Model Answer
0 min readIntroduction
Uterine fibroids, also known as leiomyomas, are benign smooth muscle tumors of the uterus, commonly found in women of reproductive age. They are a significant cause of abnormal uterine bleeding (AUB), including menorrhagia, and can contribute to infertility. The prevalence of fibroids varies with age and ethnicity, with African American women having a higher incidence. The presence of multiple fibroids, as in this case, can complicate management. A comprehensive evaluation is crucial to determine the optimal treatment strategy, balancing symptom control with the patient’s reproductive goals. This case presents a 25-year-old woman with menorrhagia and multi-fibroid uterus, necessitating a tailored approach to evaluation and management.
Evaluation
1. History Taking
A detailed menstrual history is paramount, including duration of menorrhagia, amount of blood loss (using pictorial blood loss assessment chart - PBAC), impact on quality of life, and associated symptoms like dysmenorrhea, pelvic pain, and pressure symptoms (bladder/bowel). Past medical and surgical history, including previous treatments for menorrhagia, should be elicited. Family history of fibroids or AUB is also important. Crucially, assess the patient’s desire for future fertility.
2. Physical Examination
A thorough general physical examination should be performed. Pelvic examination is essential to assess uterine size, shape, and consistency. Bimanual examination helps determine the location and size of fibroids. Assess for signs of anemia (pallor, conjunctival pallor).
3. Investigations
- Complete Blood Count (CBC): To assess for anemia secondary to menorrhagia.
- Ultrasound Pelvis (USG): Already performed, revealing multi-fibroid uterus (largest 3x3cm). USG helps determine the number, size, and location of fibroids (submucosal, intramural, subserosal).
- Hormonal Profile: TSH, prolactin, and potentially FSH/LH to rule out other causes of AUB.
- Endometrial Biopsy: To rule out endometrial hyperplasia or malignancy, especially in women over 45 or with persistent AUB despite treatment.
- Hysteroscopy: Considered if submucosal fibroids are suspected or if endometrial biopsy is inconclusive.
- MRI Pelvis: May be considered for better characterization of fibroids, especially if USG findings are unclear or surgical planning is required.
Management
1. Medical Management
Medical management aims to control symptoms, particularly menorrhagia, and may be suitable for patients not desiring immediate fertility or those awaiting definitive treatment.
- Tranexamic Acid: An antifibrinolytic agent that reduces menstrual blood loss.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Reduce prostaglandin production, decreasing uterine contractions and blood flow.
- Combined Oral Contraceptive Pills (COCPs): Regulate menstrual cycle and reduce bleeding.
- Levonorgestrel-Releasing Intrauterine System (LNG-IUS): Effective in reducing menorrhagia and can be used for up to 5 years.
- Gonadotropin-Releasing Hormone (GnRH) Agonists: Induce temporary medical menopause, shrinking fibroids and reducing bleeding. Used as a pre-operative measure to reduce fibroid size before surgery. Long-term use is limited due to side effects (bone loss).
2. Surgical Management
Surgical options are considered for patients with severe symptoms, failure of medical management, or desire for definitive treatment. Given the patient’s age and desire for fertility, conservative surgical options are preferred.
- Hysteroscopic Myomectomy: Suitable for submucosal fibroids. Minimally invasive, preserving the uterus.
- Laparoscopic/Robotic Myomectomy: For intramural and subserosal fibroids. Minimally invasive, preserving the uterus. Requires skilled surgeons. Risk of adhesions and uterine rupture in future pregnancies.
- Uterine Artery Embolization (UAE): A minimally invasive procedure that blocks blood supply to fibroids, causing them to shrink. May affect future fertility.
- Hysterectomy: Definitive treatment, but not ideal for a 25-year-old desiring future fertility. Considered only if other options fail or are not suitable.
3. Management Plan for this Patient
Given the patient’s age (25 years) and presentation with menorrhagia and multi-fibroid uterus (largest 3x3cm), the following approach is recommended:
- Initial Medical Management: Trial of tranexamic acid and/or LNG-IUS to control menorrhagia.
- If medical management fails: Consider hysteroscopic myomectomy if submucosal fibroids are contributing significantly to bleeding.
- If hysteroscopy is not feasible or intramural/subserosal fibroids are dominant: Laparoscopic/robotic myomectomy should be considered, with careful counseling regarding potential risks to future fertility.
- Pre-operative MRI: To better delineate fibroid location and size for surgical planning.
Conclusion
Managing fibroid uterus in a young woman with menorrhagia requires a tailored approach, balancing symptom control with preservation of fertility. Initial medical management is often the first step, followed by conservative surgical options like hysteroscopic or laparoscopic myomectomy if medical therapy fails. Thorough evaluation, patient counseling, and careful surgical technique are crucial for optimal outcomes. Long-term follow-up is essential to monitor for recurrence and assess reproductive function.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.