Case Study 1

Abigail, a 24‐year‐old female, presents to your office complaining 
that her menstrual cycles have become a problem.  They are 
now lasting 6‐7 days instead of 3‐4, and come every 30 days 
instead of every 26 days.  She has no pain, cramping, or vaginal 
Abnormal Uterine Bleeding Case Studies discharge.  She has never missed a menstrual cycle.  She has not 
been sexually active for over 6 months.  

Her past medical history is remarkable only for severe reflux 
disease for which she takes daily prilosec.

VETERANS HEALTH ADMINISTRATION

2

Q1: The information you want most from her is: Q1: The information you want most from her is:

A. How many tampons/pads she uses in a 24‐hour period A. How many tampons/pads she uses in a 24‐hour period

B. Whether or not she is passing clots B. Whether or not she is passing clots

C. Whether or not she is missing work or avoiding social  C. Whether or not she is missing work or avoiding social 
activities because of her menses activities because of her menses

D. If she has a family history of fibroids D. If she has a family history of fibroids

E. If she has a family history of PCOS E. If she has a family history of PCOS

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

3 4

Q2: The most useful set of laboratory tests to

Discussion Points order for evaluating Abigail would be:

• Tampon and pad counts are not reliable indicators of actual 
A. CBC, testosterone level, and Von Willebrand’s screen
blood loss
• Questions to ascertain the impact of the bleeding include: B. Ferritin, TSH, pregnancy test
– Does the bleeding interfere with her sex life? C. VonWillebrand’s screen, ferritin
– Does she have to leave work or class due to heavy 
bleeding? D. Urine pregnancy test, prolactin, and TSH
– Are there things she doesn’t due because of her periods? E. Ferritin, prolactin, urine pregnancy test

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

5 6

1
Q2: The most useful set of laboratory tests to
order for evaluating Abigail would be: Discussion Points

• Check hemoglobin/hematocrit for anemia and ferritin for iron 
A. CBC, testosterone level, and Von Willebrand’s screen deficiency
B. Ferritin, TSH, pregnancy test • Rule out pregnancy with a urine test
• Von Willebrand disease is the most common coagulation 
C. VonWillebrand’s screen, ferritin disorder causing menorrhagia; not usually checked unless there 
D. Urine pregnancy test, prolactin, and TSH are other signs of bleeding or in an adolescent
• Remember hypothyroidism presents with heavy menses and 
E. Ferritin, prolactin, urine pregnancy test should always be ruled out

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

7 8

Q3: The best alternative strategy for managing her

Case Study 1, continued cycles includes:

All laboratory tests return normal.  You find out that Abigail  A. Reassurance
is missing work 1‐2 days per month and is avoiding social 
activities during the first three days of her period.  She  B. Iron supplementation
adamantly refuses to consider combination hormonal  C. Tylenol during her menstrual cycles
contraception. 
D. Daily ibuprofen from the beginning of her menstrual 
cycle through the end of her menses
E. Contraception containing progesterone only

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

9 10

Q3: The best alternative strategy for managing

her cycles includes: Discussion Points

• The appropriate management depends on the patient’s 
A. Reassurance
medical history, risks, and personal choices
B. Iron supplementation • If contraception is desired, either combination contraception or 
progesterone‐only contraception would be indicated
C. Tylenol during her menstrual cycles
• If she is unable to take estrogen (i.e., clotting risk), a 
D. Daily ibuprofen from the beginning of her menstrual  progesterone‐only contraception is appropriate
cycle through the end of her menses • If a woman does not desire contraception, or doesn’t want to 
E. Contraception containing progesterone only take any hormones, NSAIDs alone may be enough

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

11 12

2
 Case Study 2 Q4. Labs that would be most helpful include:

Olivia, a 51‐year‐old female, presents to you with complaints of 
A. TSH, ferritin, and FSH
heavy menstrual bleeding.  She complains of 6 weeks of 
“bleeding all the time”.  She cannot be more specific about her  B. Urine pregnancy test, ferritin, and TSH
menstrual bleeding pattern.  She is fatigued.  On further 
questioning, she endorses increased sweating, palpitations, and  C. FSH and urine pregnancy test
insomnia.  D. FSH, LH and estradiol
E. FSH, LH, and TSH

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

13 14

Q4. Labs that would be most helpful include: Discussion Points

• Any woman with a history of abnormal menses should have a 
A. TSH, ferritin, and FSH urine pregnancy test

B. Urine pregnancy test, ferritin, and TSH • Check ferritin for iron deficiency and as a means to quantify the 
bleeding
C. FSH and urine pregnancy test
• Check TSH for hypothyroidism 
D. FSH, LH and estradiol
• In the perimenopause (which would be the case with this 
E. FSH, LH, and TSH woman), the FSH and estradiol levels fluctuate from month to 
month and would not offer any information beyond the clinical 
scenario

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

15 16

Q5. You conclude that Olivia is perimenopausal. Which of the Q5. You conclude that Olivia is perimenopausal. Which of the
following would make you MOST likely to recommend that following would make you MOST likely to recommend that
she undergo an endometrial aspirate to rule out endometrial she undergo an endometrial aspirate to rule out endometrial
carcinoma as an etiology of her erratic bleeding? carcinoma as an etiology of her erratic bleeding?

