management of uterine fibroids when it presents with heavy menstrual bleeding in a peri-menopausal 50 years old women.
Introduction: (150 words)
- Define uterine fibroids
- Literature review
- Incidence/prevalence and epidemiology of uterine fibroids in Australia
Mrs WM is 50-year old G4P2002 female who is presented to the operating theatre on the 11th of July for a hysteroscopy, dilatation and curettage (D&C), and Mirena insertion. The planned procedure was in the background of menorrhagia, and dysmenorrhoea.
Histopathology report from D&C on the 11th of July, secretory phase endometrium with no endometrial hyperplasia.
Mrs WM has been complaining of heavier menstrual bleeding for the last couple of months. Her usual menstrual cycle is 28-day cycle with bleeding for 6-7 days with its heaviest on the third to fourth day. She had menarche at the age of 13 years old and she is also peri-menopausal. She denied intermenstrual bleeding or post-coital bleeding. She is medically and surgically well otherwise. She is also a non-smoker, and non-drinker. She her sister has a history of heavy menstrual bleeding which is controlled with a Mirena. Socially, she lives with her partner and works as a casual worker.
Mrs WM was referred to the gynaecology clinic through her GP few months prior to the procedure with a pelvic ultrasound that showed three intra-mural uterine fibroids measuring 1.5 cm, 2 cm, and the largest 3*2 cm on the fundus of her uterus.
In the clinic, patient was asking for a hysterectomy due to the effect of her symptoms on her quality of life. However, all possible options were explained and possible effects and side effects of each. she was consented to go for a hysteroscopy, D&C (as a diagnostic procedure) and a Mirena insertion as a first line medical therapy.
Five days post the procedure (16th of July), she started having her expected normal menstrual cycle. On the 22nd of July, she went for a follow up in the gynaecology clinic and was told that her vaginal bleeding is likely to stop in the next few days. Her bleeding progressively worsens with large clots requiring a new pad every 1.5 hrs.
On the 3rd of August, she was admitted to hospital for Dysfunctional Uterine bleeding (DUB). Patient was managed and monitored accordingly and didn’t required any blood transfusion. On a transvaginal ultrasound in ED, there was no evidence of intrauterine device (Miena) in situ. Patient was unaware of passing the mirena due to the heavy bleeding.
Patient is now on acute medical therapy including; Tranexamic acid 1 gram three times a day, Norethisterone 10 mg four times a day, and Ponstan 500 mg three times a day. On 8th of August, bleeding started to get slightly better.
Patient was consulted again for other options of treatment including surgical options (uterine ablation and hysterectomy). Patient again is asking for a hysterectomy due to the effects of bleeding on her quality of life and the embarrassment caused due to bleeding going through her clothes for the last few months. Patient was discharged home with a follow up plan in the clinic to decide on the best management options. In the follow up, patient was consented and booked for an elective hysterectomy. Side effects and possible complications were explained.
Management (300 words):
- Presents important points and issues from the patient’s history, presentation and physical examination. Discusses the patient’s management including investigations and tests performed with relevance to the presented case.
Discussion part: (450 words): (using current literature and guidelines):
- Determines the main points and discusses challenges, alternative options and/or deficits in the management of the case presented.
- Management of uterine fibroids according to the New South wales guidelines? Compare the patient’s management to NICE guidelines (very important to compare it to NICE) or Western Australia guidelines, which one shows better outcomes? Possible complications, side effects for management?
- PLEASE consider patients age, peri-menopausal state, history of heavy menstrual bleeding, QUALITY OF LIFE, patient’s choice, informed consent, no history of endometrial hyperplasia in histopathology report.
Conclusion (200 words):
What do you think of the management of this case? Adequate? And why?