Villegas, Jose Bernabe GYNECOLOGY

Vinluan, Joseph David Dr. Trinidad

Wong, Deo Adiel August 28, 2007
Yague, Glenn 3rd Year-D
Yang, Caprice

Case #13
39 y/o G2P1 (1-0-1-1) came because of increase in amount of
duration of menses. She has regular menses, usually lasting for 4 days,
consuming 2-3 regular pads/day; (+) dysmenorrheal. For the past 2
months, menses lasted for 8 days, using 3 adult diapers/day. She is not
taking any meds. LMP – Aug. 26 PPE: stable VS, pale palpebral
conjunctiva; Abdomen – (+) firm, mobile, non-tender mass up to the
umbilicus; Spec: Cervix – smooth with moderate bleeding per os: IE –
firm, long, closed; Uterus – nodular, enlarged to 5 months size, movable,
non-tender.

1. What other information should be sought for?

A. General Data: Name, occupation, address, religion

B. Chief Complaint and HPI:
 excessive and prolonged menstruation (Menorrhagia)
- Characterize the bleeding: is it heavy the whole day, are there periods within
the day where there is no menstruation, or is the bleeding continuous
- What is the color and consistency of the blood? Dark or bright red?
- Is there accompanying pain? Dysmenorrhea? Fever?
- Does the patient feel weak, lightheaded, nauseous? (might indicate that the
patient is severely anemic)
- Are there any precipitating factors for the menorrhagia? Prior trauma,
infection, pregnancy complication? Any history of previous menorrhagia?
 Abdominal mass
- Onset of the mass
- Any accompanying symptoms such as pain, fever, constipation or diarrhea,
nausea and vomiting, feeling of bloating or abdominal enlargement
- Is the mass fast growing or slow growing?
- Any accompanying weight loss?
- Dyspareunia?
 Urinary frequency
- Any accompanying pain during urination, flank pain, urgency?
- Color of the urine
- Flow of urine? Is it continuous or irregular? Difficulty in emptying bladder?
C. Past Medical History
- History of bleeding disorders?
- Medications? Aspirin or other NSAIDS?
- Diabetic?
D. Personal and Social History
- Smoking, alcohol intake?
- Illicit drug use?
 - Sexual history: monogamous or polygamous?
E. Obstetric and Gynecologic History
- Any prior surgical procedures?
- Any pregnancy-related problems?
- Age of menarche
- Use of OCP and other contraceptives
F. Review of Systems: should be complete, but focus on:
- abdomen
- genito-urinary
- Check for bipedal edema

2. What other diagnostic work-up should be requested?

a. CBC (including Hgb, Hct and wbc ) – to detect anemia or thrombocytopenia.

PT and Partial Thromboplastin time – to screen coagulation.
Assess platelet function – to screen for VW disease.

b. Pregnancy test (HCG) – to rule out pregnancy-related problems.

c. Pelvic Ultrasonography – to delineate anatomic abnormalities if ovarian mass is

suspected.
- to evaluate uterine contour, endometrial thickness and
ovarian structure.
- there is high percentage of locating the mass.
- (cost is the deterring factor in the use of MRI)

d. Saline Infusion Sonohysterography (SIS) – helpful in visualizing intrauterine

problems such as polyps or submucous leiomyoma.

e. Hysteroscopy - to see the whole endometrial cavity, which is both diagnostic and
therapeutic.

f. Endometrial Sampling (histologic evaluation) – to evaluate abnormal bleeding in

women who are at risk for endometrial polyps, hyperplasia or carcinoma.
(D & C - is now replaced by endometrial biopsy in the office)

3. What is the diagnosis? What is the differential diagnosis?

The patient presented with menorrhagia (regular menses with increased duration
and amount of menses). On PE, a firm mobile mass was noted and the uterus was
nodular and enlarged to 5 months size.

