Recurrent Myoma in a Patient presenting with MenorrhagiaLYNDON WOYTUCKMBBS4 PROGRAMME AT ST GEORGES UNIVERSITY OF LONDON DELIVERED BY THE UNIVERSITY OF NICOSIASHEBA MEDICAL CENTER AT TEL HASHOMER

M.A.

46 years old Presented to the gynaecology ER on Dec 12 complaining of four days

bleeding and 2 of which heavy bleeding (menorrhagia) and symptoms of presyncope

G1P0 – spontaneous abortion at 6 weeks when aged 36 years Has a history of similar symptoms beginning 2 years ago and resolved

with surgery 30/07/15

What is your differential for this past surgical

condition?

Present Illness

Now M.A. has symptoms of: Dyspareunia Post-coital bleed Premenstrual bleeding for 2 days Then heavy menstrual bleeding for 2 days up to present Previous menorrhagia in October for two weeks, during first menses after

myomectomy in July Presyncope: lightheadedness on exertion, “about to faint” Pelvic pain 7/10 and pressure (fullness)

What is your differential?

Menorrhagia – Common diagnoses

Menstruation at regular cycle intervals but with excessive flow and duration

You must exclude PREGNANCY as the most common cause of irregular bleeding in women of reproductive age before further testing or drug therapy; particularly spontaneous, threatened or incomplete abortion, ectopic pregnancy, or

retained products of conception must be considered

Polycystic ovarian syndrome Leiomyomata (uterine fibroids) Endometritis Salpingitis (PID) Dysfunctional Uterine Bleeding Endometrial Polyp

Menorrhagia – Uncommon diagnoses

Uterine malignancy Adenomyosis Gestational trophoblastic disease

(choriocarcinoma) Ectopic pregnancy Disorders of haemostasis Hypothyroidism Endometriosis

Intrauterine contraceptive device (IUD)

Anticoagulant administration Cervical cancer Hepatic failure Renal failure

What other guided questions should you ask in the history?

Gynaecologic History

History of similar illness gradual lengthening of menstrual bleeding from 5 to 9 days over 2 years

28+5 day cycle since menarche at 14 increasingly heavier menstrual flow each period, up to 3-4x usual over the 9

days the flow was heaviest at the beginning of each period, weakness on exertion and syncope, and bilateral waist/pelvic pain, Never used contraceptives Absence of other specific symptoms, such as thyroidism, galactorrhea,

hirsutism, bruising or systemic disease

What does this history suggest?

History of Myomatous Disease

Diagnosed by transvaginal ultrasound for multiple fibroids of intramural type. 5 myomas of 4.5-5cm in size, with 14 myomas in total.

Ultrasound found uterus to be enlarged: 62×54×39mm Conservative myomectomy by laparotomy chosen between patient and

doctor in order to preserve reproductive function for child bearing

Surgical HX Abdominal Myomectomy

Immediate complications: Beware of blood loss in the anaemic patient 10.15g/dL, 31% HCT (35-47), MCV 75fL 1/150 Are converted to hysterectomy to prevent further blood loss and failure to

close after many/large uterine incisions Delayed complications:

DVT TE / PE, infection, adhesions, Post op hernia, decreased fertility due to scarring, Uterine rupture in future delivery: need for Caesarean (recommended in this case)

Post op: reduce exercise and no intercourse for 4-6weeks

What risk factors and conditions should be

addressed in the medical history?

Relevant Medical History

Past Medical: GORD since 2007, Atopic dermatitis Past Surgical: Abdominal Myomectomy July 30 Medications: Paraffin ointment, Multivitamin daily, no allergies Social/Ethno: African diplomat, trying for a child for several months,

partner is abroad, non-drinker, non-smoker, lives with sister, exercises moderately, and practicing Christian

Family: Father had hypertension at 70 years old, older sister had myomectomy 9 years prior with failure to conceive since

Which exams and what should be

ruled out?

Examination tailored to menorrhagia differential

General Conjunctival pallor indicative of anaemia, pulse regular 87/min, bp 126/82, T 36.5C BMI=23, no visible hair loss, intact nails, no oedema, and non-enlarged thyroid make

hypothyroidism unlikely Obesity, acne, male pattern hair loss, hirsutism, clitoromegaly and acanthosis nigricans -

polycystic ovary syndrome or excess androgens No Jaundice, hepatomegaly, or ecchymoses – liver impairment + resultant coagulopathy

Bimanual examination – Negative for lumps indicative of uterine fibroids, ovarian tumours or other adnexal masses, as well as pregnancy. Tenderness over the uterus, may indicate myomata, adenomyosis, endometritis, or pregnancy. Enlargement of the uterus may indicate myomata or pregnancy.

