Abnormal Uterine Bleeding

Thank you for your referral of Jane Doe, a pleasant 45-year-old woman referred for evaluation of abnormal uterine bleeding. Reason for Consultation: - Jane has been experiencing heavy menstrual bleeding for the past six months, with increasing frequency and volume. History of Present Illness: - The abnormal uterine bleeding began six months ago, characterized by prolonged and heavy periods lasting up to 10 days. - Her menstrual cycles are typically 28 days, but the bleeding has become more severe over the last three months. - She reports passing large clots and changing her tampon every hour during the heaviest days. - She experiences intermenstrual spotting and postcoital bleeding. - Associated symptoms include fatigue and mild pelvic pain. - She previously tried oral contraceptives, which she discontinued due to side effects. Past Medical History: - Hypertension, diagnosed five years ago. Medications: - Lisinopril 10 mg daily. Allergies: - No known drug allergies. Surgical History: - Appendectomy at age 25, no complications. Gynecological History: - Last pap smear was two years ago, normal results. - Menarche at age 13, no history of sexually transmitted infections. Obstetrical History: - G2P2, both pregnancies were full-term with no complications. Social History: - Non-smoker, occasional alcohol use, works as a teacher. Family History: - Mother had breast cancer at age 60. Review of Systems: - Positive for fatigue and pelvic pain, otherwise unremarkable. Physical Examination: - Vital signs: BP 130/85, HR 78, BMI 26. - Pelvic exam: uterus slightly enlarged, no adnexal masses. - Pap smear taken during the visit. Investigations: - Ordered CBC and pelvic ultrasound. Assessment: - Differential diagnosis includes fibroids and endometrial hyperplasia. - Patient is at increased risk of endometrial cancer due to age and symptoms. Plan: - Scheduled for endometrial biopsy next week. - Discussed potential treatment options, including hormonal therapy. - Advised on lifestyle modifications to manage symptoms. Once again, thank you for involving me in her care.