Case of a 26-Year-Old Female with Primary Amenorrhea Presenting with Acute Menorrhagia and Severe Pelvic Pain

Case at a Glance

A 26-year-old female with a history of primary amenorrhea, previously attributed to Polycystic Ovary Syndrome (PCOS), presented to the emergency department with an acute onset of heavy vaginal bleeding and severe, debilitating pelvic pain. The case highlights the urgent need for evaluation in patients with long-standing amenorrhea who experience a sudden change in bleeding patterns.

Patient's Story

The patient, a 26-year-old female (BMI 33.1 kg/m²), reported that she had never experienced a menstrual period in her life (primary amenorrhea). She stated that several years prior, she was informally told she might have PCOS but did not receive a formal workup or ongoing care. For the past three days, she began experiencing heavy vaginal bleeding, which she initially thought might be her first period. However, the severity of the symptoms prompted her to seek advice. She described the bleeding as profuse, requiring her to change a saturated sanitary pad every 30 to 60 minutes. The blood was bright red and contained large, thick clots. This was accompanied by constant, severe pelvic pain, which she rated as an 8-9/10, causing significant distress and episodes of sobbing.

Initial Assessment

Upon presentation to the emergency department, the patient appeared pale and in visible distress due to pain. Vital signs were notable for tachycardia (HR 110 bpm), with blood pressure within normal limits at 118/76 mmHg. A physical examination revealed significant suprapubic tenderness. A pelvic exam confirmed a large volume of bright red blood and clots in the vaginal vault, with active bleeding from the cervical os. The patient's history of primary amenorrhea, coupled with the acute onset of menorrhagia and severe dysmenorrhea, raised immediate concern for endometrial pathology secondary to chronic anovulation.

The Diagnostic Journey

An urgent workup was initiated. A urine pregnancy test was negative. A Complete Blood Count (CBC) revealed moderate normocytic anemia with a hemoglobin of 9.8 g/dL, consistent with acute blood loss. Coagulation studies were within normal limits. A transvaginal ultrasound was performed, which showed a markedly thickened and heterogeneous endometrium, measuring 18mm. Multiple small, peripheral follicles were noted on both ovaries, consistent with the previously suggested diagnosis of PCOS. No fibroids, polyps, or other structural abnormalities were identified. The primary differential diagnosis was Abnormal Uterine Bleeding (AUB) due to anovulation in PCOS, with high suspicion for underlying endometrial hyperplasia given the prolonged period of unopposed estrogen exposure.

Final Diagnosis

Acute Abnormal Uterine Bleeding (AUB-O) secondary to chronic anovulation associated with Polycystic Ovary Syndrome (PCOS), complicated by suspected Endometrial Hyperplasia.

Treatment Plan

The patient was admitted for stabilization and management. She was started on IV fluids to correct dehydration and a high-dose oral progestin regimen (medroxyprogesterone acetate) to stabilize the endometrium and control the bleeding. Intravenous analgesics were administered for pain control. The immediate goal was to achieve hemostasis and alleviate her severe pain. The long-term plan included a scheduled outpatient endometrial biopsy to rule out endometrial hyperplasia with atypia or carcinoma, a significant risk in this clinical context. Following the biopsy, she was counseled on management options for PCOS, including combined oral contraceptives to regulate her cycles, protect her endometrium, and manage symptoms, alongside lifestyle and weight management strategies.

Outcome and Follow-up

The patient's bleeding significantly decreased within 48 hours of initiating high-dose progestin therapy, and her pain became well-controlled with oral analgesics. She was discharged on a tapering dose of oral progestin with a scheduled follow-up in the gynecology clinic within two weeks for an endometrial biopsy and to initiate long-term hormonal management. The case underscored the critical importance of a thorough evaluation and management for primary amenorrhea to prevent acute complications like severe bleeding and mitigate the long-term risk of endometrial cancer.