# Clinical Cases: Uterine Disorders ## 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:** | Test | Result | Interpretation | |------|--------|----------------| | Hemoglobin | 9.8 g/dL | Moderate anemia | | Hematocrit | 31% | Consistent with anemia | | MCV | 72 fL | Microcytic | | Ferritin | 8 ng/mL | Depleted iron stores | | TSH | 2.1 mIU/L | Normal | | hCG | Negative | Not pregnant | **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 ![Uterine Fibroids MRI](case_01_image.jpg) **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. --- ## Case 2: Postmenopausal Bleeding with Endometrial Cancer ### Patient Demographics - **Age:** 64 years - **Sex:** Female - **Occupation:** Retired accountant ### Chief Complaint "I've been having vaginal bleeding for the past 3 months, and I went through menopause 12 years ago." ### History of Present Illness The patient reports intermittent vaginal bleeding over the past 3 months. Initially, it was light spotting occurring once weekly, but it has progressively increased to daily bleeding with occasional heavier episodes requiring a pad. She denies pelvic pain, urinary symptoms, or bowel changes. She has not had any vaginal bleeding since menopause at age 52 until these recent episodes. ### Gynecologic History - Menarche: Age 10 (early) - Menopause: Age 52 - No hormone replacement therapy - Prior pregnancies: G1P0010 (one spontaneous abortion at age 28, no live births - nulliparous) - Last Pap smear: 3 years ago, normal - No history of abnormal Pap smears ### Past Medical History - Type 2 diabetes mellitus x 15 years (on metformin) - Hypertension (on lisinopril) - Obesity (BMI 38) - Hyperlipidemia (on atorvastatin) ### Family History - Mother: Colon cancer at age 65 - Sister: Endometrial cancer at age 58 - No known genetic testing in family ### Risk Factor Assessment for Endometrial Cancer - Obesity (BMI 38): **Present** - major risk factor - Diabetes mellitus: **Present** - Hypertension: **Present** - Nulliparity: **Present** - Early menarche (age 10): **Present** - Late menopause: No (age 52) - Family history of endometrial cancer: **Present** (sister) - No protective factors (no OCP use, no breastfeeding) ### Physical Examination - **Vital Signs:** BP 142/88, HR 78, BMI 38 kg/m2 - **General:** Obese woman in no acute distress - **Abdomen:** Obese, soft, non-tender, no masses palpable - **Pelvic:** - External genitalia: Normal, atrophic changes - Speculum: Scant blood in vaginal vault, cervix appears normal - Bimanual: Uterus normal size, non-tender, no adnexal masses ### Red Flags **Postmenopausal bleeding is endometrial cancer until proven otherwise** - Requires urgent workup - 10% of postmenopausal bleeding is due to endometrial cancer ### Diagnostic Workup **Transvaginal Ultrasound:** - Endometrial thickness: 14 mm (abnormal in postmenopausal woman; normal <4-5 mm) - Heterogeneous endometrial echo - Myometrium: Normal - Ovaries: Atrophic, normal - No adnexal masses - No free fluid **Office Endometrial Biopsy:** - Performed with Pipelle device - Adequate tissue obtained - **Pathology: Grade 1 endometrioid adenocarcinoma** ### Additional Staging Workup **MRI Pelvis:** - Endometrial mass with less than 50% myometrial invasion - No cervical involvement - No lymphadenopathy - No adnexal abnormalities **Chest X-ray:** Normal **Laboratory Studies:** | Test | Result | |------|--------| | CBC | Normal | | CMP | Normal | | CA-125 | 28 U/mL (normal) | | HbA1c | 7.8% | ### Diagnosis **Endometrial Cancer - Grade 1 Endometrioid Adenocarcinoma** - Type I endometrial cancer (estrogen-dependent) - Clinical stage I (confined to uterus on imaging) ### Surgical Staging and Treatment **Procedure: Total Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy and Sentinel Lymph Node Mapping** **Operative Findings:** - Uterus normal size - Tumor confined to endometrial cavity grossly - Ovaries and tubes normal - No peritoneal implants - Sentinel lymph nodes identified bilaterally **Final Pathology:** - Grade 1 endometrioid adenocarcinoma - Depth of invasion: 4 mm into 18 mm myometrium (22% - less than 50%) - No lymphovascular space invasion - Cervix: Negative - Both ovaries and tubes: Negative - Sentinel lymph nodes (4): Negative for malignancy ### FIGO Stage **Stage IA** - Tumor confined to