According to Kaunitz (2014), perimenopause is the period a woman undergoes just prior to cessation of menstruation. This phase is also called as menopausal transition. The most common cause of abnormal uterine bleeding in perimenopausal women is uterine polyps, endometrial hyperplasia, cervical intraepithelial neoplasia (CIN), pelvic inflammatory disease, systemic illness or ovarian malignancy. These differentials are very overlapping therefore, meticulous examination and sound knowledge is very fundamental.
Singh et al. (2013) suggested that history and physical examination are very pivotal in ascertaining the cause of abnormal uterine bleeding because it assists in reaching to a diagnosis and then selecting the best possible treatment modality. After history and examination, a list of differential is made and then pertinent investigations are ordered which allows reaching to a definite diagnosis. Few questions that should be asked from Mrs. E. H. are the amount, frequency, pattern, regularity or irregularity of bleeding, if it is associated with intermenstrual bleeding or there is post-coital bleeding. In a perimenopausal woman, it is highly essential to differentiate between ovulatory and anovulatory cause of bleeding. Such a differentiation can be made from the history as ovulatory abnormal uterine bleeding is usually regular and is often linked with premenstrual symptoms while on the contrary, anovulatory which is more prevalent in perimenopausal women is mostly irregular, lengthy and heavy. More emphasize should be given on questions like:
Questions pertinent with anemia like blackouts, exertional dyspnea or dizziness.
Sexual history should envisage history and method of contraception, risk of infections transmitted through sex, past pregnancies and future pregnancy planning or infertility.
Other symptoms suggesting systemic illness like hypothyroidism, coagulation disorders, polycystic ovarian syndrome or adrenal disorders.
Presence of any other associated per vaginum discharge or odour.
Feeling of pelvic heaviness or pressure.
Family history of any cancer specifically endometrial, ovarian or colon cancer.
History of any current medicine use.
In Mrs. E.H. case, the orders that should be ordered are:
Complete blood count
Thyroid stimulating hormone (TSH).
Prothrombin time, bleeding time and activated partial thromboplastin time (APTT).
SGPT and assessment of liver finction.
Ultrasound scan both ovaries and lower abdomen.
Magnetic resonance imaging (MRI).
Dilatation and curettage.
General assessment should include vital signs, weight/body mass index (BMI), thyroid exam, skin exam for pallor, bruising, striae, petechiae and hirsutism, and abdominal exam for any mass and hepatosplenomegaly. Physical specific gynecological examination should include inspection of vulva, vagina, cervix, anus and urethra. Bimanual examination of uterus and adnexal structures should be done. Rectal examination to make sure the site of bleeding and rule out affiliated pathologies. History will suggest and guide in selecting the best available investigation in reaching to a diagnosis.
According to LeMone, Burke and Bauldoff (2011), interventions with abnormal uterine bleeding are centered on anxiety and sexual dysfunction. Some interventions includes discussion of test and its results with the patient, thorough information about the possible etiology of the bleeding, treatment, risk factors, prognosis, evaluation of psychosocial support and managing strategies. Mrs E.H. should be told about the likelihood of this ailment being a neoplastic process and need the removal of uterus. This may or may not be associated with adjuvant or neo-adjuvant chemo and radiotherapy. She should also be counseled regarding the complications and steps of hysterectomy and support and postoperative care.
Kaunitz, A. (2014). Abnormal uterine bleeding. Uptodate.com. Retrieved 11 July 2015, from http://www.uptodate.com/contents/abnormal-uterine-bleeding-beyond-the-basics
LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing. Upper Saddle River, N.J.: Pearson.
Singh, S., Best, C., Dunn, S., Leyland, N., & Wolfman, W. (2013). Abnormal Uterine Bleeding in Pre-Menopausal Women. Journal Of Obstetrics And Gynaecology Canada, 35(5), S7. Retrieved from http://sogc.org/wp-content/uploads/2013/07/gui292CPG1305E.pdf