Complaints of pain abdomen since today morning, history of vomitings and minimal tenderness and hemorrhagia since one week. These are the reports. Please diagnose and suggest a management.
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Clinical Analysis: Mrs. Laxmi CH, 52F
Lab Report Summary (CBP – 23/04/2026)
| Parameter | Result | Reference | Interpretation |
|---|---|---|---|
| Hemoglobin | 6.0 g/dL | 12–15 g/dL | Severe anemia |
| Total RBC Count | 2.8 million/cumm | 3.9–6.0 | Markedly reduced |
| WBC Count | 6,200/cumm | 4,000–11,000 | Normal |
| Platelet Count | 3,07,000/cumm | 1,50,000–4,50,000 | Normal |
| Neutrophils | 63% | 40–80% | Normal |
| Lymphocytes | 27% | 20–40% | Normal |
| Eosinophils | 7% | 1–6% | Mildly elevated |
| Monocytes | 3% | 2–10% | Normal |
| Basophils | 0% | 0–2% | Normal |
CT Whole Abdomen (IV Contrast) Summary
| Finding | Significance |
|---|---|
| Liver 19 cm, fatty attenuation | Mild hepatomegaly with Grade-I fatty liver (NAFLD/MASLD) |
| Pancreatic body 10×10 mm subtle hypodensity | Incidental — no surrounding inflammation, no ductal dilatation — ? significance |
| Uterus: bulky, globular, heterogeneous myometrial enhancement | Likely adenomyosis |
| Both ovaries normal for age | — |
| No ascites, no lymphadenopathy | — |
| L4–L5 chronic disc degeneration, lumbar sacralization | Incidental musculoskeletal |
| CT Chest: Normal | — |
Diagnosis
Primary (Most Likely) Diagnosis
Adenomyosis with Secondary Menorrhagia causing Severe Iron-Deficiency Anemia
This is the unifying diagnosis. The CT shows a classic bulky globular uterus with heterogeneous myometrial enhancement, highly consistent with adenomyosis. One week of menorrhagia (heavy vaginal bleeding) in a perimenopausal 52-year-old woman explains:
- Hb 6.0 g/dL (severe anemia)
- RBC count 2.8 million/cumm
- Abdominal pain (from uterine distension/cramping)
- Vomiting (pain-related vagal response)
Adenomyosis occurs when endometrial glands and stroma invade the myometrium, causing a bulky, globular, tender uterus. It classically presents with menorrhagia, dysmenorrhea, and abdominal pain — Berek & Novak's Gynecology.
Additional Findings
- Grade-I Fatty Liver (MASLD/NAFLD) — incidental, likely metabolic; no portal hypertension, no focal lesion.
- Incidental 10×10 mm pancreatic body hypodensity — no ductal dilatation, no inflammation/fat stranding. Likely a small benign lesion (serous microcystic adenoma, small IPMN, or normal variant), but requires follow-up (MRCP/EUS).
- L4–L5 disc degeneration with sacralization — may contribute to chronic lower back/pelvic pain.
Management Plan
Immediate (Emergency/Inpatient)
1. Stabilize the Severe Anemia
- Hemoglobin of 6.0 g/dL with active bleeding in a symptomatic 52-year-old woman is an indication for packed red blood cell (pRBC) transfusion.
- Target Hb ≥ 8–10 g/dL before elective procedures.
- Do NOT transfuse rapidly — rate ≤ 1 mL/kg/hour; monitor for fluid overload.
- Add Folic acid 5 mg/day to support erythropoiesis during active blood loss.
2. Control Active Bleeding (Menorrhagia)
- IV Tranexamic acid (antifibrinolytic) — 1 g IV TDS to arrest menorrhagia acutely.
- Norethisterone 5 mg TDS or high-dose oral progesterone to stop breakthrough bleeding (medical curettage effect).
- If hemodynamically unstable: consider emergency gynecology consultation for surgical hemostasis.
3. Pain and Vomiting Management
- IV NSAIDs (e.g., ketorolac or diclofenac IV) — reduce uterine cramping and have a proven role in adenomyosis-related dysmenorrhea.
- Antiemetics (ondansetron 4–8 mg IV) for vomiting.
- IV fluids for hydration if poor oral intake due to vomiting.
Definitive Management of Adenomyosis
Per Berek & Novak's Gynecology: "The management of adenomyosis depends on the patient's age and desire for future fertility. NSAIDs, hormonal contraceptives, and menstrual suppression using oral, intrauterine, or injected progestins or GnRH agonists are all useful."
Given she is 52 years old (perimenopausal), likely not wanting future fertility:
| Option | Details |
|---|---|
| Levonorgestrel IUD (Mirena) | First-line conservative — significantly reduces menorrhagia, used as alternative to hysterectomy |
| GnRH agonist (Leuprolide/Buserelin) | Medical menopause — effective short-term (3–6 months), used as bridge to surgery or in perimenopausal women close to natural menopause |
| Oral progestins (norethisterone, medroxyprogesterone) | Suppresses endometrium, reduces bleeding |
| Hysterectomy | Definitive cure — appropriate for 52-year-old with completed family, if medical management fails or severe disease |
| Uterine artery embolization (UAE) | Minimally invasive alternative to hysterectomy if she declines surgery |
At 52, if she has failed/refuses medical therapy → Total hysterectomy is the definitive treatment.
Iron Replacement (Post-Stabilization)
- Once acute bleeding is controlled: IV iron sucrose (preferred over oral if Hb < 8 and post-transfusion) — replenish iron stores.
- Oral ferrous sulfate 200 mg TDS once tolerating orally — continue for 3 months after Hb normalizes.
Follow-Up Investigations Needed
| Investigation | Reason |
|---|---|
| Serum ferritin, serum iron, TIBC | Confirm iron-deficiency profile (expected very low ferritin) |
| Peripheral blood smear | Confirm microcytic hypochromic picture |
| Reticulocyte count | Assess bone marrow response |
| Pelvic MRI | Gold standard for confirming adenomyosis; delineate extent before surgical planning |
| Endometrial biopsy / Hysteroscopy | Rule out endometrial hyperplasia or carcinoma at 52 years (perimenopausal bleeding) |
| MRCP or EUS | Characterize the 10×10 mm pancreatic body hypodensity — follow-up in 3–6 months as per radiologist's advice |
| LFTs, fasting lipids, blood sugar | Workup for fatty liver (MASLD) |
| TSH | Rule out hypothyroidism as a contributor to menorrhagia |
| Coagulation profile (PT/INR, aPTT) | Especially before any procedure/surgery |
Summary of Differentials Considered
| Diagnosis | Likelihood | Basis |
|---|---|---|
| Adenomyosis + Menorrhagia | Most likely | CT bulky globular uterus, heterogeneous myometrium, age, hemorrhagia |
| Uterine fibroids | Possible | Not explicitly seen on CT, but often coexist with adenomyosis |
| Endometrial carcinoma | Must exclude | Perimenopausal bleeding — endometrial biopsy mandatory |
| Dysfunctional uterine bleeding (DUB) | Possible | Perimenopausal hormonal fluctuation |
| Coagulation disorder | Less likely | Platelets normal |
⚠️ Clinical Priority: This patient has symptomatic severe anemia (Hb 6.0) with active uterine bleeding. She needs urgent hospitalization, blood transfusion, and gynecology consultation today. The pancreatic finding, while noted, is incidental and non-urgent but must not be forgotten at follow-up.
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