This week, as you continue exploring common gynecologic conditions, you consider diagnosis, treatment, and management strategies for patients. You also explore ways to educate patients on these conditions.

Learning Objectives – NURS 6551: Week 5: Case Study: Patient with Prolonged Menstrual Bleeding

By the end of this week, students will:

• Assess patients with common gynecologic conditions
• Evaluate differential diagnoses for common gynecologic conditions
• Analyze treatment and management plans for patients with common gynecologic conditions
• Analyze strategies for educating patients on the treatment and management of common gynecologic conditions
• Understand and apply key terms, principles, and concepts related to common gynecologic conditions
• Evaluate common gynecologic conditions in patients
• Analyze treatment modalities for common gynecologic conditions

Learning Resources 

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.

• • Chapter 24, “Normal and Abnormal Uterine Bleeding” (pp. 575-599)

This chapter differentiates normal uterine bleeding from abnormal and dysfunctional uterine bleeding. It also examines causes of abnormal bleeding and identifies assessment strategies for diagnosing and managing these conditions.

• • Chapter 25, “Hyperandrogenic Disorders” (pp. 603-618)

This chapter explores the etiology, clinical presentation, and impact of hyperandrogenic disorders. It also provides strategies for assessing, diagnosing, and managing patients with these conditions, including adolescents and pregnant women.

• • Chapter 26, “Benign Gynecologic Conditions” (pp. 621-652)

This chapter explains the incidence, presentation, assessment, and management of common benign gynecologic conditions. It also explores differential diagnoses for these conditions and types of treatment options.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.

• • Chapter 7, “Care of the Woman with Reproductive Health Conditions”

• • • “Care of the Woman with Amenorrhea” (pp. 372-376)

This section differentiates between primary and secondary amenorrhea and describes treatment options for managing patients with this condition.

• • • “Care of the Woman with Abnormal Uterine Bleeding” (pp. 368-372)

This section explains the causes of dysfunctional uterine bleeding and recommends treatment options for managing this condition.

• • • “Care of the Woman with Endometriosis” (pp. 395-398)

This section identifies the prevalence of endometriosis in women. It also provides strategies for diagnosing, treating, and managing patients with this condition.

• • • “Care of the Woman with Fibroids” (pp. 398-401)

This section describes the classification of fibroids and their prevalence in women of childbearing age. It also presents methods for identifying, diagnosing, and treating this common benign tumor.

• • • “Care of the Woman with Polycystic Ovarian Syndrome” (pp. 433-437)

This section identifies the criteria for a polycystic ovarian syndrome diagnosis. It also presents treatment options for this disorder, including therapeutic options and alternative measures.

Optional Resources – NURS 6551: Week 5: Case Study: Patient with Prolonged Menstrual Bleeding

Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved from http://www.cdc.gov/women/

National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved from http://orwh.od.nih.gov/

U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/

Discussion: Diagnosing and Managing Gynecologic Conditions

Gynecologic conditions can be difficult to diagnose for a variety of reasons, including overlapping symptoms, lack of patient knowledge, or even patient fear or embarrassment about sharing information. Your role provides you the opportunity to develop a relationship of trust and understanding with these patients so that you can gather the appropriate details related to medical history and current symptoms. When caring for this patient population, it is important to make these women an integral part of the process and work collaboratively with them to diagnose and develop treatment and management plans that will meet their individual needs. For this Discussion, consider diagnosis, treatment, and management strategies for the patients in the following four case studies:

Case Study 1:A 32-year-old African American female is concerned about increasing dysmenorrhea over the past three years. In the past year, this was associated with painful intercourse. She has been in a monogamous relationship with one male partner for the past five years. They tried to have children without success. Menarche was at age 10; menstrual cycles are 21 days apart and last for 6–7 days. The first day of her last menstrual period was 10 days ago and was normal. She denies vaginal itching or discharge. On gynecologic exam there was no swelling, external lesions, or erythema, urethral swelling, or vaginal discharge. Cervix is pink without lesions or discharge. Uterus was small, retroverted, and non-tender. Adnexa were small and non-tender. Nodules are noted along the cul de sac.

Case Study 2:

A 42-year-old African American female is in the clinic for a routine gynecologic exam. When asked, she admits to noticing bleeding in between her menstrual periods for the past several months. She has been pregnant three times and has three children. She is sexually active with one male sex partner in a monogamous relationship. During her bimanual exam, you note an irregular intrauterine non-tender mass about 4 cm in diameter. The mass is palpable abdominally. The remainder of her gynecologic exam was normal.

Case Study 3:

A 48-year-old Caucasian female is in the clinic concerned about prolonged menstrual bleeding for three weeks now. Her prior menstrual periods have been irregular for the past eight months, lasting no more than three days each. There have been one to two months when she had no menstrual cycles at all. She reports occasional hot flushes and mood swings.

Case Study 4:

A 16-year-old Caucasian female comes to the clinic concerned because she has not had a menstrual period for three months. She’s a junior in high school and active in sports. She has lost about 10 lbs. in the past two months. She is currently 5 ft. 4 in. and weighs 100 lbs.

To prepare:

• Review Chapter 26 of the Schuiling and Likis text and Chapter 7 of the Tharpe et al. text.
• Review and select one of the four provided case studies. Analyze the patient information.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or nonpharmacologic treatments.
• Consider strategies for educating patients on the treatment and management of the sexually transmitted infection you identified as your primary diagnosis.

