What are the next steps in managing dysfunctional uterine bleeding and a hemorrhagic ovarian cyst in a 29-year-old female with persistent daily vaginal bleeding for 53 days, currently taking Skelaxin (cyclobenzaprine) and previously taking Meloxicam (meloxicam), with a history of fibromyalgia, inflammatory arthritis of the sacroiliac (SI) joints, migraines with aura, anxiety/depression, and Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

For a patient with dysfunctional uterine bleeding and a hemorrhagic ovarian cyst who has been bleeding for 53 days, I strongly recommend a comprehensive management plan while waiting for the OBGYN appointment on June 27th, prioritizing the patient's morbidity, mortality, and quality of life. The patient's history of fibromyalgia, inflammatory arthritis of SI joints, migraines with aura, anxiety/depression, and ADHD should be considered when developing the management plan. Given the prolonged bleeding, a repeat complete blood count (CBC) is necessary to monitor for anemia, and a follow-up pelvic ultrasound may be beneficial to reassess the hemorrhagic cyst and evaluate the 3mm hyperechoic focus in the endometrial stripe noted on the previous ultrasound, as suggested by 1. For symptom management, hormonal therapy such as medroxyprogesterone acetate (Provera) 10mg daily for 10 days can help stop the bleeding by stabilizing the endometrial lining, as recommended by 1. Alternatively, a combined oral contraceptive pill can be prescribed to regulate bleeding, as suggested by 1 and 1. For pain management, ibuprofen 600mg every 6 hours (if not contraindicated) can help reduce both pain and menstrual flow, as recommended by 1 and 1. The patient should monitor for signs of severe anemia (dizziness, shortness of breath, extreme fatigue) or acute hemorrhage (soaking through a pad per hour for 2+ consecutive hours) which would warrant immediate medical attention. Iron supplementation with ferrous sulfate 325mg daily may be appropriate if anemia is present, as it is a common complication of prolonged bleeding. Dysfunctional uterine bleeding often results from hormonal imbalances causing irregular shedding of the endometrial lining, while hemorrhagic cysts typically resolve spontaneously but can cause pain and irregular bleeding in the interim, as noted in 1 and 1.

Some key points to consider in the management plan include:

• Monitoring for anemia and acute hemorrhage
• Symptom management with hormonal therapy and pain management
• Iron supplementation if anemia is present
• Follow-up pelvic ultrasound to reassess the hemorrhagic cyst and evaluate the endometrial stripe
• Consideration of the patient's medical history, including fibromyalgia, inflammatory arthritis, migraines, anxiety/depression, and ADHD.

Overall, the management plan should prioritize the patient's morbidity, mortality, and quality of life, and be guided by the most recent and highest quality evidence, including 1, 1, and 1.

From the Research

Top 3 Questions for the Visit

• Q1. Do I need any tests before I see the obgyn?
  • According to 2, the management of menorrhagia should include the exclusion of pathology in the genital tract.
  • Given the patient's history of dysfunctional uterine bleeding and a hemorrhagic ovarian cyst, it may be necessary to conduct further tests, such as a CBC or CMP, to rule out any underlying conditions that may be contributing to the bleeding.
• Q2. What can I do to manage this problem while I wait for my appointment?
  • 3 suggests that the goals of treatment for anovulatory bleeding are to stop the acute bleeding, avert future episodes, and prevent long-term complications.
  • Medical treatments, such as nonsteroidal anti-inflammatory drugs or oral contraceptive pills, may be effective in managing the symptoms of dysfunctional uterine bleeding, as noted in 4 and 5.
  • Additionally, reducing activity during days of heavy flow and avoiding aspirin in the week before and on days of flow may also be helpful, as suggested in 2.
• Q3. Next steps in management
  • 6 recommends that patients with abnormal uterine bleeding receive a comprehensive history and physical, including a pelvic examination and speculum and bimanual components.
  • The patient's treatment plan may involve medical treatments, such as levonorgestrel intrauterine devices or oral contraceptive pills, or surgical treatment options, such as endometrial ablation or hysterectomy, as noted in 6.

Management of Dysfunctional Uterine Bleeding

• The patient's history of fibromyalgia, inflammatory arthritis of SI joints, migraines with aura, anxiety/depression, and ADHD should be taken into consideration when developing a treatment plan, as these conditions may impact the patient's overall health and response to treatment.
• As noted in 2, cycle regulation can be affected by monthly courses of progestin, such as medroxyprogesterone acetate (Provera), 10 mg daily for 10 days each month.
• The patient's persistent daily vaginal bleeding for 53 days and associated suprapubic pain should be addressed through a comprehensive treatment plan that takes into account the patient's medical history and current symptoms.