Jan 3rd, 2010 - 00:09:53
My question is similar to that answered by Dr. Marsh in March: premenstrual bleeding...
Please help: I'm at the end of my wits! I'm a physician myself and the fact that I can't get any answers is even more frustrating! Here is the story...
Prior to 6 yrs ago my menses were 7 days. Since then my monthly bleeding became longer and longer and now are 14 days. Initially I thought this was all menses. As I am trying to conceive I found that the bleeding starts 7-9 days after ovulation (ovulation kit.) Subsequent workup inluded day 21 progesterone, which was 15. Day 21 biopsy (occurring on the day of onset of bleeding) was c/w dates. Because of the biopsy I know that the first week of my bleeding is really during secretory phase. Now I learned to also noticed changes in dysmenorrhea so I can get when the actual menses starts. Additional w/u included 3 or 4 sonos (incl saline enhanced) - all neg for polips or other anatomic abnormalities. HSG (part of my infertility w/u) was normal. Prolactin,TFTs, LH, FSH,estrodiol ara all nl. Of note OCP never fixed the problem and progesterone started day 10 just brought on the bleeding for the rest of the cycle.
What is the diagnosis? What do I do next? How can implantation occur if I'm bleeding: i.e is clomid worthwhile? I want to conceive, but it this doesn't happen I want at least for the bleeding to stop. I can't tolerate 14 of 28 days of bleeding!!!
It must be frustrating to have premenstrual bleeding and not have a good diagnosis. I have three suggestions.
First of all, even though you have had sonography, at this point you really need a hysteroscopy and D&C for diagnosis. Sonography, including saline enhanced, will not pick up all lesions including small polyps, endocervical lesions, and small fibroids. Also a D&C can be therapeutic.
Since you have dysemenorrhea, endometriosis is a possibility. Even though endometriosis is not really a cause of bleeding, having a very experienced surgeon do a combination hysteroscopy, D&C and diagnostic and therapeutic laparoscopy (including CO2 laser to treat any endometriosis) would get your reproductive system in the best possible state with one outpatient surgery.
Secondly, you likely have some type of luteal phase defect Your workup to date has been throroughly inadequate. The best characterization of luteal phase defects is in Dr. Hilger's textbook. You need measurements of progesterone and estradiol 5,7,and 9 days after ovulation. There are four types of luteal phase defects. It is not enough to have a progesterone of 15 on day 21. In one type of luteal defect, all progesterones are low. In another the initial progesterone is adequate, but sharply falls off. In yet another, the estradiols are low. In addition, you do not mention a day 2 or 3 FSH to check for premenopause. Estradiols 1-3 days prior to ovulation are also useful. You do not mention anything about cervical mucus, cycle length, fasting insulin, androgens. Also TSH should really be 2.5 or below (although many labs say "normal" is up to 5.5). Even without symptoms, minimally reduced thyroid function can have adverse reproductive effects. Physicians trained by Hilgers I think do the best in meticulously diagnosing and normalizing hormonal function. Presuming you have a luteal phase defect of both estradiol and progesterone and mildly diminished estradiol in other parts of the cycle, I have found a regimen of Clomid 25 mg. day 3,4,5 of the cycle followed by HCG 2000 Units IM 3,5,7 and 9 days after ovulation to be most helpful.
Finally, your weight and nutrition are important. Avoding sugar, refined carbohydrates, alcohol, cigarette and NSAID's. Good supplements such as Optivite and 3 grams daily of flax oil daily have been helpful to many women. NFP charting, in particular FertilityCare (Creighton), can help assist in diagnosis and treatment.
Mary L. Davenport, M.D.
Dr. Mary Davenport is an obstetrician-gynecologist in private practice in El Sobrante, California.
She graduated from Tufts University School of Medicine and completed her residency at the University of California, San Diego.
Dr. Davenport is also a Fellow of the American College of Obstetrics and Gynecology.
She has an NFP-only medical practice and is a Medical Consultant in Natural Family Planning.
She is a board member for CANFP and the American Association of Pro-Life OBGyn's.
© Copyright 2005 by CANFP
The information on this page and web site is for informational purposes only,
and is not a substitute for medical diagnosis and treatment by a physician.
Top of Page