A 40-year-old woman with a history of heavy irregular menses and uterine fibroids presents to the urgent care with heavy vaginal bleeding. The patient has a history of uterine fibroids and anemia. She has been seen in the ED before, where she had a blood transfusion for anemia. She was prescribed birth control pills in the past but stopped taking them after her tubal ligation was performed. A hysterectomy was recommended but the patient declined since the symptoms resolved over the last year and she remained asymptomatic until now. You do a quick assessment and her vital signs are stable. However, a pelvic examination reveals that her fibroids are up to the umbilicus and she is passing large blood clots. Which of the following treatment plans would be most appropriate for this patient?
- Refer the patient to her gynecologist to implant an LNG-IUS.
- Establish 2 large-bore peripheral IV lines for a blood transfusion and crystalloid fluids. Initiate EMS transfer.
- Refer the patient to the emergency department for abdominal and pelvic ultrasound, blood transfusion, and medical therapy.
- Use a tamponade device to stop the bleeding, then prescribe a combined OCP and naproxen.
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Answer: C. This patient presented with a long history of uterine fibroids that had been treated conservatively with hormonal therapy. You recalled that perimenopausal patients still have ovarian function, so you considered the possibility that her fibroids could have continued to grow under the influence of estrogen. Her history of anemia requiring blood transfusion was also a potential ongoing concern related to her fibroids. In addition to uterine fibroids, your differential included a gynecologic cancer of the uterus and adnexal pathology (eg, ovarian cysts or tumors). Given these concerns, you decided to refer the patient to the ED for further evaluation, including abdominal and pelvic ultrasound or CT scan of the abdomen and pelvis to assess the size of the uterine fibroids and the surrounding organs, and possible admission for blood transfusion for anemia and/or medical therapy such as progesterone or tranexamic acid. You explained this to the patient, who agreed to go to the ED.
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Last Updated on September 3, 2024
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
