Case Study Analysis – Secondary Dysmenorrhea Due to Leiomyomas

Case Study Analysis – Secondary Dysmenorrhea Due to Leiomyomas

Ann Tomlin, a 33-year-old female, presents with severe dysmenorrhea, causing significant work absences. Her symptoms include menstrual cramps, diarrhea, and fatigue, which have intensified over the past year. Physical examination reveals an enlarged, non-tender uterus. A pelvic ultrasound confirms the presence of three uterine fibroids, leading to a final diagnosis of secondary dysmenorrhea due to leiomyomas.

Main Diagnosis (ICD-10: D25.9)

Ann’s basic diagnosis is secondary dysmenorrhea due to leiomyomas (uterine fibroids). Based on the Practice Committee of the American Society for Reproductive Medicine, leiomyomas are benign growths that develop in the uterus and contribute to heavy menstrual bleeding, prolonged bleeding, and dysmenorrhea due to increased prostaglandin synthesis and uterine contractions (Wei et al., 2022). Since Ann complains of regular and painful menstruation and during the physical examination, she was found to have an enlarged uterus; these are manifestations of leiomyomas. Fibroids are more prevalent in women of childbearing age and can grow to different sizes and numbers, hence causing symptoms like those of Ann.

Differential Diagnoses

Endometriosis (ICD-10: N80.9)

Endometriosis is a pathologic condition where endometrial tissue grows ectopically and causes chronic pelvic pain, dysmenorrhea, and dyschezia. Using gendered analysis, one could observe that Ann’s symptoms of severe menstrual cramps and fatigue might be due to endometriosis. Still, lack of any pelvic pain apart from the menstrual period and normal-sized ovaries lowers the chances of this diagnosis. Also, such diseases as endometriosis are characterized by symptoms in the form of dyspareunia and chronic pelvic pain, which Ann does not complain of. Some clinical features assist in differentiating it from other similar entities, such as leiomyomas.

Adenomyosis (ICD-10: N80.0)

Adenomyosis involves the distribution of endometrial tissue within the uterine muscle and is characterized by an enlarged uterus and very painful menstruation. Ann’s enlarged, non-tender uterus and severe dysmenorrhea confirm the diagnosis of adenomyosis. Nonetheless, when fibroids are seen on ultrasound, leiomyomas are a more plausible primary diagnosis (Upson & Missmer, 2020). Adenomyosis is characterized by the involvement of the entire uterine corpus and may be associated with more vague and diffuse pelvic pain and abnormal uterine bleeding compared with the symptoms of leiomyomas.

Diagnostic Plan

To confirm the diagnosis of leiomyomas, a pelvic ultrasound was conducted, which showed three uterine fibroids. Another diagnostic test is a complete blood count (CBC) for anemia from menorrhagia; other imaging, like an MRI, can be done if required. These tests are consistent with the clinical reference for managing abnormal uterine bleeding and diagnosing pelvic masses. An MRI can provide additional imaging if the ultrasound results are not clear or if there is another possible pathology of the uterus, which may be confused with fibroids (Florence & Fatehi, 2019).

Treatment Plan

The treatment plan for Ann includes both symptomatic management and addressing the underlying cause of her dysmenorrhea.

Levonorgestrel Intrauterine Device (LNG-IUD)

The LNG-IUD is used to manage menstrual bleeding and dysmenorrhea caused by fibroids. It delivers progestin confined to the uterus, thus suppressing endometrial proliferation and lessening menstrual flow. Ann has chosen this treatment; it is efficient and not very invasive. LNG-IUD can also shrink the size of fibroids and, in general, enhance the overall well-being of the uterus, making it a long-term option for her (Bianchi et al., 2022).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

According to the American College of Obstetricians and Gynecologists, over-the-counter drugs like ibuprofen are recommended for the management of primary dysmenorrhea through the blockade of prostaglandin synthesis, which inhibits uterine contractions and, therefore, pain (Sanford et al., 2021). These are widely recommended and can be taken periodically, depending on the severity of the pain and inflammation caused by the menstrual cycle.

