Presentation
Good morning, sir. Miss AA is a 36-year-old banker, nulligravida, recently married, who presents with heavy menstrual bleeding for 4 years and a gradually enlarging lower abdominal swelling for 2 years. She bleeds for 8 days every 28 days, soaking a pad every 2 hours with clots on the heaviest days, and has been transfused twice. She has congestive dysmenorrhoea, urinary frequency and constipation, but no intermenstrual or postcoital bleeding and no weight loss. She has been trying to conceive for 18 months. Her sister had a myomectomy. Her last cervical screening was negative. She is genotype AA. On examination she is pale, not jaundiced, with normal vital signs. The abdomen shows a suprapubic swelling corresponding to a 20-week gravid uterus, arising from the pelvis, firm, with an irregular bosselated surface, non-tender and mobile from side to side. There is no ascites. On speculum examination the cervix is healthy and pulled up; on bimanual examination the mass moves with the cervix and the adnexa cannot be felt separately.
Diagnosis
Symptomatic uterine fibroids (20-week size) causing heavy menstrual bleeding, pressure symptoms and chronic iron-deficiency anaemia, in a nulliparous woman with primary infertility who wants to conceive.
Differential diagnoses
- Adenomyosis — uniformly enlarged, tender, globular uterus, severe dysmenorrhoea; often coexists
- Pregnancy or a pregnancy in a fibroid uterus — always check hCG
- Ovarian tumour adherent to the uterus — separate from the cervix on bimanual examination, ultrasound shows an adnexal origin
- Uterine sarcoma (leiomyosarcoma) — rapid growth after menopause, pain; cannot reliably be distinguished before surgery
- Endometrial cancer — older, postmenopausal bleeding, risk factors
- Tubo-ovarian mass — history of PID, tender
Investigations
| Test | What you expect or look for |
|---|---|
| Full blood count, ferritin | Microcytic anaemia, low ferritin |
| Pregnancy test | Negative |
| Pelvic and transvaginal ultrasound | Multiple well-defined hypoechoic myometrial masses; number, size, location; cavity distortion; ovaries normal; hydronephrosis |
| Saline infusion sonography or hysteroscopy | Submucous fibroids and cavity distortion |
| MRI pelvis | Mapping before myomectomy; adenomyosis; features of sarcoma |
| Renal ultrasound, urea and creatinine | Ureteric compression and hydronephrosis |
| Blood group and cross-match | Before surgery |
| Infertility work-up | Partner's semen analysis, tubal patency (HSG or at surgery), ovulation (mid-luteal progesterone) |
| Cervical screening | If due |
| Endometrial biopsy | If over 45, irregular bleeding or risk factors |
FIGO leiomyoma classification
| Type | Location |
|---|---|
| 0 | Pedunculated, intracavitary |
| 1 | Submucous, less than 50% intramural |
| 2 | Submucous, 50% or more intramural |
| 3 | Intramural, touching the endometrium |
| 4 | Intramural |
| 5 | Subserous, 50% or more intramural |
| 6 | Subserous, less than 50% intramural |
| 7 | Subserous, pedunculated |
| 8 | Other — cervical, broad ligament, parasitic |
Management
Care is by the gynaecologist with the anaesthetist, haematologist and, for fertility, the reproductive medicine team. I would explain that fibroids are benign, discuss her options in the light of her wish to conceive, and counsel her about myomectomy, including the small risk of hysterectomy.
Non-pharmacological
- Correct anaemia before surgery; diet advice
- Expectant management is reasonable for small asymptomatic fibroids — not in this case
- Counselling about fertility and the timing of conception after surgery
Pharmacological
| Option | Use |
|---|---|
| Tranexamic acid 1 g three times daily during menses (up to 4 days) | Reduces bleeding |
| NSAIDs (mefenamic acid 500 mg three times daily) | Bleeding and pain |
| Levonorgestrel IUS | If the cavity is not distorted and she does not want pregnancy |
| Combined oral contraceptive or progestogens | Bleeding control in small fibroids |
| GnRH agonist (goserelin 3.6 mg or leuprorelin 3.75 mg monthly) for up to 3 months before surgery | Shrinks fibroids by 30–50%, stops bleeding so haemoglobin can rise; causes menopausal symptoms and bone loss with longer use |
| Relugolix combination therapy (GnRH antagonist with oestradiol and norethisterone acetate) | Long-term medical treatment of heavy bleeding; not while trying to conceive |
| Ulipristal acetate | Restricted because of rare severe liver injury |
| Iron — oral, or IV before surgery | Correct anaemia |
Surgical and interventional
- Abdominal myomectomy — the appropriate choice here:
- Aim for haemoglobin of 10 g/dL or more; cross-match 2–4 units
- Reduce blood loss with a uterine tourniquet, dilute vasopressin injection, preoperative misoprostol, IV tranexamic acid, and cell salvage where available
- Remove as many fibroids as possible through as few incisions as possible (preferably anterior); close dead space in layers
- Consent for hysterectomy if bleeding cannot be controlled (rare)
- Hysteroscopic resection for type 0–2 submucous fibroids up to about 4–5 cm
- Laparoscopic myomectomy for fewer, smaller subserous or intramural fibroids with an experienced surgeon
- Uterine artery embolisation for women who do not want surgery — less suitable when pregnancy is desired
- Hysterectomy — definitive treatment for women who have completed their family
- Advice after myomectomy: wait 3–6 months before conceiving; if the cavity was entered or the myometrium extensively incised, recommend caesarean section before labour because of rupture risk
Complications and follow-up
- Of fibroids: anaemia, infertility, recurrent miscarriage, pressure on bladder, ureters and bowel, torsion of a pedunculated fibroid, degeneration (hyaline, cystic, calcific, red, sarcomatous — rare, below 1%), prolapse of a submucous fibroid through the cervix
- In pregnancy: red degeneration with pain (treated with analgesia), malpresentation, obstructed labour from a cervical or lower segment fibroid, preterm labour, postpartum haemorrhage
- Of myomectomy: haemorrhage and transfusion, conversion to hysterectomy, infection, adhesions affecting fertility, recurrence (up to half within 5 years), uterine rupture in a later pregnancy
Review 6 weeks after surgery with histology, haemoglobin and fertility plans; refer for fertility assessment if she has not conceived within 6–12 months of trying.
Examiner questions
References
- Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Corton MM, Schaffer JI, eds. Williams Gynecology. 4th ed. New York: McGraw Hill; 2020.
- Munro MG, Critchley HOD, Fraser IS. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. International Journal of Gynecology and Obstetrics. 2018;143:393–408.