Menorrhagia

The correct answer is C.

This patient has menorrhagia, likely due to an anovulatory cycle. During the first few years after menarche, it is common for women to have some anovulatory cycles and irregular menses.

During an anovulatory cycle, because no egg is released and no corpus luteum is formed, there is no progesterone production. This lack of progesterone means that the endometrium is stimulated by unopposed estrogen. This leads to a buildup of the endometrial lining and often, when the period does come, menorrhagia. The treatment for this type of bleeding is with oral contraceptive pills.

The pills, by providing estrogen and progesterone, can help to stabilize the endometrium and halt the bleeding. Because this patient is bleeding heavily and now has a significant hematocrit drop (30%), it is reasonable to provide high doses of hormones. A common method of doing this is to have the patient take three pills per day for three days, followed by 2 pills per day for three days, followed by one pill per day until the pack is finished. It is important in this case to note that pregnancy was ruled out with a negative urine hCG test. It is essential to rule out pregnancy in a young woman who presents with bleeding from the vagina.

Expectant management (choice A) would not be appropriate. This patient is losing enough blood to have dropped her hematocrit to 30%. If one does not intervene, there is the risk that the patient will continue to bleed and to drop her hematocrit even further. Patients with dysfunctional uterine bleeding such as this can lose enough blood to require a blood transfusion with the corresponding risks (e.g. infection and transfusion reaction.)

Hysteroscopy (choice B) would not be the most appropriate option. With such severe vaginal bleeding, hysteroscopy will likely not provide sufficient visualization of the endometrium. Also, hysteroscopy exposes the patient to the risks of surgery (e.g. perforation of the uterus, damage to internal organs) for a problem that can be managed effectively medically.

Laparoscopy (choice D) and laparotomy (choice E) would not be appropriate. This patient is having uterine bleeding that is most likely coming from inside the uterus (i.e. the endometrial lining). Laparoscopy and laparotomy will provide a view of only the exterior of the uterus (the serosal surface) and thus will not be an effective approach to this problem.

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