On June 4, 2008, a 40-year-old white G0 presented to the defendant ob/gyn with complaints of hair loss, weight gain, and premenstrual dysphoric disorder (PMDD). She reported that her Pap smears were always normal (her most recent one had been in March 2008), but that she had tested positive for human papillomavirus (HPV) in April 2007. More recently, she had amenorrhea for 3 months at the beginning of the year and her follicle stimulating hormone (FSH) levels were consistent with menopause.
During this visit, an ultrasound (U/S) revealed a uterine fibroid measuring 6 x 8 cm, which the ob/gyn felt was possibly related to her Hashimoto’s disease. Because the patient had no symptoms related to the fibroid, the ob/gyn did not initiate estrogen therapy. The patient was directed to return to the office in 6 months. However, she called the office on June 24 and reported that she was having more hair loss and was interested in a hysterectomy and hormone therapy.
The patient called the ob/gyn again on July 2 and reported that her last menstrual period was on May 31. She also reported moodiness and worsening depression. The doctor prescribed estradiol and Prometrium. The patient was seen in the ob/gyn’s office on December 17 and reported that her hair loss was still a problem. The doctor performed another U/S, which showed that the fibroid was stable and measured 6.2 x 7.6 cm.
The patient was next seen by the ob/gyn on March 22, 2010. The doctor documented that she had a long conversation with the patient about feeling unhappy on low-dose estrogen therapy. An U/S performed by the doctor revealed that the fibroid measured 9.0 x 7.0 cm. The patient’s preference for not getting another U/S at an outside facility was also documented. A Pap smear showed no intraepithelial lesion or malignancy. The ob/gyn increased the estrogen dose.
When the patient returned to the doctor on August 16, she reported firmness on her left side and frequent urination. U/S showed the fibroid was “significantly larger,” measuring 10.6 x 9.6 cm. The doctor encouraged her to have a laparoscopically assisted vaginal hysterectomy (LAVH) and removal of the cervix. She also advised her to have a bilateral salpingo-oopherectomy (BSO). The patient was to come back in 3 to 6 weeks to discuss surgical options.