Peripheral arterial disease in a female using high-dose combined oral contraceptive pills
A 40-year-old lady was admitted with complaint of heavy menstrual bleeding for the previous 6 years. Her menstrual cycles were regular lasting for 6-7 days and associated with passage of clots and there was no history of dysmenorrhea.\nShe had been prescribed Tab Ovral-G (Ethinyl estradiol 50 mcg and levonorgestrel 0.25 mg) for 2 months about 3 years ago for severe bleeding. However, the patient continued to take the high- dose OC pills on her own for the next 3 years. She had developed severe peripheral arterial disease of both lower limbs for which she had undergone a right common femoral to distal posterior tibial artery bypass grafting with saphenous vein, 7 months ago. However, arterial insufficiency progressed to gangrene of the right 1st, 2nd, and 3rd toes, which had to be amputated 5 months prior to presentation to our hospital. She also had a history of blurring of vision off and on. She was a known hypertensive on medications. She was also on Tab Clopidogrel 75 mg once daily. Throughout preceding 7-8 months, she had been advised several times to stop taking the OC pills, but never complied.\nOn admission, the blood pressure was 150/100 mm Hg. Gynecologic examination revealed no mass palpable per abdomen, a healthy cervix, and vagina with bleeding through cervical os, a bulky, mobile, non-tender, anteverted uterus with fornices free.\nRoutine hematological and biochemical workup was unremarkable except for hemoglobin of 7 g/dL. Lipid profile showed hypercholesterolemia, hypertriglyceridemia, reduced high-density lipoprotein (HDL) and elevated values of low-density and very low-density lipoproteins (LDL and VLDL). Test for coagulations were normal. Ultrasonography of abdomen and pelvis demonstrated uterus size 9.6 cm × 6.2 cm × 5.3 cm, with endometrial thickness of 1.4 cm. Ophthalmoscopic examination of the fundus revealed a high myopic fundus and Grade I hypertensive retinopathy without evidence of vascular occlusion. Echocardiography revealed normal left and right ventricular function with normal valves. Doppler mapping of both lower limb arterial systems revealed no flow in right popliteal, dorsalis pedis and posterior tibial and left dorsalis pedis and anterior tibial arteries. There was no evidence of deep vein thrombosis.\nA diagnosis of perimenopausal dysfunctional uterine bleeding was made. Ovral-G, which the patient was continuing at that time was stopped. In consultation with the cardiologist, the patient was started on Tab Amlodipine 2.5 mg OD, statins and dual anti-platelet therapy (Aspirin-Clopidogrel) for peripheral arterial disease and on Tab Mefenamic acid 500 mg thrice daily. The bleeding reduced after 3-4 days and patient was discharged with instructions to come for pre-menstrual diagnostic curettage after stopping the anti-platelet drugs. Endometrial sampling carried out later revealed hyperplastic endometrium. Following dilatation and curettage (D and C) bleeding stopped. The patient was advised hysterectomy, but refused surgery and continues to be on follow-up with us.