What is the diagnosis and recommended treatment for a 22-year-old female patient with a 3-week history of pelvic and abdominal pain, irregular menstruation, and spotting, with a normal Transvaginal Ultrasound (TVUS) result?

Diagnosis: Abnormal Uterine Bleeding (AUB) - Anovulatory Type

For this 22-year-old female with prolonged irregular menstruation, pelvic pain, and normal transvaginal ultrasound, the diagnosis is Abnormal Uterine Bleeding (AUB) secondary to anovulatory cycles, and first-line treatment consists of combined oral contraceptives or cyclic progestins to regulate menstrual cycles and control bleeding. 1

Medical Assessment

Diagnosis Confirmation

• Anovulatory AUB is the most likely diagnosis given the patient's age, prolonged irregular bleeding pattern (1 month of on-and-off menstruation with spotting), and normal transvaginal ultrasound excluding structural pathology 2
• The normal TVS effectively rules out endometrial polyps, leiomyomas, adenomyosis, and other structural causes that would require different management 2, 3
• At 22 years old, endometrial sampling is NOT indicated as endometrial cancer risk is negligible in this age group without risk factors 1

Clinical Reasoning

• Anovulatory cycles are common in reproductive-age women and present with irregular, prolonged bleeding patterns exactly as described 1
• The pelvic pain (dysmenorrhea) is consistent with prolonged menstrual bleeding and uterine cramping 1
• Normal ovarian appearance on ultrasound supports functional ovulatory dysfunction rather than structural pathology 2

Treatment Plan

First-Line Medication (PhilHealth Konsulta Formulary)

Tranexamic Acid 500mg

• Dosing: 1 tablet three times daily (TID) during heavy bleeding days
• Dispense: 30 tablets
• Duration: Take during menstruation only, up to 5 days per cycle
• Cost: Approximately ₱150-200 for 30 tablets
• Mechanism: Reduces menstrual blood loss by 40-50% through antifibrinolytic action 1

Mefenamic Acid 500mg

• Dosing: 1 tablet three times daily (TID) with food during menstruation
• Dispense: 15 tablets
• Duration: During menstrual bleeding and cramping, maximum 5 days
• Cost: Approximately ₱50-80 for 15 tablets
• Mechanism: Reduces menstrual blood loss by 20-30% and provides pain relief 1

Total medication cost: Approximately ₱200-280 (within ₱300 budget)

Hormonal Regulation (If Available in Formulary)

• If combined oral contraceptives or cyclic progestins are available in PhilHealth Konsulta formulary, these should be added for cycle regulation 1
• Levonorgestrel IUD would be ideal long-term management but requires separate procedure 4, 1

Recommendations

Immediate Management

• Start tranexamic acid and mefenamic acid during current bleeding episode 1
• Monitor hemoglobin if heavy bleeding continues (check for anemia) 1
• Expectant management is reasonable if bleeding improves with symptomatic treatment 1

Follow-up Plan

• Return in 2-4 weeks to assess treatment response 4
• If bleeding persists beyond 3 months or worsens, consider hormonal therapy (combined oral contraceptives or cyclic progestins) 1
• Repeat TVS only if new symptoms develop or bleeding pattern significantly changes 2

Red Flags Requiring Urgent Re-evaluation

• Soaking through pad/tampon every 1-2 hours
• Dizziness, weakness, or signs of severe anemia
• Fever (suggesting infection)
• Severe abdominal pain (suggesting other pathology)

Patient Education

Explanation of Condition: Ang iyong irregular menstruation ay sanhi ng hindi regular na ovulation (paglabas ng itlog mula sa ovary). Ito ay normal na nangyayari sa mga kabataang babae at karaniwang hindi seryoso. Ang normal na ultrasound ay nagpapakita na walang tumor, polyps, o iba pang structural na problema sa iyong matres. Ang gamot na ibibigay ay makakatulong na bawasan ang bleeding at sakit habang naghihintay na mag-regular ang iyong menstruation.

Ang prolonged bleeding ay maaaring magdulot ng anemia (kakulangan sa dugo), kaya mahalaga na kumain ng iron-rich foods (liver, green leafy vegetables, red meat) at bumalik para sa follow-up.

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Medical Certificate

This certifies that patient has been seen and examined today with the diagnosis of: Abnormal Uterine Bleeding (AUB) - Anovulatory Type

And recommendation of: Symptomatic treatment with tranexamic acid and mefenamic acid during menstruation, iron supplementation, and follow-up in 2-4 weeks for reassessment. Patient may continue regular activities but should avoid strenuous physical exertion during heavy bleeding days.

This medical certificate is issued upon the request of the patient for: whatever purpose it may serve.