Re: Daily bleeding, fibroids
From: Joe Cutchin (forcep@shore.intercom.net)
Wed Feb 28 19:24:15 2001
Caitlin Cusack MD wrote:
> Yesterday I inherited a patient who is extremely attached to her uterus.
> She is a 50 y/o who had a myomectomy about 7 years ago. She came in for
> a 'routine annual' and tells me she has bled everyday since her
> myomectomy-approximately once a month she will bleed very heavily with
> clots, and then returns to her baseline of daily bleeding, heavy enough
> to need a pad. In reviewing her chart someone did a CA-125 a year ago
> that was 40. (ordered because a grandmother died of ovarian cancer-just
> explaining, not defending...). It was repeated 2 more times and was
> above 35 each time. She had an u/s which showed a large uterus and
> bilateral small simple cysts, the largest being 1.5 cm, endometrial
> lining of 10mm. She was referred to a gyn oncologist who recommended a
> hysterectomy-she did not follow up after this until she showed up on my
> schedule.
> On exam she indeed has a bloody discharge in her vault. She has a 16
> week size uterus. The cervix is deflected up behind her symphasis, her
> posterior cul-de-sac is filled with fiboid. In order to do a pap I got
> a tenaculum on the underside of her cervix to bring the cervix down
> enough to do a pap-a huge struggle (I think I was standing on my head by
> the time I finally got it). Her virginal introitus did not help. I
> wanted to do an endo. bx but could not manipulate the pipelle to the
> angle needed to get into the uterus.
> I'm very uneasy with this patient. I've ordered an FSH to see if this
> might be post-menopausal bleeding, a repeat u/s to re-evaluate her
> ovaries and her endometrium. She feels this is all too much-that she
> has bled every day for 7 years and 'this is normal for me and is due to
> my myomectomy'. Of course the right thing to do is a hyst-but she
> adamently refuses. Any suggestions? Has anyone ever had a patient that
> bled secondary to a myomectomy? Should I put her on progesterone and see
> if I can at least cycle her (assuming her FSH shows she is still
> pre-menopausal)? Should I insist on taking her to the OR to try and do a
> D&C? Not sure this will be possible even if cut her hymen given the
> sharp angle of her cervix. Very frustrating to be taking care of a
> patient who really doesn't want us to take care of her.
>
> --
> C. Cusack MD
Do no harm.You abide by the patient's wishes.Unfortunately due to our legal
system you will spend more time creating on paper your defense in following
the patient's wishes.
--
Joseph H. Cutchin MD FACOG 4105463125
314 West Carroll Street 4105463128 Fax
Salisbury,Maryland 21801
http://www.penobgyn.com