The most likely diagnosis is uterine leiomyoma. Uterine leiomyomas occur in as

many as one half of all women older than age 35 years and are the most common
tumors of the genital tract. Leiomyomas, or myomas or fibroids, the most common
tumors in women, are benign uterine tumors which may be subserosal, intramucosal or
submucosal within the uterus or in the cervix. They are most common in women in active
reproductive life (which our patient belongs to), and are related to estrogenic stimulation.
Current studies posit that leiomyomas originate from a single neoplastic cell within the
smooth muscle of the myometrium. A pseudocapsule separates the myoma from the
myometrium, allowing for easy enucleation during surgery. They are frequently
 diagnosed via ultrasound, depending on their location, and surgically removed when
they are greater than 3 cm in diameter or when they cause significant pain or
menorrhagia. Fortunately, very few leiomyomas undergo malignant degeneration.
Most leiomyomas are asymptomatic. The most common presenting symptom is
menorrhagia; submucosal myomas are the most likely to cause bleeding. Bleeding is
also the most common cause for surgical intervention. Uterine leiomyomas are
frequently diagnosed on the basis of clinical findings enlarged irregular uterus on pelvic
examination, which was noted in this patient. Leiomyomas may also present with pelvic
pain. Acute pelvic pain (which this patient does not have) result from torsion of a
pedunculated leiomyoma or from infarction. Chronic pelvic pain is due to the size of the
enlarged myoma encroaching on supporting ligaments or other somatic structures to
cause pain.

Differential diagnosis:
a. Adenomyosis
Adenomyosis occurs when endometrial tissue is present within the myometrium.
Unlike the ectopic glands in endometriosis, the ectopic glands in adenomyosis do not
undergo monthly cyclical changes. It is frequently asymptomatic; the dysmenorrhea that
occurs with adenomyosis starts a few days before menses and may not end until
menstruation has stopped. Symptoms of adenomyosis classically include dysmenorrhea
and menorrhagia (heavy menstrual bleeding). As the disease progresses, so does the
dysmenorrhea. On physical examination, the uterus is soft, globular, and uniformly
enlarged but there is no associated adnexal pathology. Typically, the uterus is tender just
before and during menstruation. The definitive diagnosis of adenomyosis is made during
hysterectomy; this is also the treatment for this condition, but NSAIDs and OCPs may be
useful. This condition is likely if our patient has a diffusely enlarged uterus with a
negative pregnancy test.
b. Endometrial polyps
Endometrial polyps can cause intermenstrual bleeding, irregular bleeding, and
menorrhagia, although as with leiomyomas, most endometrial polyps are aymptomatic.
The incidence of endometrial polyps increases with age throughout the reproductive
years. The diagnosis is based on either visualization with hysteroscopy or
sonohysterography or the microscopic assessment of tissue obtained by a biopsy done
in the office or curettage specimen. Endometrial polyps can regress spontaneously. In
one study in which asymptomatic women underwent repeat sonohysterography after 2.5
years, four of seven polyps resolved. The larger polyps were more likely to result in
abnormal bleeding. In one large series, it was rare to find atypia or carcinoma in an
endometrial polyp from a premenopausal woman.
c. Uterine cancer
Invasive neoplasms of the female pelvic organs account for almost 15% of all
cancers in women. The most common of these malignancies is uterine cancer,
specifically, endometrial cancer. Endometrial cancer is the fourth most common cancer
in women, following breast, lung, and colorectal cancer, in that order. However, it is only
the eighth most common cause of cancer deaths because it is usually detected in early
stages. The most common symptom in up to 90% of women is postmenopausal (PMP)
bleeding.
Sixty percent of endometrial carcinomas are adenocarcinomas. Other histologic
subtypes include adenosquamous, clear cell, and papillary serous carcinomas.
Sarcomas make up about 4% of uterine corpus malignancies, including
 carcinosarcomas or mixed homologous müllerian tumors (48-50%), leiomyosarcomas
([LMS] 38-40%), and endometrial stromal sarcomas ([EES] 8-10%).
Endometrial cancer is primarily a disease of postmenopausal women. The
average age at diagnosis is approximately 60 years. Women diagnosed with endometrial
cancer when they are younger than 40 years make up only 5% of the total cases. These
women invariably have specific risk factors such as morbid obesity, chronic anovulation,
and hereditary syndromes. Since our patient is still in the reproductive age group, this
diagnosis would be less of a consideration.