uterus, less than 50% myometrial invasion ### Tumor Molecular Classification - **MSI testing:** Microsatellite stable (MSS) - **p53:** Wild-type - **POLE mutation:** Not detected - Classification: No specific molecular features (NSMP) - intermediate prognosis ### Adjuvant Treatment - Stage IA, Grade 1 with no lymphovascular invasion: **No adjuvant therapy required** - Low risk of recurrence (<5%) - Surveillance only ### Prognosis - Five-year survival for Stage IA, Grade 1: >95% - Excellent prognosis ### Genetic Counseling Given family history (sister with endometrial cancer, mother with colon cancer): - Lynch syndrome evaluation recommended - MSI testing was negative on tumor, but germline testing discussed - Patient referred for genetic counseling ### Surveillance Plan - History and physical every 3-6 months for 2 years, then every 6-12 months - Vaginal cytology (Pap) not routinely recommended - Imaging only if symptomatic - Patient education on symptoms of recurrence ### Teaching Points - Postmenopausal bleeding requires urgent evaluation - 10% is endometrial cancer - Endometrial thickness >4 mm in postmenopausal women requires biopsy - Type I endometrial cancer (80%) is estrogen-dependent, associated with obesity - Surgical staging (hysterectomy, BSO, lymph node assessment) is standard treatment - Stage IA, Grade 1 has excellent prognosis with surgery alone - Lynch syndrome should be considered in patients with endometrial cancer ### Clinical Image ![Endometrial Cancer Ultrasound](case_02_image.jpg) **Image Description:** Transvaginal ultrasound demonstrating thickened, heterogeneous endometrium measuring 14 mm in a postmenopausal woman, suspicious for endometrial pathology. The thickened endometrial stripe contains areas of increased echogenicity. **Attribution:** Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0. --- ## Case 3: Pelvic Organ Prolapse ### Patient Demographics - **Age:** 68 years - **Sex:** Female - **Occupation:** Retired nurse ### Chief Complaint "I feel a bulge coming out of my vagina and I'm having trouble emptying my bladder." ### History of Present Illness The patient has noticed a progressively worsening sensation of vaginal bulging over the past 2 years. She initially noticed pressure and heaviness in her pelvis, but over the past 6 months she can feel and see tissue protruding from her vagina, especially when standing or straining. The bulge is worse at the end of the day and improves when lying down. She reports difficulty initiating urination and feels she does not completely empty her bladder. She sometimes has to manually reduce the bulge to urinate. She denies urinary incontinence but does have occasional urinary frequency. ### Gynecologic History - Menarche: Age 13 - Menopause: Age 51 - No hormone replacement therapy - Prior pregnancies: G4P4 (4 vaginal deliveries, largest baby 9 lbs 2 oz) - 2 episiotomies with first two deliveries - No prior pelvic surgeries ### Past Medical History - Chronic constipation (strains frequently) - Osteoarthritis - Hypertension (controlled with HCTZ) ### Social History - Former smoker (quit 10 years ago) - No alcohol use - Retired, lives with husband - Active - enjoys gardening and walking ### Risk Factors for Pelvic Organ Prolapse - Vaginal deliveries (4): **Major risk factor** - Macrosomic infant (>9 lbs): **Present** - Chronic straining (constipation): **Present** - Menopause/estrogen deficiency: **Present** - Prior episiotomy: **Present** - Age: **Present** ### Physical Examination **Standing Examination:** - Visible tissue prolapsing past the vaginal introitus **Supine Examination with Valsalva:** - **Anterior compartment:** Cystocele - anterior vaginal wall descends 3 cm beyond the hymen - **Apical compartment:** Uterus descends to 1 cm beyond the hymen - **Posterior compartment:** Rectocele - posterior vaginal wall descends 2 cm beyond the hymen **POP-Q Assessment:** | Point | Measurement | |-------|-------------| | Aa | +3 | | Ba | +3 | | C | +1 | | gh | 4 cm | | pb | 3 cm | | TVL | 8 cm | | Ap | +2 | | Bp | +2 | | D | -4 | **POP-Q Stage: III** (leading edge >1 cm past hymen but not complete eversion) **Rectal Exam:** Moderate rectocele confirmed, no rectal masses ### Associated Symptoms Assessment - **Voiding dysfunction:** Yes - incomplete emptying, need