Speculum examination – Negative for cervical or vaginal lesions - whether inflammatory or structural; if a lesion is found it must be biopsied – some blood found at the os

Examination and Immediate Management

Ultrasonography – 62x54x38mm –consistent with last measurement One myoma: ~3cm, submucosal, anterior and near cervix

Pain management with analgesic therapy-optalgin 1000mg PO Fluid resuscitation / blood replacement if necessary (None given) Phlebotomy If necessary, medical therapy like GnRH agonists (e.g., leuprorelin) and

antiprogestogens (e.g., mifepristone) can be used as an adjunct to surgery requiring a period of stabilization from significant anaemia

What are the relevant

investigations?

Investigations

Phlebotomy bHCG negative (<2 IU/L) CBC HB 10.69 g/dL, 33.76 % HCT, MCV 75.7fL – possible Fe deficiency Imaging

100% sensitivity and 95% specificity for submucosal myomas in TVUS with poor differentiation for endometrial polyps

Hysteroscopy for diagnostic purposes can visualise endometrial polyps very well (sensitivity 92%), but it is less accurate for the diagnosis of submucosal fibroids (82%, specificity 87%)

This is compared with 94% sensitivity and 95% specificity for sonohysterography in the diagnosis of submucosal fibroids

Outpatient hysteroscopy: 17/11/2015 had diagnostic hysteroscopy – Anterior wall submucosal myoma 3-4cm, over 50% intracavitary

What procedure should she undergo for

removal?

Hysteroscopic Myomectomy

The advantage of hysteroscopy is the ability to visualize, obtain a specimen for histology, and/or resect during the same procedure.

Also used as an important investigation of persistent abnormal uterine bleeding associated with a negative endometrial biopsy.

A resectoscope is passed and a cautery loop is used to excise the fibroid

Outpatient procedure, back at work and exercise in two days

How should she be monitored post-op?

Recurrence in Myomectomy Patients

Recurrence: approximately 10-15% after 5 years by laparotomy and 33-44% after 5 years by laparoscopy. Risk factors are age, myoma size, and number of tumors. Particular attention to recurrence is required for patients with uterine myomas of ≥10 cm diameter, with numerous myomas, and those age 35 years or older.

Annual pelvic exam should be given to document stable size and growth in patients suffering from leiomyomata.

Rapid changes in uterine size or de novo development of fibroid-like growth following menopause are hallmarks of endometrial cancer

Risk of leiomyosarcoma is small between 0.13 and 0.29% Abnormal vaginal bleeding, pain or urinary or GI symptoms require equal

attention as in other patients

Can M.A. bear children?

Child-bearing after Myomectomy

M.A. stated that one of the doctors said she would not be able to bear children and is worried considering her sister’s history

Persistent or recurrent myoma reduces chances of conception or taking pregnancy to full term after myomectomy.

Myomectomy is the only surgical procedure that preserves fertility for fibroid removal, as opposed to uterine artery embolization or hysterectomy

An English speaking patient in an Israeli hospital

There are many issues when a patient does not speak the same language as her carers M.A. expressed the loneliness of her situation when being ported by staff, and being

admonished by the anaesthesiologist when she asked to speak with the gynaecologist prior to her surgery

She experienced confusion and helplessness in the OR and in other healthcare interactions, but she was also delivered excellent surgical, emergency and follow up care

For her, a friendly face, taking a little extra time for her to process the medical information, and to ask a few questions was all she wanted, but culturally she felt unwanted and alone

“Shnia Rega!” was her impression of the Israeli health system, but I think it could be so much more

References

Medscape “Menorrhagia” accessed from: http://emedicine.medscape.com/article/255540-overview

BMJ BestPractice “Menorrhagia: Diagnosis” accessed from: http://bestpractice.bmj.com/best-practice/monograph/171/diagnosis/differential-diagnosis.html

BMJ BestPractice “Uterine fibroids: Treatment” accessed from: http://bestpractice.bmj.com/best-practice/monograph/567/treatment.html

Recurrence of uterine myoma after laparoscopic myomectomy: What are the risk factors? Gynecology and Minimally Invasive Therapy, Volume 1, Issue 1, Pages 34-36. Mitsuru Shiota, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, Hiroshi Hoshiai

Arnaud Fauconnier, Charles Chapron, Katayoun Babaki-Fard and Jean-Bernard Dubuisson. Recurrence of leiomyomata after myomectomy. Human Reproduction Update 2000, Vol. 6 No. 6 pp. 595-602