Case Mrs K: Female – Age 48 at presentation
Lady of medium build, face of a reddish complexion, casually dressed, open and makes good eye contact. Relaxed, with a sense of humour.
Presents with perimenopausal metrorrhagia.
“I’ve been bleeding since 26th February. I had a hysteroscopy and a dilatation and curettage done on 2nd July, which were normal. The gynaecologist says it is a hormonal imbalance.
The problem is that I can’t swallow tablets. My throat seizes up. Even with the smallest pill. I know it is purely psychological. My friends say that the food I swallow is bigger than any pill, but I still can’t swallow pills. No choking. Liquids and food are OK.”. No globus.
Menses normal until 3 years ago. 4/28. The middle day was heavy. No clots.
Then, for 3 years it shortened to a 4/24, but normal. Nine months ago my periods stopped for 3 months, and then I started bleeding the whole time since the 26th February. Now there is no pattern. Mostly heavy. It flows 24 hours a day. No special time. I can sit in the toilet and it pours. I have difficulty coming out the shower. It is dark red, sometimes dark brown. Mostly liquid. Occasional clots. It looks gritty in the pan. At the start it smelt rotten, but not now. I’m using towels rather than constant Tampax. I’m fed up with it.
There are no associated cyclical changes/PMT/bloating/cramps/pain/emotional changes. No clear causation.
Para 2+0. Menarche at 14.5 years.
Past history of yellow, smelly constant, leucorrhoea which stained underwear.
“My mother had similar bleeding for 9 months before haemorrhaging and needing an emergency hysterectomy.”
“I’m foul on waking. For the first half hour I want to be left alone. I get annoyed if anyone talks to me.”
Social drinker. 14 units/week. “Happy when drunk. Want to dance.”
Smokes 40 cigarettes/day. No cough.
Past medical history: Tubal ligation. Straightening nasal septum.
Family history: Mother Died 59 carcinoma pancreas. PGM Died 82 cancer.
Drug history: none
Energy dip 6.30-8.00 p.m.
Chilly, averse cold.
Sleeps “like a log”. Position: on stomach, with right leg out to the side and arms above head. Twiddles the pillow and sucks her tongue before going to sleep.
Appetite poor. Never eats anything all day, but will have a meal at night.
Averse to fish because once had a fishbone which got stuck.
Drinks 7 cups of coffee /day. Would find it hard to stop.
48 years old woman with perimenopausal metrorrhagia. Fully investigated – “hormonal imbalance”. Mother exhibited same pattern, resulting in a hysterectomy after 9 months. Few other useful symptoms. In general a well adjusted person. The case can be considered one-sided. The centre of gravity is physical, specifically focused on the reproductive tract. Her inability to swallow pills can be considered as very strange, rare and peculiar, but unfortunately no rubrics could be found to represent this feature unequivocally. The following rubrics were taken to cover her gynaecological symptoms. In addition, the irritability on waking was marked, so 2 rubrics were included to give an indication if this feature is covered in the leading remedies, but were given zero weighting as this has been part of her personality, and may not be part on the new disease state that has manifested in the last 6 months. Note that the first rubric is taken as eliminative because it is so central to the case.
Sum of symptoms (sort:deg) Intensity is considered
|1||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – menopause – during (Elimination)||51|
|2||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – plethoric women; in||17|
|3||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – dark blood – clots, with||14|
|4||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – profuse||55|
|5||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – offensive||12|
|6||1234||1||FEMALE GENITALIA/SEX – METRORRHAGIA – painless||17|
|7||1234||0||MIND – IRRITABILITY – waking, on||58|
|8||1234||0||MIND – IRRITABILITY – morning – waking on||43|
Sabina and crocus are the only 2 remedies to cover all the symptoms. Belladonna, Secale and Ustilago also cover the symptoms well.
Looking at the materia medicae (Vermeulen’s Concordant and Synoptic, Clarke’s Dictionary and Morison’s Desktop Guide) :
Sabin. and Secale are markedly warm-blooded and < heat (while this patient is chilly) so they are less likely candidates. Croc. is characterised by dark, stringy, viscid haemorrhages, which is not the case here. Belladonna typically has bright red menorrhagia, although it can also be dark blood. The flow is meant to be like “hot gushes”, but she did not experience this. In addition, Belladonna has the irritability on waking, sleeping on the abdomen, and heavy sleep. An argument could be made to associate her difficulty in swallowing pills with the sense of constriction and difficulty in swallowing that can be seen in Bell and other remedies of the hydrophobinum miasm . Belladonna cannot be excluded.
Ustilago has menorrhagia at climaxis, with dark blood, slow bleeding or clots, and constant flooding. This fits the case best. (It can be stringy, but not necessarily). It can also have blood that is bright red, copious, that does not coagulate easily, but this is more usually cyclical. Ustilago was chosen as the remedy which fits best. Belladonna usually has bright red blood, but it cannot be ruled out as it also fits the picture. However, I will reserve it as second choice.
In the choice of potency, the fact that the patient is unable to give up coffee and that this could potentially antidote the action of the remedy (though Ustilago is not in the rubric coffee <) repetition is favoured. LMs or a 6c could be used, but I would prefer a brisk action in case the patient is going to follow the pattern of her mother and haemorrhage in 3 months time. A 30c split dose was chosen, repeated weekly unless there is an obvious effect from the remedy, in which case it should not be repeated.
Ustilago 30c/2, repeated weekly if necessary.
4 weeks since Ustilago 30c. “Worked.” “The bleeding started to decrease within hours of taking the tablet, and just petered off. It had started on the 25th of February, and stopped on 25th August completely Took another tablet one week later, but none since.” On week 3 the discharge returned. Not severe. Yellow, stains underwear. No smell. No itching. No further bleeding.
It appears that the difficulty in swallowing is a general feature of fungi too.