By Day 3

Post an explanation of the differential diagnosis for the patient in the case study you selected. Provide a minimum of three possible diagnoses and list them from highest priority to lowest priority. Explain which is the most likely diagnosis for the patient and why. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments. Finally, explain strategies for educating patients on the disorder.

Read a selection of your colleagues’ responses.

By Day 6 Case Study: Patient with Prolonged Menstrual Bleeding

Respond to at least two of your colleagues on two different days in both of the ways listed below. Respond to colleagues who selected different case studies than you did.

• Explain how missing information from the patient history might change the diagnoses for the patients in the case studies your colleagues selected.
• Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or contrasting perspectives.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! NURS 6551: Week 5: Case Study: Patient with Prolonged Menstrual Bleeding.

ADDITIONAL INFORMATION;

Prolonged Menstrual Bleeding

Introduction

Prolonged menstrual bleeding (PMB) is when the cervix does not completely close in a normal fashion after you have your period. This can lead to spotting and bleeding for 2-4 weeks after your period ends. PMB isn’t dangerous, but it can be uncomfortable, and it may affect how effective your contraception is.

In most cases, PMB is caused by an anatomical problem with the uterus or fallopian tubes that requires surgery or other treatment. In some cases of prolonged menstrual bleeding (more common among teenage girls), there are no clear underlying causes that can be identified without further testing.

Appearance

When your menstrual bleeding lasts longer than two weeks, you may experience a number of symptoms. These include:

• Dark red or black blood

• Coagulated (sticky) blood clots

• Blood mixed with mucus and tissue (called menstrual discharge)

• Blood mixed with pus or other fluids that can be found in the vagina (also called purpura).

Frequency

Frequent and heavy bleeding is a common symptom of many conditions, including hormonal imbalances, endometriosis and fibroids.

Frequent bleeding can refer to any menstrual period lasting five or more days, while heavy bleeding refers to periods lasting longer than 7 days. Your doctor will be able to determine if you have frequent or heavy menstrual bleeding based on your age and medical history.

Duration

In general, menstrual bleeding lasts between two and five days. The length of your period depends on how long it takes for the lining of your uterus to break down (called menstruation). It’s normal for this to take two weeks or longer.

If you have blood loss that lasts more than seven days, talk to your doctor right away because it could be a sign of a medical problem like pregnancy or anemia.

Age

Age is not a factor in determining cause of prolonged menstrual bleeding. However, older women are more likely to have longer cycles and therefore may experience bleeding issues that result from the length of their cycle.

Medical History

• Ask about current medications. Does she take any prescription or over-the-counter medications? If so, check the ingredient list and make sure that none of them contain synthetic hormones.

• Ask about past medical history. Did she have a previous pregnancy or birth that ended in miscarriage, stillbirth or other major complication? Did she experience any complications during her last delivery (such as preterm labor)? Is there any history of chronic illness (including heart disease) in either parent’s family tree?

• Ask about past pregnancies. Has she had any spontaneous abortions (miscarriage) during previous pregnancies? Has she had any prior Caesarean sections that required stitches; if so, how many stitches were there and what type were they made from (i.e., surgical cloth thread versus dental floss).

If this is an older woman who has been diagnosed with PCOS then ask whether she has ever had any surgery on her uterus because this might explain why menstruation cycles are so irregular but it could also be related to endometriosis which would require further testing before making conclusions based off symptoms alone.”

Menstrual History

The menstrual history is an important part of your overall health. It can help you identify any conditions that may be contributing to prolonged bleeding and also determine if there are any other risks associated with it, such as pregnancy.

If you have a long-term history of prolonged bleeding, make sure that this is not due to another condition (like endometriosis or uterine fibroids) before making any changes to your medication regimen.

Lifestyle and Habits

Lifestyle and habits can affect menstrual bleeding.

• Exercise: If you exercise regularly, your body may produce more blood flow to the uterus during menstruation. This extra blood flow helps with the healing process of your period or cramps by bringing extra nutrients and oxygen to areas that need it most.

• Smoking: Smoking increases the risk of uterine fibroids, which are benign tumors in or around the uterus that cause heavy periods and painful cramps. Smoking also reduces fertility because it causes problems with sperm production (testosterone levels).

Medication History

A thorough drug history, including all medications and supplements you’ve taken in the past year, is essential to your diagnosis. The following list includes some of the most common causes of prolonged menstrual bleeding:

• Birth control pills: birth control pills can cause amenorrhea (the absence of a period). They also may interfere with ovulation by inhibiting progesterone production. If you have been taking birth control pills for more than three years and still haven’t gotten pregnant, talk to your doctor about switching to another method until this problem clears up.

• Medications used for depression or anxiety medications such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), citalopram (Celexa), duloxetine (Cymbalta) and venlafaxine ER can cause prolonged bleeding by suppressing ovulation or delaying menstruation altogether.* Medications used for heart disease medications like digoxin, disopyramide and warfarin may prevent ovulation by interfering with thyroid function.* Other medications that affect hormone levels include birth control pills; hormone replacement therapy; antidepressants such as SSRI’s; beta blockers/ACE inhibitors such as metoprolol succinate & enalapril maleate; antihistamines such as hydroxyzine

Expected Course

The majority of women with prolonged menstrual bleeding are diagnosed with a benign condition. If bleeding is severe and not controlled with medication, surgery may be needed to remove the uterus (hysterectomy).

If the cause is not identified, it’s important to follow up with a doctor who specializes in women’s health concerns.

Conclusion

Prolonged menstrual bleeding is not uncommon and often requires clinical assessment to determine cause. If you are experiencing prolonged heavy menstrual bleeding, contact your healthcare provider as soon as possible.