• Risk factors for endometrial cancer

o Obesity (relative risk of 2-11) - Relative risk of 3.0 in women 21-50 lb overweight
and 10 in women more than 50 lb overweight
o Nulliparity (relative risk of 2-3)
o Late menopause, ie, occurring in women older than 52 years (relative risk of 2.4)
o Exogenous unopposed estrogen (relative risk of 1.6-12)
o Tamoxifen (relative risk of 1.7-2.5)
o Diabetes (relative risk of 1.3-2.7)
o Hypertension (relative risk of 1.2-2.1)
o High dietary fat consumption
o Radiation therapy (relative risk of 8)

Abnormal uterine bleeding in the reproductive years should be considered a

complication of pregnancy until proven otherwise. All women of reproductive age should
have a urine or serum pregnancy test.
In women with evidence of ovulation, abnormal uterine bleeding should prompt
suspicion of benign pelvic lesions. Evidence of ovulation includes bleeding at regular
intervals preceded by premenstrual symptoms (eg, bloating, lower abdominal discomfort),
a biphasic temperature curve, a change in cervical mucus, or an endometrial biopsy
sample demonstrating secretory endometrium. These patients should undergo thorough
endometrial evaluation for pelvic lesions when there is no obvious alternative cause of
abnormal bleeding.
Without exception, perimenopausal or postmenopausal women with abnormal
uterine bleeding should undergo endometrial evaluation. Until malignancy has been ruled
out, it should be considered the cause. About 20% to 25% of cases of endometrial
carcinoma occur before the menopause. Endometrial evaluation should be considered in
women under 35 years of age who show evidence of chronic anovulation. These women
are at increased risk for endometrial carcinoma secondary to prolonged unopposed
estrogen stimulation of the endometrium.
Hypothyroidism is an uncommon, although important, cause of metrorrhagia or
menorrhagia. Women with unexplained severe menorrhagia should undergo thyrotropin
assay. With thyroid replacement therapy, abnormal uterine bleeding resolves in 3 to 6
months.
Dysfunctional uterine bleeding is a diagnosis of exclusion. In the vast majority of
cases, it is secondary to anovulation, which is more common at the extremes of
reproductive age (ie, during the postmenarchal and perimenopausal periods). The positive
feedback of estradiol secretion is usually the last step in the process of pubertal
neuroendocrine maturation, and until this secretion begins, menstrual cycles are
anovulatory. When women are in their 40s, anovulation again becomes more prevalent.
 Chronic anovulation may also be associated with thyroid or prolactin disorders,
premature ovarian failure, adult-onset congenital adrenal hyperplasia, or polycystic ovary
syndrome. Some common causes of hypothalamic anovulation are weight loss or gain,
eating disorders, stress, chronic illness, and excessive exercise. Women with chronic
anovulation that is not attributable to any of these causes are considered to have
idiopathic chronic anovulation.
Anovulatory bleeding can be thought of as estrogen breakthrough bleeding. This
type of bleeding is related to the levels of estrogen stimulating the endometrium. For
example, high levels of estrogen for prolonged periods result in amenorrhea followed by
acute intermittent heavy bleeding, and continually low levels of estrogen availability result
in intermittent spotting.
Our patient is not an adolescent anymore, but for the sake of completion, one
differential diagnostic consideration is coagulopathy. All adolescents with menorrhagia
severe enough to require hospitalization or significantly reduce hemoglobin levels (to <10
g/dL) should undergo evaluation for coagulopathy. Disorders of both platelet number and
function may cause menorrhagia. Von Willebrand's disease, a defect in platelet adhesion
and a deficiency of factor VIII, is the most common bleeding disorder, affecting about 1%
of the population. Diseases causing thrombocytopenia include idiopathic
thrombocytopenic purpura, leukemia, and aplastic anemia. In adolescents, the prevalence
of a primary coagulation disorder requiring hospitalization for abnormal uterine bleeding
ranges from 3% to 20%.

4. What are the best treatment options?

NONSURGICAL (Usually indicated for asymptomatic leiomyomas)

a. GnRH agonists – produces hypoestrogenism resulting to a 40-60 % decrease in
uterine volume and should be used only for short time because if its associated
reversible bone loss and symptoms like hot flashes.
i. To preserve fertility in women preoperatively and before attempting
conception (large myomas)
ii. Anemia treatment preoperatively
iii. To avoid surgery in women nearing menopause
iv. Preoperative treatment in large myomas for better view of certain procedures
like vaginal hysterectomy, hysteroscopic resection or ablation, or
laparoscopic destruction
v. To avoid surgery in women with medical contraindications
vi. To delay surgery in women with personal indications or even medically

b. GnRH antagonists – has similar clinical results with GnRH agonists. The advantage of
these medications is the rapid onset of clinical effects and absence of an agonist
phase.

