A case study on a patient presenting with menorrhagia in a history of recurrent myomatous disease. The patient details have been changed to anonymize the individual.

1. Recurrent Myoma in a
Patient presenting with
Menorrhagia
LYNDON WOYTUCK
MBBS4 PROGRAMME AT ST GEORGES UNIVERSITY OF LONDON DELIVERED BY THE UNIVERSITY OF NICOSIA
SHEBA MEDICAL CENTER AT TEL HASHOMER

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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