A 39-year-old woman complains of increasingly long and heavy periods over the last 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 intermenstrual bleeding between most periods but no postcoital 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 laparo- scopic 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 any other gynaecological problems.
The abdomen is soft and non-tender with no palpable masses. Speculum examination shows a normal cervix. On bimanual palpation the uterus is bulky (approximately 8 week size), mobile and anteverted. There are no adnexal masses.
· What is the diagnosis?
· How would you manage this patient and counsel her about the management and its potential risks?
The ultrasound scan shows a submucosal fibroid and this is confirmed by the hysteroscopy image. At hysteroscopy, a fibroid is a solid smooth immobile structure, whereas a polyp appears pink and fleshy and mobile. Submucosal fibroids are a common cause of menorrha- gia and can cause, as in this case, intermenstrual bleeding. The cramp-like pain occurs as the uterus tries to expel the fibroid. In some cases this eventually occurs with the fibroid becoming pedunculated and extending through to the vagina on a pedicle.
The management is by hysteroscopic (transcervical) resection of the fibroid (TCRF). This can be performed as a day case under general anaesthetic (or even local anaesthetic if the fibroid is small). The important points in counselling the patient are as follows.
Description of the procedure: the procedure involves stretching (dilatation) of the cervix and insertion of an endoscope into the uterus (hysteroscopy) to view the fibroid. The fibroid is ‘shaved’ away with a hot wire loop (diathermy). Fluid is circulated through the uterine cavity to enhance the view and allow cooling.
· bleeding: it is rare to bleed heavily but in the extreme situation blood transfusion could be required, or even a hysterectomy to control the loss
· fluid overload: during the procedure, irrigation fluid is absorbed into the circula- tion. Excessive absorption can cause breathing difficulties (pulmonary oedema) and the need for hospital admission
· uterine perforation: rarely the hysteroscope perforates the wall of the uterus and if this occurs or is suspected then laparoscopy is needed immediately to confirm it, secure any bleeding and check for damage to surrounding bowel or bladder.
What to expect afterwards: most women experience bleeding, discharge and passing of ‘debris’ for up to 2 weeks after the procedure.