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Abnormal Uterine Bleeding in a Peritoneal Dialysis Patient: Emphasizing the Need for a Holistic Approach
Corresponding author: Vinay Rathore, Department of Nephrology, AIIMS Raipur, Raipur, Chhattisgarh, India. E-mail: vinayrathoremd@gmail.com
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How to cite this article: Yelavarthy YM, Rajaram NR, Rathore V, Behera SK. Abnormal Uterine Bleeding in a Peritoneal Dialysis Patient: Emphasizing the Need for a Holistic Approach. Indian J Nephrol. doi: 10.25259/IJN_283_2025
Dear Editor,
Acute abnormal uterine bleeding (AUB) represents a significant clinical challenge in women with ESKD, sometimes posing a threat to life. We present a 36-year-old female with ESKD on peritoneal dialysis (PD) for the past 3 years, who presented with severe menstrual bleeding, requiring a change of sanitary pad every 2-3 hours. She had been experiencing menstrual irregularities for the past 2 months. She had no other bleeding manifestations or hemorrhagic PD effluent. Examination revealed tachycardia (heart rate: 132/min), severe pallor, and mild pedal edema. The gynecological examination was unremarkable except for the presence of clots in the vaginal vault. A pelvic ultrasound showed a normal myometrium with an endometrial thickness of 4.2 mm. Investigations [Table 1] revealed severe anemia (Hb: 3.2 g/dL).
| Laboratory parameter | Value |
|---|---|
| Hemoglobin (g/dL) | 3.2 |
| Total leukocyte count (×10⁹/L) | 3.26 |
| Platelets (/µL) | 169,000 |
| PT (sec) | 12 |
| INR | 1.1 |
| aPTT (sec) | 28 |
| Total bilirubin (mg/dL) | 0.82 |
| AST/ALT (U/L) | 76.89 / 45.44 |
| Alkaline phosphatase (U/L) | 141.52 |
| Albumin (g/dL) | 1.63 |
| Creatinine (mg/dL) | 8.3 |
| iPTH (pg/mL) | 322.1 |
| 25 (OH) Vitamin D (ng/mL) | 28 |
| Phosphorus (mg/dL) | 3.94 |
| Total calcium (mg/dL) | 7.87 |
| TSH (mIU/L) | 5.9 |
| Serum beta-hCG (mIU/mL) | 0.616 |
| FSH (mIUm/L) | 2.2 |
| LH (mIU/mL) | <0.1 |
| Estradiol (pg/mL) | 50.03 |
| Prolactin (ng/mL) | 80.07 |
PT: Prothrombin time, INR: International normalized ratio, aPTT: Activated partial thromboplastin time, AST: Aspartate aminotransferase, ALT: Alanine transferase, iPTH: Intact parathyroid hormone, TSH: Thyroid stimulating hormone, FSH: Follicle stimulating hormone, LH: Leuteinizing hormone
She was resuscitated with 3 units of blood transfusion and intravenous tranexamic acid (10 mg/kg/dose thrice daily). Despite these measures, the bleeding persisted, and she was started on oral medroxyprogesterone acetate (20 mg) three times daily, which stopped the bleeding. Later, a levonorgestrel-releasing intrauterine system was inserted to prevent further bleeding.
AUB is estimated to affect 3%-30% of women of reproductive age, with prevalence reaching as high as 75% among those undergoing dialysis.1 Hormonal abnormalities (reduced renal clearance of prolactin, decreased sensitivity to dopaminergic activity, and inhibition of LH and FSH surges), bleeding and coagulation abnormalities, anemia, hyperparathyroidism, and uremia are proposed to contribute to higher AUB prevalence in CKD.2
Medical management includes resuscitation, antifibrinolytics, hormonal therapy, and dialysis intensification, while surgical options like dilation and curettage (D&C), endometrial ablation, uterine artery embolization, and hysterectomy are reserved for refractory cases.3
The index case highlights the complex gynecological problems that a nephrologist may sometimes encounter, which require a thorough understanding of female reproductive biology and multidisciplinary management.
Conflicts of interest
There are no conflicts of interest.
References
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