A. Her age A. Her age

B. A long history of oral contraceptive use B. A long history of oral contraceptive use

C. A history of polycystic ovarian syndrome with anovulatory  C. A history of polycystic ovarian syndrome with anovulatory 
cycles cycles

D. A history of fibroids D. A history of fibroids

E. The fact that she is obese E. The fact that she is obese

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

17 18

3
 Q6. Appropriate management for Olivia’s symptoms
of abnormal bleeding in the perimenstrual time
Discussion Points
period include all EXCEPT:
• Late consequences of Polycystic Ovarian Syndrome include 
endometrial cancer due to anovulatory cycles and prolonged  A. Combination hormonal contraception
exposure to unopposed estrogen B. Combination postmenopausal hormone therapy with 
• Age is certainly a risk factor for endometrial cancer; above 40  estradiol and medroxyprogesterone acetate
increases the risk but in this case is not the MOST worrisome 
C. Intermittent medroxyprogesterone acetate
feature
• The same is true for obesity D. Mirena IUD

• Fibroids confer no increased risk; OCP use is actually protective

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

19 20

Q6. Appropriate management for Olivia’s symptoms

of abnormal bleeding in the perimenstrual time
Discussion Points
period include all EXCEPT:
• A combined estrogen/progestin contraceptive such as the pill, 
A. Combination hormonal contraception patch, or intravaginal ring will provide enough hormone to shut 
down the ovaries and thus control the bleeding by regulating 
B. Combination postmenopausal hormone therapy with 
the cycle
estradiol and medroxyprogesterone acetate
• Hormone therapy in a patient who is still intermittently 
C. Intermittent medroxyprogesterone acetate ovulating does not suppress ovarian function; thus HT plus 
normal cycling may actually make perimenopausal bleeding 
D. Mirena IUD
worse
• Levonorgestrel (Mirena) IUD and intermittent 
medroxyprogesterone acetate will thin the uterine lining and 
thus diminish bleeding
VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION
21 22

Q7. You are considering a diagnosis of polycystic

ovarian syndrome. Which would be most helpful in
Case Study 3
making the diagnosis?

Susan, a 24‐year‐old female, presents to your office with a  A. A family history of PCOS
longstanding history of irregular menstrual cycles. She can go 
months at a time without a menstrual cycle and then will bleed  B. The knowledge that her menstrual cycles became regular on 
for 20 days.  combination hormonal contraception
C. A history of infertility
D. A history of acne and hirsutism
E. The fact that she is obese

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

23 24

4
Q7. You are considering a diagnosis of polycystic
ovarian syndrome. Which would be most helpful in
making the diagnosis? Diagnosis of PCOS

Rotterdam Criteria: Two of Three (2003)
A. A family history of PCOS
• Clinical or biochemical evidence of hyperandrogenism (so in 
B. The knowledge that her menstrual cycles became regular  this case her acne and hirsutism meet this criteria for 
on combination hormonal contraception diagnosis along with irregular menstrual cycles)

C. A history of infertility • Oligo‐ovulation or anovulation (<9 periods/year)

• Presence of polycystic ovaries on pelvic ultrasound
D. A history of acne and hirsutism
E. The fact that she is obese
NOTE:  Does NOT include obesity or insulin resistance or family 
history; everyone will regulate their menstrual cycles on OCPs

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

25 26

Q8. You make a diagnosis of PCOS in Susan based Q8. You make a diagnosis of PCOS in Susan based
on an elevated serum testosterone level. You on an elevated serum testosterone level. You
recommend: recommend:

A. Starting oral contraceptives A. Starting oral contraceptives
B. Starting metformin and oral contraceptives B. Starting metformin and oral contraceptives
C. Starting metformin alone C. Starting metformin alone
D. Starting spironolactone D. Starting spironolactone
E. Mirena IUD E. Mirena IUD

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

27 28

Discussion Points Case Study 3, continued

• Combination contraception is first‐line treatment
Susan needs contraception if she does not desire pregnancy. OCPs provide  After regulating her menstrual cycles and managing her 
endometrial protection plus contraception. OCPs also increase SHBG and thus  hirsutism, you begin thinking about Susan’s overall health and 
decrease signs of excess androgen. long‐term risks of disease.  She is about 20 pounds overweight, 
• Metformin is FDA‐approved for type 2 diabetes so first and foremost you recommend weight loss.
It has been used off‐label to treat the following in PCOS: 
– Oligomenorrhea (combination estrogen‐progestin contraceptives are first‐
line treatment)
– Obesity
– Hirsutism ‐ combination estrogen‐progestin contraceptives are first‐line 
treatment (2008 Endocrine Society Guidelines)
– Prevention of type 2 diabetes mellitus (not for women with normal glucose 
tolerance)
VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION
29 30

5
Q9. Other recommendations, at a minimum, that Q9. Other recommendations, at a minimum, that
you would make include: you would make include:

A. Fasting lipid profile A. Fasting lipid profile

B. Fasting lipid profile and a hemoglobin A1C B. Fasting lipid profile and a hemoglobin A1C

C. Fasting lipid profile and a sleep study to rule out sleep  C. Fasting lipid profile and a sleep study to rule out sleep 
apnea apnea

D. Fasting lipid profile and a pelvic ultrasound to evaluate  D. Fasting lipid profile and a pelvic ultrasound to evaluate 
endometrial lining thickness endometrial lining thickness

E. Nothing other than weight loss at this time E. Nothing other than weight loss at this time

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION

31 32

Discussion Points

• Screen all women with PCOS for the metabolic syndrome and 
diabetes, which is especially important in this patient since she 
is overweight
– Need a fasting lipid profile to screen for the metabolic 
syndrome
– Screen for diabetes with either a GTT or a hemoglobin A1C; 
a fasting glucose alone is not enough
• It’s a good idea to ask about symptoms of sleep apnea even in 
women with normal BMIs
• No need to check endometrial lining in a woman this young

VETERANS HEALTH ADMINISTRATION

33