Multiple complaints in a tired woman with vaginal bleeding

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A woman older than her years has a variety of symptoms that are traceable to a single source.

The nurse’s note read “IUD removal—bleeding,” so I was surprised as I entered the room to see a woman who appeared 20 years older than the 36 years noted on the chart. Since Mrs. V was a new patient, I took some history. She spoke slowly and seemed tired and uninterested. In good health until recently, she had not seen a doctor since her postpartum visit after the birth of her 11-year-old son. That was when her intrauterine device (IUD) was inserted.

The vaginal bleeding had been intermittent over the past few months. She wasn’t sure exactly when it started, but she was feeling very tired and thought her fatigue must be related to the bleeding. She wanted the IUD removed. She was not interested in having a physical exam or other evaluation because she did not have medical insurance. Her husband was a self-employed farmer, and she worked at home caring for the children and helping with the farm.

A TROUBLING APPEARANCE

Mrs. V was obese and appeared unkempt, with coarse features and a puffy face. Her ankles were swollen, and she exhibited shortness of breath when walking across the exam room. Her skin was pale, as were her conjunctivae. The pelvic exam was unremarkable. She was not bleeding at the time of the examination, and the IUD was removed without difficulty. I was able to convince her to at least let me do a complete blood count.

When the laboratory called to say that my patient’s hemoglobin was 5 g/dL, I called Mrs. V. After a long discussion, she agreed to meet me at the hospital for a full evaluation. The severity of her anemia did not fit with the history of intermittent bleeding, and on inspection, there was no sign the IUD had a problem that might have caused the bleeding.

EXAM FINDINGS

A complete physical exam revealed an obese woman who was weak and short of breath with minimal activity. Sclerae were anicteric; conjunctivae were pale. Jugular venous distension was present at 45°. In addition to the edema, her lung exam revealed rales in the lower two thirds of both lung fields. Her heart was irregularly irregular, and the ECG confirmed atrial fibrillation (AF). On abdominal exam, the liver felt moderately enlarged and slightly tender.

Admission labs were remarkable for severe microcytic, hypochromic anemia. Electrolytes, blood urea nitrogen, and creatinine were unremarkable. Aspartate aminotransferase and alanine aminotransferase levels were about twice normal. Prothrombin time was not prolonged.

Labs were sent off for iron, total iron-binding capacity, vitamin B12, and folate determinations as well as thyroid and hepatitis profiles before starting Mrs. V on diuresis with IV furosemide (Lasix) and transfusion with packed RBCs.

A PRELIMINARY DIAGNOSIS

Clearly, this patient was in congestive heart failure (CHF), and she was treated appropriately. She also had profound anemia and elevated liver enzymes. Her heart was not enlarged on chest x-ray. Was the anemia enough to cause this degree of CHF in a woman so young? I questioned her husband about alcohol intake. She did drink some beer, he reported, but not an excessive amount.

The AF came and went. Mrs. V’s heart rate had been regular in the office earlier that afternoon, but the irregular rhythm on admission had prompted us to order a thyroid profile, as thyroid disease is a common cause of AF. While we contemplated anticoagulating her, she converted to and remained in sinus rhythm.

Mrs. V diuresed quickly with furosemide. After receiving four units of packed RBCs, her color began to return and she felt less tired. As her CHF resolved, the liver enzymes returned to normal. Liver congestion had caused the increase.

KEY LAB RESULT

The rest of Mrs. V’s labs showed a high thyrotropin and undetectable free thyroxine. Her profound hypothyroidism could explain all her symptoms, from the vaginal bleeding to the CHF, the fatigue, and the anemia. She was started on replacement levothyroxine, which was gradually increased over a period of weeks until she was euthyroid.

Primary hypothyroidism is a common endocrinology disturbance that affects women, especially elderly women, more than it does men. The condition can have far-reaching consequences throughout the body, including the cardiovascular, neurologic, GI, dermatologic, and reproductive systems. Besides the symptoms noted by Mrs. V, patients may experience dry skin, dry brittle hair and nails, infertility, and joint pains.

The most common cause is an autoimmune thyroiditis, although drugs, such as amiodarone, and radiation or surgical therapy for hyperthyroidism may result in a hypothyroid state. Hypothyroidism that goes untreated may lead to a life-threatening myxedema coma.

Fortunately for Mrs. V and other hypothyroid patients, thyroid replacement is often successful. Her CHF resolved and did not recur. Iron supplements restored her blood count to normal. She lost about 75 lb, and her energy returned. Her face changed as the puffiness resolved, and her skin texture returned to normal.

SUCCESSFUL THERAPY

When Mrs. V returned for her follow-up appointment six months later, she looked like a different person. She was smiling and no longer overweight. She had gotten a job. My only regret is that I don’t have before-and-after pictures.

Dr. Majeroni is associate professor of clinical family medicine at The State University of New York at Buffalo.

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