BENIGN PATHOLOGIES OF THE UTERUS - Cases Joseph NASSIF, MD Case No 1A 47 year old female patient presents to your clinic

with intermenstrual bleeding. She is G6P5A1. She had 5 NVDs and no previous history of abdominal surgery. Her intermenstrual bleeding started 7 months ago but she did not consult her physician. Her LMP was 10 days ago. 1 What is the medical term of intermenstrual bleeding? 2 How would you assess the severity of her bleeding? 3 What would you search in the physical exam in this patient? 4 What is the first test that you would order in this patient? 5 Give 3 differential diagnosis. You did a pelvic ultrasound to this patient that came normal. 6 - How would you increase the sensitivity of this ultrasound? 7 If this patient have been diagnosed with a cervical polyp, how would you treat her? 8 In this case what is the percentage of this patient having an endometrial polyp?

Case No 2A 37 year old female G1P1A0 patient presents to the Emergency Room with heavy bleeding during her menses. She is having this menorrhagia since 5 months. She has been diagnosed with uterine leiomyoma and was treated with progestin containing pills. 1 How would her physician diagnose the leiomyoma in this patient? 2 What tests would you recommend in the ER for this patient? 3 What are the alternative treatments to progestin pills?

Case No 3A 51 years old lady, G4P4A0, presents to the OPD with severe dysmenorrheal of 8/10 on the Visual Analogous Scale (VAS) since two years. Recently, she developed along with her dysmenorrheal, heavy menstrual bleeding. She has 2 NVDS and 2 C-sections (the first one for fetal distress). She also reports clotting during menses. She has dyspareunia of 4/10. She is taking pain killers, especially paracetamol and NSAIDS but they were not efficient treating her pain. 1 If you suspect adenomyosis, what are the physical exam characteristics? 2 What are the imaging modalities to diagnose this pathology? 3 What is the best medical treatment for adenomyosis? 4 What is the definitive treatment of adenomyosis?

Case No 4 History A 36-year-old African-Caribbean woman has noticed abdominal swelling for 10 months. She has to wear larger clothes and people have asked her if she is pregnant, which she finds distressing having been trying to conceive. She has no abdominal pain and her bowel habit is normal. She feels nauseated when she eats large amounts. She has urinary frequency but no dysuria or haematuria. Her periods are regular, every 27 days, and have always been heavy, with clots and flooding on the second and third days. She has never received any treatment for her heavy periods. She has been with her partner for 7 years and despite not using contraception she has never been pregnant. Examination The woman has a very distended abdomen. A smooth firm mass is palpable extending from the symphysis pubis to midway between the umbilicus and the xiphi-sternum (equivalent to a 32week size pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the mass. On speculum examination it is not possible to visualize the cervix. Bimanual examination reveals a non-tender firm mass occupying the pelvis. Haemoglobin Mean cell volume White cell count Platelets 6.3 g/dL 68 fL 4.9 x 10E9/L 267 x10E9/L 11.715.7 g/dL 8099 fL 3.511 x 10E9/L 150440 x10E9/L

Magnetic resonance images (MRI) of the abdomen and pelvis are shown

Questions What is the diagnosis? How would you further investigate and manage this woman?