives and were more likely to continue their treatment. Because her fibroid does not distort the cavity, an IUD can be placed. Renee chose the levonorgestrel IUD.

Plan and Follow-Up

The levonorgestrel 52 mg IUD was placed at a second visit. She was told that irregular spotting is common for the first three to six months and that bleeding usually decreases substantially over time. Tranexamic acid 1,300 mg three times daily for up to five days during heavy flow was prescribed as a bridge for the first cycles. Oral iron, 65 mg of elemental iron taken every other day, was started, with a repeat hemoglobin and ferritin in eight weeks. She will return in three months to assess bleeding and anemia, with referral to gynecology if bleeding remains heavy, if anemia does not improve or if the fibroid grows. She was advised to seek care for bleeding that soaks a pad every hour for more than two hours, dizziness or fainting.

Her follow-up also includes a check of symptoms that would suggest a different cause, such as new bleeding between periods or after intercourse, which would prompt repeat evaluation.

Conclusion

Renee's heavy bleeding was not simply a sign of approaching menopause. A systematic evaluation using PALM-COEIN, guided by ACOG recommendations, found iron deficiency anemia and a small fibroid and excluded endometrial hyperplasia and cancer. A levonorgestrel IUD, supported by trial evidence and chosen by the patient, together with iron replacement and follow-up, addresses both the bleeding and its consequences.

References

American College of Obstetricians and Gynecologists. (2012). Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstetrics & Gynecology, 120(1), 197-206. https://doi.org/10.1097/AOG.0b013e318262e320

Gupta, J., Kai, J., Middleton, L., Pattison, H., Gray, R., & Daniels, J. (2013). Levonorgestrel intrauterine system versus medical therapy for menorrhagia. New England Journal of Medicine, 368(2), 128-137. https://doi.org/10.1056/NEJMoa1204724

Munro, M. G., Critchley, H. O. D., Broder, M. S., & Fraser, I. S. (2011). FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology & Obstetrics, 113(1), 3-13. https://doi.org/10.1016/j.ijgo.2010.11.011