Obgyn · Year 3 · from Obgyn
Case 2: Heavy Menstrual Bleeding with Submucosal Fibroid
Patient Demographics
- Age: 42 years
- Sex: Female
- Occupation: Restaurant manager
Chief Complaint
"My periods are so heavy I can't leave the house for the first two days."
History of Present Illness
The patient reports progressively worsening menstrual bleeding over the past 2 years. Currently, she soaks through a super tampon and pad together every 1-2 hours on her heaviest days. She passes large clots (larger than a quarter). Her periods last 8-9 days. She has to take sick days from work during her period. She recently noticed fatigue, shortness of breath with exertion, and dizziness when standing.
Gynecologic History
- Menarche: Age 12
- Prior cycles: Regular, 28 days, moderate flow (5 days)
- Current pattern: Regular cycles but heavy flow x 8-9 days
- LMP: 1 week ago (just finished)
- Contraception: Tubal ligation after third child
- Prior pregnancies: G3P3003 (3 term vaginal deliveries)
Past Medical History
- No chronic conditions
- No prior surgeries except tubal ligation
PALM-COEIN Assessment
Bleeding Pattern (FIGO Terminology):
- Heavy menstrual bleeding (>80 mL or subjectively heavy)
- Prolonged bleeding (>8 days)
- Regular cycles
Physical Examination
- Vital Signs: BP 110/68, HR 92 (mild tachycardia), orthostatic hypotension present
- General: Pale conjunctivae, appears fatigued
- Abdomen: Soft, non-tender, mild suprapubic fullness
- Pelvic: Cervix normal, uterus 12-week size, irregular contour, non-tender, no adnexal masses
Diagnostic Workup
Laboratory Studies:
| Test | Result | Interpretation |
|---|---|---|
| CBC | Hgb 8.2 g/dL, MCV 72 fL | Microcytic anemia |
| Iron studies | Ferritin 8 ng/mL, TIBC elevated | Iron deficiency |
| TSH | 1.8 mIU/L | Normal |
| Pregnancy test | Negative |
Transvaginal Ultrasound:
- Uterus: 10 cm length, 8 cm width
- Submucosal fibroid: 3.5 cm, protruding into endometrial cavity (Type 1)
- Additional intramural fibroid: 2 cm (Type 4)
- Endometrium: 6 mm, regular contour (but distorted by submucosal fibroid)
- Ovaries: Normal
Saline Infusion Sonohysterography:
- Confirms Type 1 submucosal fibroid (approximately 40% intracavitary)
- Stalk visible arising from posterior wall
- Amenable to hysteroscopic resection
Diagnosis
Abnormal Uterine Bleeding - Leiomyoma (AUB-L)
- Type 1 submucosal fibroid causing heavy menstrual bleeding
- Secondary iron deficiency anemia
Endometrial Biopsy
- Performed given age >40 with AUB
- Result: Proliferative endometrium, no hyperplasia or malignancy
Management Discussion
Medical Options:
- Tranexamic acid: Reduces bleeding by 50%
- Hormonal IUD: Not ideal due to cavity distortion by fibroid
- GnRH agonist: Temporary shrinkage, bone loss limits long-term use
Surgical Options (Recommended):
- Hysteroscopic myomectomy: Best option for Type 0-1 submucosal fibroids
- Minimally invasive, uterine preservation
- High success rate for bleeding improvement
- Endometrial ablation: Not ideal with fibroid present
- Hysterectomy: Definitive but more invasive
Iron Replacement:
- Ferrous sulfate 325 mg twice daily with vitamin C
Surgical Treatment: Hysteroscopic Myomectomy
Procedure:
- Performed under general anesthesia
- Resectoscope used to shave fibroid in fragments
- Complete resection achieved
- EBL: Minimal
- Pathology: Benign leiomyoma
Postoperative Follow-up (3 months)
- Periods: Significantly lighter, 5-day duration
- No longer soaking through protection
- Returned to normal activities during menses
- Hemoglobin: 11.8 g/dL (improved)
- Ferritin: 35 ng/mL (repleting)
- Will continue iron supplementation until ferritin >50
Teaching Points
- Submucosal fibroids are the most common cause of heavy menstrual bleeding among structural causes
- FIGO classification (Type 0-7) guides surgical approach
- Types 0-2 (submucosal) amenable to hysteroscopic resection
- Endometrial biopsy indicated for women >45 or with risk factors for hyperplasia
- Iron deficiency anemia is common with chronic heavy bleeding
Clinical Image
Image Description: Saline infusion sonohysterography demonstrating a submucosal leiomyoma (fibroid) protruding into the endometrial cavity. The fibroid appears as a well-circumscribed, hypoechoic mass partially surrounded by saline, allowing clear delineation of its intracavitary component.
Attribution: Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.