Gynaecology Note

Date: 1 November 2024 34y/o female, now with heavy and painful menstrual periods. Medical History: 34y/o female # Hypertension, well-controlled on Amlodipine 5mg OD, no target-organ-damage. Latest BP 128/76 mmHg. No recent blood tests available. # Past appendectomy in 2005, uncomplicated. # Allergies: Penicillin - anaphylaxis Gynaecological History: Menarche: 12 years old Cycle length: Irregular, 21-28 days Severity of bleeding: Heavy, requiring change of super plus tampon every 1-2 hours for 3 days; clots present. Associated with severe dysmenorrhoea. Sexually active: Yes, in a monogamous relationship, uses condoms for contraception. Gravida: 2 Parity: 2 Dyspareunia: Occasional, mild, deep dyspareunia. Personal history of malignancy: None Familial history of malignancy: Maternal aunt had ovarian cancer at age 55. Weight issues: No significant weight fluctuations, BMI 24. History of sexual trauma: Denied Presenting Complaint: Patient presents with a 6-month history of increasingly heavy and painful menstrual periods (menorrhagia and severe dysmenorrhoea). Bleeding lasts 7-8 days, with 3 days of very heavy flow. Pain is described as cramping, radiating to the back and thighs, 8/10 severity during heavy flow, partially relieved by ibuprofen. Associated with fatigue and occasional dizziness. Denies intermenstrual bleeding, post-coital bleeding, or abnormal vaginal discharge. Denies recent changes in contraception or lifestyle. Social History: Works as a primary school teacher. Lives with her partner. Does not smoke. Occasional alcohol consumption (1-2 units per week). Exercises regularly. Reports increased stress due to work. Physical Examination: BP: 125/78 mmHg HR: 72 bpm SATS: 98% on room air T: Apyrexic HGT: 5.2 mmol/L Hb: 11.5 g/dL (from recent FBC) Weight: 68 kg Height: 168 cm General appearance: Appears comfortable, alert and oriented. No pallor noted. Respiratory system: Normal chest expansion, clear breath sounds bilaterally, no adventitious sounds. Cardiovascular system: S1 S2 heard, no murmurs, rubs, or gallops. Normal peripheral pulses, no oedema. Neurological system: GCS 15, pupils equal and reactive, oriented to time, place, and person. Cranial nerves intact. Motor and sensory findings normal. Other relevant systems: Thyroid: No palpable goitre or nodules. Gynaecological Examination: Breast examination: No masses, tenderness, or nipple discharge. Symmetrical. Abdominal system: Soft, non-tender, non-distended. No palpable masses or organomegaly. Bowel sounds present. External genitalia: Normal female external genitalia, no lesions, discharge, or signs of inflammation. Internal genitalia: Speculum examination: Cervix appears healthy, no lesions or discharge. Vault clear. Bimanual examination: Uterus anteverted, normal size, smooth, mobile, mildly tender to palpation. Adnexa non-tender, no masses appreciated. Assessment: 34-year-old female presenting with menorrhagia and severe dysmenorrhoea, concerning for endometriosis or adenomyosis given the painful heavy periods and deep dyspareunia. Anaemia secondary to blood loss is possible, though current Hb is borderline. Fibroids remain in the differential. Plan: 1. Biochemistry requested: Full Blood Count (FBC), Ferritin, Thyroid Function Tests (TFTs), Coagulation screen. 2. Imaging: Pelvic ultrasound to assess for fibroids, adenomyosis, or ovarian pathology. 3. STAT medication: Not required. 4. Pharmacology: Discussed trial of Tranexamic Acid for heavy bleeding and Mefenamic Acid for pain during periods. Discussed potential for hormonal contraception (e.g., combined oral contraceptive pill or Mirena IUS) for long-term management. 5. Gynaecologist opinion or referral: Referral to Gynaecologist for further evaluation and management, especially if conservative measures are ineffective or imaging is abnormal. 6. Allied health referral: Not required at this stage. 7. Counselled on: Nature of her symptoms, potential causes (endometriosis, adenomyosis, fibroids), management options (symptomatic relief, hormonal), and importance of further investigation. 8. Follow-up instructions: Return for review of blood test and ultrasound results in 2-3 weeks. Monitor symptoms and effectiveness of new medications. Tasks to be created: Referral letter to Gynaecology. Request forms for FBC, Ferritin, TFTs, Coagulation screen, and Pelvic Ultrasound.