Model Answer
0 min readIntroduction
Uterine fibroids (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 lead to infertility. The prevalence of fibroids varies with age and ethnicity, with African American women having a higher incidence. A 25-year-old woman presenting with menorrhagia and multi-fibroid uterus requires a thorough evaluation to determine the optimal management strategy, balancing symptom control with preservation of fertility. This case necessitates a careful consideration of both medical and surgical interventions.
Evaluation
A comprehensive evaluation is crucial to confirm the diagnosis, assess the extent of the disease, and guide management decisions.
1. History Taking
- Menstrual History: Detailed assessment of menorrhagia – duration, amount of bleeding, impact on quality of life (using pictorial blood loss assessment chart - PBAC).
- Obstetric History: Previous pregnancies, deliveries, abortions, and any history of infertility.
- Symptoms: Inquire about pelvic pain, pressure symptoms (bladder, bowel), dyspareunia, and any history of anemia.
- Family History: Fibroids run in families.
- Medical History: Any co-morbidities like bleeding disorders.
2. Physical Examination
- General Physical Examination: Assess for signs of anemia (pallor, fatigue).
- Abdominal Examination: Palpate for uterine enlargement and assess the size and location of fibroids.
- Pelvic Examination: Bimanual examination to assess uterine size, shape, and consistency. Identify the location and size of fibroids.
3. Investigations
- Complete Blood Count (CBC): To assess for anemia.
- Ultrasound Pelvis (USG): Already done, confirming multi-fibroid uterus with the largest measuring 3x3cm. USG helps determine the number, size, and location of fibroids (submucosal, intramural, subserosal).
- Hysteroscopy: If submucosal fibroids are suspected, hysteroscopy can provide direct visualization and allow for biopsy to rule out malignancy.
- Saline Infusion Sonohysterography (SIS): Improves visualization of submucosal fibroids.
- Magnetic Resonance Imaging (MRI) Pelvis: Provides detailed anatomical information, especially useful for complex cases or when USG findings are inconclusive. Helps differentiate fibroids from adenomyosis.
- Serum CA-125: Can be elevated in fibroids, but not specific. Used to monitor response to treatment in some cases.
Management
Management options depend on the patient’s symptoms, age, desire for future fertility, and fibroid characteristics.
1. Medical Management
- Hormonal Contraceptives: Combined oral contraceptive pills (COCPs), progestin-only pills, or the levonorgestrel-releasing intrauterine system (LNG-IUS) can reduce menstrual bleeding.
- Tranexamic Acid: An antifibrinolytic agent that reduces heavy menstrual bleeding.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Can reduce pain and bleeding.
- Gonadotropin-Releasing Hormone (GnRH) Agonists: Induce a temporary menopausal state, reducing fibroid size and bleeding. Used as a pre-operative measure to shrink fibroids before surgery. Long-term use is limited due to bone loss.
- Selective Progesterone Receptor Modulators (SPRMs): Like ulipristal acetate, can reduce bleeding and fibroid size.
2. Surgical Management
- Hysteroscopic Myomectomy: For submucosal fibroids. Minimally invasive, preserves fertility.
- Laparoscopic/Robotic Myomectomy: For intramural and subserosal fibroids. Minimally invasive, preserves fertility, but carries a risk of bleeding and adhesion formation.
- Laparotomy Myomectomy: Open surgical removal of fibroids. Used for large or numerous fibroids. Longer recovery time.
- Uterine Artery Embolization (UAE): A minimally invasive procedure that blocks blood supply to the fibroids, causing them to shrink. May affect future fertility.
- Hysterectomy: Surgical removal of the uterus. Definitive treatment, but eliminates future fertility. Considered for women who have completed childbearing.
3. Management in this specific case
Given the patient’s age (25 years) and desire for future fertility, medical management should be the initial approach. LNG-IUS or tranexamic acid can be used to control menorrhagia. If medical management fails, laparoscopic myomectomy is a suitable option, given the relatively small size of the largest fibroid (3x3cm). UAE should be discussed with the patient, outlining the potential impact on future fertility. Hysterectomy is not indicated at this age unless other factors necessitate it.
| Treatment | Advantages | Disadvantages | Fertility Impact |
|---|---|---|---|
| LNG-IUS | Non-invasive, reduces bleeding | May cause irregular bleeding initially | Preserves fertility |
| Laparoscopic Myomectomy | Minimally invasive, preserves fertility | Risk of bleeding, adhesions, uterine rupture in future pregnancy | Preserves fertility |
| UAE | Minimally invasive | Potential impact on ovarian reserve and future fertility | May affect fertility |
| Hysterectomy | Definitive cure | Loss of fertility, surgical risks | Eliminates fertility |
Conclusion
Managing a 25-year-old woman with fibroid uterus and menorrhagia requires a tailored approach prioritizing fertility preservation. Initial medical management with LNG-IUS or tranexamic acid is recommended, followed by laparoscopic myomectomy if medical therapy fails. Thorough patient counseling regarding the risks and benefits of each treatment option is essential. Long-term follow-up is crucial to monitor for recurrence and assess reproductive outcomes. Further research into non-invasive therapies and personalized treatment strategies is needed to improve the management of uterine fibroids.
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.