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Problem representation

Progressively worsening bleeding associated with periods in a young woman.

Hypothesis generation

Abnormal uterine bleeding can be defined as bleeding from the uterus that is longer than usual or that occurs at an irregular time. Bleeding may be heavier or lighter than usual and occur often or randomly.

Abnormal bleeding can be considered structural (e.g. polyps, malignancy) or non-structural (e.g. coagulopathy, ovulatory dysfunction). The age of the patient should have a bearing on your hypothesis generation. In older women – perimenopausal or postmenopausal – malignancy should always be considered.

In young women, coagulopathy is most common. For Maria, you need to consider the following as the likely causes of her symptoms:

Likely diagnosis 

  • Adenomyosis
  • Fibroids
  • Polyps (endometrial, cervical).

Possible diagnosis 

  • Complications of pregnancy
  • Endometriosis
  • Medicines
  • Ovarian cyst (benign)
  • Pelvic inflammatory disease
  • Polycystic ovary syndrome
  • Salpingitis
  • Systemic causes (e.g. coagulation disorders, hypothyroidism)
  • Uterine myoma.

Critical diagnosis 

  • Malignancy.

Continued information gathering

Maria says her periods are regular, last between five and seven days, and are generally painful but not debilitating. Her last period was a week ago and again she had very heavy bleeding. This has now happened for the last six months or so. She says that for the last couple of months she has experienced lower back pain and hip pain, and has struggled with constipation-like symptoms. 

You need to consider this symptom history against the three conditions you feel are most likely (see table). The description Maria gives seems to best fit a differential diagnosis of fibroids. Polyps seem less likely due to the presence of GI symptoms and pain other than dysmenorrhoea. Adenomyosis is more likely than polyps but tends not to exhibit GI/urinary symptoms.

Problem refinement

When considering fibroids as the diagnosis, you could see if Maria has any risk factors for their development. These include age, onset of menarche, pregnancy, ethnicity and obesity. She tells you that she started her periods when she was about 11 or 12 and has no children. 

You observe she seems overweight. This seems to suggest she does have risk factors – early age of menarche, nulliparity (not given birth) and being overweight – and strengthens your differential diagnosis of fibroids. 

You still have not specifically ruled out other causes of her bleeding (‘possible diagnosis’ list), although you know she is not pregnant and some of the other conditions show inter-menstrual bleeding, which Maria is not experiencing.  

She tells you that she is not taking hormonal contraception but uses barrier methods, and takes no medication on a regular basis. Malignancy always needs to be considered but she tells you she is up-to-date with her cervical screening, the results of which were normal. 


Treatment options for fibroids are mainly governed by the woman’s fertility wishes. In Maria’s case, you confirm that she wants to continue with contraceptive measures and has no desire currently to become pregnant. 

A short-term option for managing her heavy periods could be tranexamic acid. If further treatment is required beyond controlling bleeding, further tests need to be considered. 

Anaemia is often associated with heavy bleeding so a full blood count should be taken. Additionally, thyroid dysfunction can be a cause of menstrual irregularity, so it would be sensible to check thyroid function too. In line with NICE guidance, Maria should be referred for a pelvic ultrasound scan.

Summary of signs/symptoms for adenomyosis, fibroids and polyps
Dysmenorrhoea Pain other than dysmenorrhoea Painful sex Abdominal discomfort UTI/GI symptoms
Polyps Uncommon No No Uncommon No
Adenomyosis Common Pelvic pain Possible Common Unusual
Fibroids Common Pelvic and back pain Possible Common Sometimes

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