Heavy menses and uterine bleeding signal a greater problem

A thorough work-up helps a clinician make an unusual diagnosis in a young patient.

Heavy menses and uterine bleeding signal a greater problem
Heavy menses and uterine bleeding signal a greater problem

A quiet, young 24-year-old woman presented with her husband complaining of heavy menses and abnormal bleeding. This is a pretty common complaint, but with her I could tell this was not some run of the mill abnormal uterine bleeding.

She denied any possibility of pregnancy, as she needed the use of fertility medications to conceive her 1-year-old daughter. However, she had checked a few home pregnancy tests over the course of the summer, which were negative.

The patient reported normal menses following the delivery of her daughter, but starting in January the menses seemed never ending. She would bleed for weeks at a time. Why she didn't contact the office earlier, I'm not sure. Throughout the summer she continued with these heavy, frequent menses until she could no longer stand it.

Her exam itself was fairly normal. She looked pale and worn out, and reported feeling tired. We reviewed her medical history, which was negative. There was no cancer in family history. Her pelvic exam was unremarkable apart from the large amount of menstrual bleeding she was currently experiencing.

Figuring she maybe had some thyroid imbalance, as well as anemia, I sent her off for a pregnancy test, CBC and TSH. I also ordered a pelvic ultrasound to rule out any fibroids or abnormalities. Her pregnancy test was negative; her TSH was normal. But when the lab called and informed me her CBC showed a Hgb 9.4 and platelets of 25, I knew something was very wrong. It's never good to a personal call from the lab. We ran a differential and that wasn't any better. She had blasts at 60 and NRBC 2 with 2+ poikilocytosis. Needless to say we forwent the ultrasound.

I'm so thankful to have collaborating physicians who are patient and willing to listen the concerns of nurse practitioners. I spoke with my OB/GYN, who was on call, and just by the look on his face I knew my gut suspicions of leukemia were correct. I was then put in contact with one of our hematologist/oncologists, and he insisted upon working her into his schedule that same day.

We were able to track the patient down after she left the lab, and she presented to hematology/oncology the same day I saw her. She had a bone marrow biopsy, which confirmed acute myeloid leukemia. She was admitted and has undergone chemotherapy.

I'm happy to report the patient is now doing very well. I had the opportunity to visit her while she was an inpatient, and she thanked me for saving her life. I told her I was thankful she came in when she did and that her daughter will have a mom around to see her grow.

I will never forget this patient. I'm sure I'll have many more 'remember whens' throughout my career, but she is certainly one of my most memorable.



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