Clinical case report: Dou...

A 46-year-old woman presented with chief complaints of heavy and prolonged menstrual bleeding for the last 7–8 months. Her last menstrual period lasted for seven days, and she had clots, which required changing pads five times a day. She experienced cycles once every 15 days, lasting 3–4 days, which improved with oral progesterone (norethisterone). Pregnancy was ruled out. There was no intermenstrual spotting, dysmenorrhea, or abdominal mass. The patient did not have a history of white discharge from the vagina, backache, dyspareunia, weight loss/gain, heat/cold intolerance, or any urinary complaints. Despite being married for 25 years, she was nulligravida, attributed to male factor infertility, and unresponsive to fertility therapy. She had no known medical comorbidities. Her father and mother had died due to lung and liver cancer, respectively. On examination, her vitals were stable, and systemic examination was insignificant. Her weight was 42 kg, with a body mass index of 17 kg/m2. She also had peripheral tremors and a slightly prominent thyroid mass. The cervix and vagina were healthy, and on vaginal examination, the uterus was of 8-week size, retroverted, mobile with bilateral free and nontender fornices. Hemograms, electrolytes, urine, and glucose profiles were normal. Ultrasonography of the pelvis showed an endometrial thickness of 20 mm, focal adenomyosis, and a 47 mm × 35 mm subserosal fibroid. Adnexa and pouch of Douglas were normal. Endometrial sampling on histopathological examination suggested simple endometrial hyperplasia without atypia. In the investigatory work-up, TSH was 5.34 uIU/ml. This elevated TSH was not in concurrence with the peripheral signs of hyperthyroidism. Moreover, despite the slightly elevated TSH and normal T3 of 1.06 ng/ml, both T4-13.91 ug/dl and FT4-1.38 ng/dl were elevated, concurring with peripheral signs of hyperthyroidism. To evaluate this deranged thyroid profile, further evaluation was done by endocrinologists, and it was determined that the patient must have had a central cause of hyperthyroidism. An MRI suggested pituitary microadenoma and pituitary adenoma on sagittal and axial views of MRI, respectively. In addition, the alpha-subunit was <0.1 ng/ml. For the management of hyperthyroidism, the patient was initiated on carbimazole 10 mg 1-0-0 and tablet propranolol 40 mg 1-0-0 for six weeks. The overall diagnosis established for this patient is Abnormal uterine bleeding (leiomyoma, adenomyosis) with pituitary microadenoma. 1