Obgyn · Year 3 · from Obgyn

Case 1: Symptomatic Uterine Fibroids with Fertility Considerations

Patient Demographics

• Age: 34 years
• Sex: Female
• Occupation: Marketing executive

Chief Complaint

"My periods have become very heavy and painful, and I'm having trouble getting pregnant."

History of Present Illness

The patient presents with a 2-year history of progressively worsening menstrual bleeding and dysmenorrhea. She now soaks through a super tampon every 2 hours on the heaviest days and passes large clots. Her periods last 8-10 days (previously 5 days). She experiences cramping pain rated 7/10 that starts 1-2 days before her period and continues throughout. She and her husband have been trying to conceive for 14 months without success. She also reports urinary frequency and a sensation of pelvic pressure.

Gynecologic History

• Menarche: Age 12
• Prior cycles: Regular, 28 days, 5 days of moderate flow
• Current: 28-day cycles, 8-10 days of heavy flow with clots
• LMP: 1 week ago
• Sexually active: Yes, married x 3 years
• Prior pregnancies: G0
• No prior surgeries

Past Medical History

• Iron deficiency anemia (diagnosed 6 months ago)
• Taking ferrous sulfate 325 mg twice daily

Family History

• Mother: Hysterectomy at age 42 for fibroids
• Maternal aunt: Fibroids

Physical Examination

• Vital Signs: BP 118/76, HR 82, Temp 98.4F
• General: Well-appearing, no acute distress
• Abdomen: Soft, non-tender, palpable firm mass arising from pelvis extending to 4 cm above umbilicus
• Pelvic:
• Cervix: Normal appearance, parous os
• Uterus: 18-week size, irregularly enlarged, non-tender
• Adnexa: Not palpable due to uterine size

Diagnostic Workup

Laboratory Studies:

Pelvic Ultrasound:

• Uterus enlarged: 14 x 12 x 10 cm
• Multiple fibroids identified:
• Submucosal fibroid (FIGO Type 2): 4 cm, posterior wall, 60% intracavitary
• Intramural fibroid (FIGO Type 4): 6 cm, anterior wall
• Subserosal fibroid (FIGO Type 5): 5 cm, fundal
• Endometrial cavity distorted by submucosal fibroid
• Ovaries: Normal bilaterally

Saline Infusion Sonohysterography:

• Confirms Type 2 submucosal fibroid with significant intracavitary component
• Endometrial cavity significantly distorted

MRI Pelvis (for surgical planning):

• Confirms ultrasound findings
• Detailed fibroid mapping for surgical planning
• No adenomyosis
• Ovaries normal

Diagnosis

Symptomatic Uterine Leiomyomas (Fibroids)

• FIGO Type 2 submucosal (4 cm) - causing heavy bleeding and likely infertility
• FIGO Type 4 intramural (6 cm)
• FIGO Type 5 subserosal (5 cm)
• Secondary iron deficiency anemia
• Secondary infertility

Multidisciplinary Discussion

Considerations:

• Patient desires fertility preservation
• Submucosal fibroid likely contributing to infertility and heavy bleeding
• Large fibroid burden requires surgical planning

Fertility Implications:

• Submucosal fibroids are most associated with infertility
• Intramural fibroids >4 cm may also affect implantation
• Removal of cavity-distorting fibroids improves fertility outcomes

Management Options Discussed

1. Medical Management:

• GnRH agonists: Would shrink fibroids 30-50% but temporary; not appropriate for fertility planning
• Tranexamic acid: Would reduce bleeding but not address fertility
• Neither appropriate given fertility goals

2. Uterine Artery Embolization:

• Not recommended for patients desiring fertility
• Risk of ovarian failure and uterine necrosis

3. Surgical Options (Recommended):

• Hysteroscopic myomectomy for submucosal fibroid
• Laparoscopic myomectomy for intramural and subserosal fibroids
• Can be staged or combined depending on surgical expertise

Surgical Treatment Plan

Stage 1: Hysteroscopic Myomectomy

• For Type 2 submucosal fibroid (4 cm)
• Goal: Restore normal endometrial cavity

Stage 2: Laparoscopic Myomectomy (6 weeks later)

• For intramural (6 cm) and subserosal (5 cm) fibroids
• Will require uterine closure in layers

Operative Details

Hysteroscopic Myomectomy:

• Resectoscope used
• Complete resection of submucosal fibroid achieved
• Cavity restored to normal configuration
• EBL: 50 mL
• Pathology: Benign leiomyoma

Laparoscopic Myomectomy (6 weeks later):

• GnRH agonist given for 6 weeks preoperatively (shrinkage)
• Both fibroids removed intact (no morcellation due to fertility desires)
• Uterus closed in 3 layers
• EBL: 200 mL
• Pathology: Benign leiomyomas

Postoperative Care and Counseling

• Wait 3-6 months before attempting conception
• Cesarean delivery recommended due to full-thickness myometrial incisions
• Recurrence rate: 15-30% within 5 years
• Iron supplementation continued until ferritin >50 ng/mL

Follow-up (6 months postoperatively)

• Periods: Regular, 5-day duration, moderate flow
• Hemoglobin: 12.8 g/dL (normalized)
• Ultrasound: No recurrent fibroids, normal endometrial cavity
• Cleared to attempt conception

Follow-up (14 months postoperatively)

• Patient is now 10 weeks pregnant
• Early prenatal care initiated
• Planned cesarean delivery counseled

Teaching Points

• Submucosal fibroids (FIGO Types 0-2) are most associated with heavy bleeding and infertility
• FIGO classification guides surgical approach: Types 0-2 amenable to hysteroscopic resection
• MRI provides detailed fibroid mapping for surgical planning
• Myomectomy preserves fertility but has 15-30% recurrence rate
• Avoid morcellation when possible due to concern for occult leiomyosarcoma
• Cesarean delivery recommended after full-thickness myomectomy

Clinical Image

Image Description: MRI of the pelvis demonstrating multiple uterine fibroids including a submucosal fibroid distorting the endometrial cavity, an intramural fibroid in the anterior wall, and a subserosal fibroid at the fundus. The fibroids appear as well-circumscribed masses with low signal intensity on T2-weighted imaging.

Attribution: Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.

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