CASE SCENARIO

A 32 year old woman complains of increasingly long and heavy periods over
the past 5 years. Previously she bled for 4 days but now bleeding lasts
up to 10 days. The periods still occur every 28 days. She experiences
inter menstrual bleeding between most periods but no post coital bleeding.
The periods were never painful previously but in recent months have become
extremely painful with intermittent cramps. She has had four normal
deliveries and had a laparoscopic sterilization after her last child. Her
smear tests have always been normal, the most recent being 4 months ago.
She has never had any previous irregular bleeding or other gynecological
problems.
Upon examination, the abdomen is soft and nontender. With Speculum,
theres no palpable examination mass and shows a normal cervix. On
bimanual palpation, the uterus is bulky (approximately 8 week size), mobile
and anteverted.
During investigations, it revealed:
Haemoglobin 9.2 g/dL
Mean cell volume 75 f
White cell count 4.5 * 109/L
Platelets 198 * 109/L
Hysteroscopy was done.
This woman was diagnosed to have a Submucosal fibroid. Submucosal
fibroids are a common cause of menorrhagia and can cause, as in this case,
intermenstrual bleeding. Fibroids usually dont cause intermenstrual
bleeds other than when there is ulceration or it is submucous or cervical
fibroid

1. What symptoms do fibroids cause?

Most fibroids cause no symptoms at all. Depending on their size,
location and number, fibroids can become significantly problematic.
Some common symptoms associated with fibroids include:
1.
2.
3.
4.
5.

Abnormal uterine bleeding, heavy or long periods

Bulk and pressure symptoms
Bladder pressure, frequent urination
Rectal pressure, constipation
Infertility or recurrent miscarriages/pregnancy loss

6. Pregnancy complications
7. Pain
8. Anemia
2. Causes
Doctors don't know the cause of uterine fibroids, but research and clinical experience
point to these factors:
Genetic changes. Many fibroids contain changes in genes that differ from those in normal
uterine muscle cells. There's also some evidence that fibroids run in families and that
identical twins are more likely to both have fibroids than nonidentical twins.
Hormones. Estrogen and progesterone, two hormones that stimulate development of the
uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote
the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than
normal uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in
hormone production.
Other growth factors. Substances that help the body maintain tissues, such as insulin-like
growth factor, may affect fibroid growth.
3. Risk factors
There are few known risk factors for uterine fibroids, other than being a woman of
reproductive age. Other factors that can have an impact on fibroid development include:

Heredity. If your mother or sister had fibroids, you're at increased risk of developing
them.

Race. Black women are more likely to have fibroids than women of other racial
groups. In addition, black women have fibroids at younger ages, and they're also likely to
have more or larger fibroids.

Other factors. Onset of menstruation at an early age, having a diet higher in red
meat and lower in green vegetables and fruit, and drinking alcohol, including beer,
appear to increase your risk of developing fibroids.

4.

What are the treatment options for fibroids?

Medical management:

Gonadotropin-releasing hormone agonists (GnRH agnosits): This medication

is given as an injection (shot), either every month or every three months, and
puts you in a temporary state of menopause. While on the medication the
fibroids shrink. Once the medication is stopped, the fibroids usually re-grow and
symptoms return. GnRH agonists are usually used to prepare women for surgery
or to bridge women close to their natural menopause. GnRH agonists are not
usually used for long-term treatment.

Surgical management:
Myomectomy is a surgical procedure in which only the fibroids are removed, preserving
the uterus. As an alternative to hysterectomy, one advantage of a myomectomy is that
with the uterus in place, childbearing remains an option. A disadvantage of a
myomectomy is that when the uterus remains in place, fibroids can recur,
sometimes requiring additional surgery.
Fibroids can be removed by hysteroscopic myomectomy, laparoscopic myomectomy or
an open abdominal myomectomy.
Hysteroscopic myomectomy is a technique used to remove fibroids that
aresubmucosal. A hysteroscope, a thin tube containing a video camera, is passed
through the cervix and into the uterus. The fibroid is then removed by shaving it
out. There are no incisions with a hysteroscopic myomectomy. It is a day surgery
procedure (you typically leave the hospital 1 hour after the completion of the procedure)
with a 1-day recovery period.
Laparoscopic myomectomy is a technique used to remove fibroids that are intramural
(deep in the muscle of the uterine wall), subserosal or pedunculated(on the outside of the
uterus). This minimally invasive technique uses alaparoscopic technique to remove the
fibroids through very small incisions. It is a day surgery procedure (you typically leave
the hospital 1-2 hours after the completion of the procedure) with a 1-2 week recovery
period.
Open myomectomy uses a traditional large abdominal incision to remove the
fibroids. Most fibroids can be removed by minimally invasive techniques; the use of the
open method is limited to women with specific situations where laparoscopic or
hysteroscopic removal of fibroids is not appropriate.
5. If the patient refuses to surgical operation, what could be the possible
complications of this?
Although uterine fibroids usually aren't dangerous, they can cause discomfort and
may lead to complications such as anemia from heavy blood loss. Fibroids usually
don't interfere with conception and pregnancy. However, it's possible that fibroids
could cause infertility or pregnancy loss. Submucosal fibroids may prevent
implantation and growth of an embryo. In such cases, doctors often recommend
removing these fibroids before attempting pregnancy or if you've had multiple

miscarriages. Rarely, fibroids can distort or block your fallopian tubes, or interfere
with the passage of sperm from your cervix to your fallopian tubes.

CASE SCENARIO
A 32 year old woman complains of increasingly long and heavy periods over
the past 5 years. Previously she bled for 4 days but now bleeding lasts
up to 10 days. The periods still occur every 28 days. She experiences
inter menstrual bleeding between most periods but no post coital bleeding.
The periods were never painful previously but in recent months have become
extremely painful with intermittent cramps. She has had four normal
deliveries and had a laparoscopic sterilization after her last child. Her
smear tests have always been normal, the most recent being 4 months ago.
She has never had any previous irregular bleeding or other gynecological
problems. Upon examination, the abdomen is soft and nontender. With
Speculum, theres no palpable examination mass and shows a normal
cervix. On bimanual palpation, the uterus is bulky (approximately 8 week
size), mobile and anteverted. This woman was diagnosed to have a
Submucosal fibroid.
1.
2.
3.
4.

What symptoms do fibroids cause?

What usually causes uterine fibroids?
What are the possible risk factors of this disease?
What are the treatment options for fibroids?
5. If the patient refuses to surgical operation, what could be the
possible complications of this?