to reduce prolapse to void - **Stress urinary incontinence:** No (but may have occult SUI masked by prolapse) - **Defecatory dysfunction:** Yes - difficulty evacuating, sometimes splints vagina ### Diagnostic Workup **Post-Void Residual:** 180 mL (elevated, normal <100 mL) - suggests outlet obstruction **Urinalysis:** Negative **Urodynamic Testing (with prolapse reduced):** - Occult stress urinary incontinence unmasked when prolapse reduced - No detrusor overactivity ### Diagnosis **Pelvic Organ Prolapse, POP-Q Stage III** - Anterior compartment: Cystocele (Stage III) - Apical compartment: Uterine prolapse (Stage II) - Posterior compartment: Rectocele (Stage III) - Associated voiding dysfunction - Occult stress urinary incontinence ### Treatment Options Discussion **Conservative Management:** 1. **Pessary:** - Non-surgical option - Ring pessary with support often effective - Requires ability to remove/insert or regular follow-up for care - Trial offered 2. **Pelvic floor physical therapy:** - May help with mild prolapse - Unlikely to resolve Stage III prolapse alone - Can complement other treatments 3. **Vaginal estrogen:** - Improves vaginal tissue health - Adjunct to pessary or surgery **Surgical Management:** 1. **Reconstructive Surgery (uterine preservation or hysterectomy with vault suspension):** - Native tissue repair vs. mesh-augmented repair - Address all compartments - Concurrent anti-incontinence procedure for occult SUI 2. **Obliterative Surgery (colpocleisis):** - For patients who do not desire vaginal intercourse - Lower recurrence rate - Shorter surgery, faster recovery ### Patient's Initial Choice: Pessary Trial **Pessary Fitting:** - Ring pessary with support, size 4 - Successfully fit - Patient able to void with pessary in place - Post-void residual improved to 40 mL - Educated on removal, cleaning, and reinsertion ### Follow-up (6 weeks) - Pessary well-tolerated - Bulge sensation resolved with pessary - Vaginal estrogen cream started (twice weekly) - Some vaginal discharge - normal ### Follow-up (6 months) - Patient reports pessary becoming uncomfortable - Vaginal irritation noted - Desires definitive surgical treatment - Discussed options; patient elects reconstructive surgery ### Surgical Treatment: Vaginal Hysterectomy with Uterosacral Ligament Suspension, Anterior Colporrhaphy, Posterior Colporrhaphy, and Midurethral Sling **Procedure Details:** - Vaginal approach - Hysterectomy performed - Uterosacral ligament suspension for apical support - Anterior repair for cystocele - Posterior repair for rectocele - Retropubic midurethral sling for occult SUI **Operative Findings:** - Uterus 80 grams, normal - Ovaries grossly normal (left in place given age) - No complications ### Postoperative Course - Voiding trial passed POD 1 - Discharged POD 1 - Vaginal packing removed at discharge - Activity restrictions: No heavy lifting, intercourse, or straining for 6 weeks ### Follow-up (6 weeks postoperative) - Healing well - No bulge sensation - Voiding normally, no incontinence - Cleared for gradual return to activities ### Follow-up (1 year postoperative) - Asymptomatic - Exam: Well-supported vaginal vault, no recurrent prolapse - Continent of urine - Satisfied with outcome ### Teaching Points - Vaginal delivery is the most significant risk factor for pelvic organ prolapse - POP-Q is the standardized system for documenting prolapse severity - Pessaries are effective first-line treatment; many patients can avoid surgery - Occult stress incontinence should be assessed before surgery (unmasked when prolapse reduced) - Surgical options include reconstructive (vaginal or abdominal) and obliterative procedures - Native tissue repairs have ~30% recurrence; mesh augmentation has risks - Vaginal estrogen improves tissue quality for pessary use and surgical outcomes ### Clinical Image ![Pelvic Organ Prolapse](case_03_image.jpg) **Image Description:** Clinical photograph demonstrating Stage III pelvic organ prolapse with the vaginal walls and cervix/uterus descending beyond the vaginal introitus. The image illustrates the anterior vaginal wall prolapse (cystocele) and uterine descent characteristic of advanced multi-compartment prolapse. **Attribution:** Educational illustration. Used for medical education purposes.