c. Mifepristone — This antiprogestin (RU-486) reduces uterine volume comparable to

that observed with GnRH-agonists.

d. Danazol and gestrinone — Danazol has progestin-like effects. Its mechanisms of

action include inhibition of pituitary gonadotropin secretion, direct inhibition of
endometriotic implant growth, and direct inhibition of ovarian enzymes responsible for
estrogen production. Since it induces amenorrhea, danazol may control anemia due
to fibroid-related menorrhagia, but does not appear to reduce uterine volume. On the
 other hand, Gestrinone decreases myoma volume and induces amenorrhea. An
advantage of this drug is that there is a carry-over effect after it is discontinued.

e. Raloxifene — In one study of postmenopausal women with uterine leiomyomas,

raloxifene (60 mg/day for 12 months) reduced leiomyoma size when compared to
placebo.

***It is also important to note the cost of GnRH agonists in treating anemia. Iron
supplementation preoperatively could increase the hematocrit.

***GnRH agonists with add-back therapy – important in the reduction of the symptoms
in GnRH therapy. Low dose estrogen-progestin therapy maintains amenorrhea and
the reduction in uterine volume while preventing significant hypoestrogenic side
effects.

***NSAIDs and antifibrinolytic agents are useful in the treatment of idiopathic

menorrhagia, but have not been extensively studied in leiomyoma–related
menorrhagia. NSAIDs do not appear to reduce blood loss in women with myomas.

***Ineffective therapies — Medical treatments that are commonly prescribed, but

appear ineffective, include oral contraceptives, progestational agents, and
nonsteroidal antiinflammatory drugs. However, they may be useful in women with
coexisting problems (eg, pain or oligoovulation).

***Although progesterone cream is a popular treatment for leiomyomas, there are no

published studies demonstrating efficacy. Furthermore, in vitro data suggest that
progestins are growth factors for myomas.

***Steroidal agents — Many algorithms for the treatment of abnormal bleeding due to
myomas suggest a trial of OCPs or progestin therapy prior to proceeding to definitive
therapy. There is no evidence to suggest that these are effective therapies for
myomas. However, correcting oligoovulation and inducing endometrial atrophy by
hormonal therapy may help to decrease overall bleeding.

SURGICAL
a. Hysterectomy – definitive treatment; eliminates both current symptoms and the
chance of recurrent problems. Moreover, a two year follow-up study of 1,299 women
who had undergone hysterectomy for benign conditions found that >90% noted
significant reductions in symptom severity, depression, and anxiety levels, and an
improvement in quality of life.
b. Myomectomy - option for women who desire future pregnancies or otherwise wish to
retain their uterus. Although myomectomy is an effective therapy for menorrhagia and
pelvic pressure, the disadvantage of this procedure is the significant risk that more
leiomyomas will develop from new clones of abnormal myocytes.
c. Uterine artery embolization – provide short-term relief of bulk-related and bleeding
symptoms, although serious consequences like massive bleeding and necrosis
requiring emergency surgery have been reported.
d. Myolysis - laparoscopic thermal coagulation or cryoablation (cryomyolysis) of
leiomyoma tissue. This technique is easier to master than resection, which requires
 suturing. However, localized tissue destruction without repair may increase the
chance of subsequent adhesion formation or rupture during pregnancy
e. Laparotomy — A transabdominal myomectomy is the treatment of choice when there
are multiple myomas, the uterus is significantly enlarged (myomas greater than 5 to 8
cm or volume greater than 16 weeks' size), or the myomas are deep and intramural.
f. Hysteroscopic myomectomy – preferred conservative surgical option for women with
symptomatic intracavitary fibroids. Candidates include those with abnormal uterine
bleeding, infertility or recurrent miscarriage, after other etiologies have been excluded.
g. Endometrial ablation — Endometrial ablation, either alone or in combination with
hysteroscopic myomectomy, may alleviate bleeding with minimal invasiveness in
women with uterine leiomyomas who have completed childbearing.

REFERENCES:
• Berek, J. Novak’s Gynecology, 14th edition.
• http://www.slwhc.com/Patient%20education/Treatment%20for%20Uterine%20Leiomyom
as.htm
• www.emedicine.com