Benign Tumour of Uterus - Fibroid Uterus

Q.1 - Possible Causes of Menorrhagia (5 marks)

1. Uterine fibroids (Leiomyomata uteri) - especially submucosal type; Type 0 and Type 1 fibroids are strongly associated with menorrhagia and anemia
2. Adenomyosis - diffuse infiltration of myometrium by endometrial glands
3. Endometrial polyps - focal endometrial overgrowth
4. Endometrial hyperplasia - especially in perimenopausal women
5. Endometrial carcinoma - must be excluded in a 45-year-old

Note: The key teaching point from Berek & Novak (p. 504) is that "the association of fibroids with heavy menstrual bleeding is not clearly established" - therefore, other etiologies, particularly coagulopathies such as von Willebrand disease, should always be considered.

Q.2 - Relevant Investigations (5 marks)

1. Complete Blood Count (CBC) - to assess hemoglobin, platelets (anemia is expected; low Hb is significantly associated with submucosal fibroids)
2. Serum iron, TIBC, serum ferritin - to assess iron deficiency anemia
3. Coagulation profile (PT, aPTT, bleeding time) - to rule out coagulopathy; Von Willebrand factor assay if clinically indicated
4. Thyroid Function Tests (TSH, T3, T4) - to exclude hypothyroidism

Q.3 - Most Probable Diagnosis (3 marks)

• 45-year-old woman with menorrhagia for 12 months (regular cycles)
• Uterus of 14 weeks size on bimanual examination (enlarged uterus)
• Cervix normal on speculum (rules out cervical pathology)
• Low hemoglobin (anemia - characteristic of submucosal fibroids)
• Sonography: 6x4 cm hypoechoic mass in the body of uterus with submucosal extension

Q.4 - Non-Surgical Treatment Options (5 marks)

1. Antifibrinolytic Agents

• Tranexamic acid 1.3 g three times daily for 3-5 days during menstrual bleeding. A pooled RCT analysis demonstrated significant reduction in menstrual blood loss compared to placebo in women with fibroids (Berek & Novak, p. 515). Adverse effects: headache, nausea.

2. GnRH Agonists (Gonadotropin-Releasing Hormone Agonists)

• Leuprolide acetate / Buserelin / Goserelin (monthly depot injections)
• Mechanism: downregulate pituitary GnRH receptors - hypoestrogenic state - shrink fibroids
• Reduce fibroid volume by ~30% and total uterine volume by ~35% within 3 months
• 37 of 38 women had resolution of heavy bleeding by 6 months
• Limitations: Side effects in 95%: hot flushes (78%), vaginal dryness, headaches, bone loss after 6 months
• For this 45-year-old perimenopausal patient, short-term GnRH-a can bridge her to natural menopause; 15/34 perimenopausal women in one study went into natural menopause after treatment - avoiding surgery altogether (Berek & Novak, p. 516)
• Add-back therapy (low-dose estrogen + progestin) may be considered to reduce hypoestrogenic side effects

3. Selective Progesterone Receptor Modulators (SPRMs)

• Ulipristal acetate (UPA) 5 mg or 10 mg daily orally in 12-week courses
• Achieves amenorrhea in ≥70% of women within 1 week
• ~80% of women achieve >25% reduction in volume of fibroids by the 4th treatment course
• Improves hemoglobin, pain scores, and quality of life
• E2 levels maintained above postmenopausal range - bone mineral density spared (Berek & Novak, p. 516-517)

4. Levonorgestrel-releasing Intrauterine System (LNG-IUS / Mirena)

• Significantly reduces menstrual blood loss and increases hemoglobin and ferritin
• Does NOT reduce fibroid volume
• Caution: expulsion rate is 15.4% with fibroids >3 cm - the fibroid here is 6x4 cm, making insertion technically difficult and expulsion risk high; hysteroscopic guidance recommended
• Suitable only if fibroid does not distort the uterine cavity significantly

5. GnRH Antagonist

• Ganirelix (daily SC injection) reduces fibroid volume 29% within 3 weeks; causes immediate GnRH suppression without the initial flare seen with agonists

6. Mifepristone (Antiprogesterone)

• 48% decrease in mean uterine volume after 6 months; controls bleeding
• Monitor with endometrial biopsy - risk of endometrial hyperplasia (28% in one review)

7. Correction of Anemia

• IV iron infusion (faster and more effective than oral iron - mean Hb increase 3.0 g/dL vs 0.8 g/dL for oral)
• Oral iron supplementation (concurrent with all above measures)

8. Uterine Artery Embolization (UAE) - Minimally Invasive (Non-Surgical)

• A radiological interventional procedure - not conventional surgery
• Reduces uterine volume by 35%; significantly improves frequency, urgency, and bleeding symptoms in the majority of patients
• An option to discuss if the patient wishes to avoid open surgery

Q.5 - Surgical Treatment After 2 Years (2 marks)

Recommended Surgery: Hysterectomy (Total Abdominal Hysterectomy)

• She is nulligravida, unmarried, and does not desire future fertility
• She is perimenopausal (47 years) - close to natural menopause
• The fibroid is large (6x4 cm) with submucosal extension, uterus 14 weeks size
• Hysterectomy provides definitive cure for menorrhagia from fibroids - no risk of recurrence

• Total Abdominal Hysterectomy (TAH) with or without bilateral salpingo-oophorectomy (BSO) - decision on ovarian conservation depends on intraoperative findings and patient discussion
• At 47 years, ovarian conservation is usually preferred unless ovarian pathology is present, to avoid surgical menopause

• Hysteroscopic myomectomy - for submucosal fibroids; however, with a large 6x4 cm fibroid and uterus of 14-week size, hysteroscopy alone may be insufficient
• Abdominal myomectomy - if she specifically requests uterine conservation despite not wanting children; Berek & Novak (p. 518) notes myomectomy relieves symptoms in ~80% but fibroid recurrence is possible

Note: For this specific patient - nulligravida, no desire for fertility, perimenopausal - Total Abdominal Hysterectomy (TAH) is the definitive and most appropriate surgical procedure, as it eliminates all symptoms and prevents recurrence.