Iron Supplements

Since there is a high probability of iron deficiency anemia due to blood loss through menstruation, the use of iron supplements is encouraged. Close follow-up of Ann’s hemoglobin will also be required to prevent anemia, and iron administration must be adapted.

Patient Education and Follow-Up

Ann will be educated on how to use LNG-IUD and NSAIDs, the need to adhere to the treatment, and the need to report any signs of side effects. Education will also involve recommendations on how to deal with the symptoms through diet, exercise, and stress reduction techniques. An appointment will be made after six weeks to review the outcome of the treatment, and changes, if any, will be made. Subsequently, during follow-up visits, the general improvement in the quality of life and the severity of the symptoms as influenced by the treatment plan will be assessed to align with Ann’s management.

References

Bianchi, P., Guo, S.-W., Habiba, M., & Benagiano, G. (2022). Utility of the levonorgestrel-releasing intrauterine system in the treatment of abnormal uterine bleeding and dysmenorrhea: A narrative review. Journal of Clinical Medicine, 11(19), 5836. https://doi.org/10.3390/jcm11195836

Florence, A. M., & Fatehi, M. (2019, February 13). Leiomyoma. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538273/

Sanford, B. H., Labbad, G., Hersh, A. R., Heshmat, A., & Hasley, S. (2021). Leveraging American College of Obstetricians and Gynecologists Guidelines for point-of-care decision support in obstetrics. Applied Clinical Informatics, 12(04), 800–807. https://doi.org/10.1055/s-0041-1733933

Upson, K., & Missmer, S. A. (2020). Epidemiology of adenomyosis. Seminars in Reproductive Medicine, 38(02/03), pp. 089–107. https://doi.org/10.1055/s-0040-1718920

Wei, D., Legro, R. S., & Chen, Z.-J. (2022). The application of artificial intelligence in reproductive medicine: Baby steps. Fertility and Sterility, 118(1), 109–110. https://doi.org/10.1016/j.fertnstert.2022.05.002

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SUMMARY AND DETAILS:

 Ann Tomlin is a 33-year-old female with a significant history of worsening menstrual cramps over the past year, severe enough to cause missed workdays. Her menstrual cycles are regular, occurring every 29 days and lasting 6-7 days, with the most intense cramps on the second and third days, often accompanied by diarrhea and significant fatigue. Physical exam reveals slight suprapubic tenderness and an enlarged, 10-12 weeks-sized, nontender, and easily mobile uterus. Her pelvic exam was otherwise normal, with ovaries of normal size and no abnormal lesions or foul-smelling discharge present. Given her symptoms and physical findings, further evaluation is necessary to rule out underlying conditions such as uterine fibroids or adenomyosis.

 Family Medicine 32: 33-year-old with painful cycles

Ann Tomlin is a 33-year-old female presenting to an ambulatory family medicine office with several months of dysmenorrhea so severe it causes her to miss work. Differential diagnosis includes fibroids, endometriosis, and adenomyosis. On a gynecologic exam, she has an enlarged, mobile, non-tender uterus. Pelvic ultrasound shows three uterine fibroids. Discussion of therapeutic options including long-acting reversible contraception (LARC) options occurs. She opts to have a levonorgestrel intrauterine device placed for symptomatic treatment.

• Differential diagnosis: Adenomyosis, cervical stenosis, chronic pelvic

inflammatory disease, endometriosis, leiomyoma (fibroids), inflammatory bowel disease, irritable bowel syndrome, ovarian cysts, mental health condition, uterine polyps, primary dysmenorrhea, endometrial adenocarcinoma, endometrial hyperplasia, leiomyosarcoma

• Final diagnosis: Secondary dysmenorrhea due to leiomyomas

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