Abnormal bleeds needed checking

A patient attends with abnormal vaginal bleeding and abdominal pains. Dr Barney Tinsley explains

A 38-year-old woman presented with abnormal vaginal bleeding while taking a low-dose combined Pill.

These bleeds occurred 14–21 days into her cycle, were much heavier than her normal withdrawal bleed and included some very small clots. She described dragging, cramping pains in her lower abdomen during the bleeds.

A cervical smear was normal. There was no dyspareunia or post-coital bleeding. Her mother had had a hysterectomy for fibroids and endometriosis.

Examination revealed a soft abdomen with no guarding or rebound and no palpable masses. The cervix felt normal and cervical excitation was present.

There were no palpable adnexal masses, but the uterosacral ligaments were tender to touch. An ultrasound revealed a slightly bulky anteverted uterus with several intramural fibroids noted throughout the myometrium. Endometrial thickness was normal at 2mm. Normal ovaries and no adnexal masses or free fluid.

There was no evidence of cystic lesions within either ovary. Her swabs came back negative and her blood tests were normal.

Five weeks after her initial attendance and investigations, she was changed to a different Pill in the hope of normalising her menstrual bleeding.

Increasing pain
Unfortunately she re-attended four weeks later, with increasing abdominal pains and blood loss.

She also reported burning pain on moving her bowels, but no overall change in bowel habit. She had no urinary symptoms at this time and urinalysis was negative. She was sent for an urgent gynaecological referral. During the next three weeks she felt profoundly lethargic, and had two episodes of collapse.
Her blood tests remained completely normal. Urgent hysteroscopy and laparoscopy revealed endometriosis across the pouch of Douglas, with the left utero-sacral ligament thickened and enlarged, and pulled across the uterus in retroversion.

There was some tethering of the left ovary in relation to this, but otherwise her ovaries and fallopian tubes were free, and there was no endometriosis in the utero-vesical pouch.

The endometriosis spots in the pouch of Douglas were treated by diathermy and she is currently receiving monthly gonadorelin analogue injections to down-regulate GnRH receptors. She is continuing her course of the gonadorelin analogue for six months under her gynaecological consultant supervision. Hysteroscopy was reported as normal. Since treatment, the patient’s pain has lessened dramatically, and her vaginal bleeding stopped.

Endometriosis is a common disorder characterised by endometrial glands and stroma outside of the endometrial cavity, with a variable amount of fibrosis and bleeding. The endometriotic deposits may be out of phase with the woman’s menstrual cycle.

Classically, it is found in women in their thirties and forties and occurs most frequently in Caucasians. Endometriosis is important because of its distressing symptoms, association with infertility and the potential for invasion of the gastrointestinal and urinary tracts, although it is regarded as benign.

Severe endometriosis can  reduce fertility to 35 per cent with the chance of conception greatest in the two years following surgery.

Effective surgical intervention can limit endometriosis recurrence rates to less than 20 per cent. Endometriosis should be considered as an underlying diagnosis in cases of painful abnormal vaginal bleeding not controlled by the Pill.

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