Ms. F, a 48-year-old AA, G2, P2, woman presented to the clinic for her annual exam.  She states that she has been having “hot flashes” but her menses continue to be regular. She also notes that her periods are heavier, with clots and more cramping than she’s experienced before. She “doesn’t use contraception” because she assumes, at her age, she will not be at risk for a pregnancy. 

Ms. F lives with her husband of 20 years and works part time at a local bakery. She has no significant health problems. She states that she recently has begun an exercise program and is limiting her carbohydrate intake in an effort to lose weight.

Ms. F states that she has her menses every 28 to 35 days for 7 days, passes “some clots,” and takes Aleve for cramping.  She complains of hot flashes, but also night sweats that disturb her sleep. She feels tired and “run down”.

PMH: Two spontaneous vaginal deliveries, uncomplicated. Has a yearly exam with her PCP.

FH: Mother – Deceased.  Alzheimer’s disease.

        Father – Deceased.  Melanoma.

Ms. F’s vital signs are good: BP 120/70mm Hg; pulse rate 90bpm. She is 5′ 5″ tall and weighs 180lbs.

On physical examination:            

                HEENT:  normal limits (NL)

                Breast exam:  pendulous, no masses

                Abdomen:  minimal BS; non tender; obese


                                Vulva:  NL

                                Vagina: Well rugated; physiologic discharge

                                Cervix: Clear, parous

                                Uterus: AV, NT

                                Adnexa: Negative for masses

                                Rectal: Confirms

Following a normal GYN exam, it is concluded that Ms. F is perimenopausal, suffers from heavy menstrual bleeding, and is obese. A hormonal contraceptive should be selected to manage her symptoms.

A low-dose oral contraceptive (OCP) is prescribed to Ms. F to manage her perimenopausal symptoms and heavy menstrual bleeding. Despite her age and weight, these factors did not have to be used to select the optimal OCP therapy for Ms. F. While a levonorgestrel or a copper IUD were considered, these therapies would help only with the bleeding and not with her vasomotor symptoms.