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 flood-ing 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 xiphisternum (equiva-lent to a 32-week 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.
Questions
• What is the diagnosis?
• How would you further investigate and manage this woman?
Medicine
The woman has a large uterine fibroid (leiomyoma). This is causing menorrhagia and hence the microcytic anaemia from iron deficiency. It is also likely that the fibroid is accounting for her infertility history, although this warrants investigation as a separate problem.
Fibroids are benign tumours of the myometrium which may be extrinsic (subserous) as in this case. Alternatively they may be intramural or submucosal (projecting into the endo-metrial cavity).
Fibroids are not typically painful unless they undergo degeneration, usually in pregnancy. African-Caribbean women tend to develop fibroids more commonly than other ethnic groups.
Further investigation Ferritin and folate levels should be checked to confirm the iron-deficiency status. It is also advisable to arrange renal function tests and a renal tract ultrasound, as very large fibroids can cause ureteric obstruction and hydronephrosis, which would need urgent treatment.
Management
The woman should be treated for her anaemia with ferrous sulphate. The menorrhagia can be reduced with tranexamic acid during menstruation. Gonadotrophin-releasing hormone analogues temporarily shrink fibroids and cause amenorrhoea to allow correction of iron deficiency. Definitive treatment for fibroids is traditionally by hysterectomy or myomec-tomy. Myomectomy is favourable for this woman who is keen to have a family, so con-servation of the uterus is essential. Uterine artery embolization also causes fibroid degeneration by interruption of the blood supply. However research into long-term safety and potential effects on uterine function during pregnancy are not clear, and this option is currently advised in the context of a research setting only.
KEY POINTS
• Fibroids may be small and incidental or occupy most of the abdomen.
• Anaemia should be suspected in any women with menorrhagia.
• Treatment of fibroids depends on the presence of symptoms and the necessity to preserve fertility.
• The optimal operative approach depends on the size and location of the fibroids.
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