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Menorrhagia and uterine fibroid

Menorrhagia and uterine fibroid Posted by G. K.
Dear Dr. Paul:Please guide me on how to approach the following question:

A 45-year old presents with a long history of regular heavy peroids.
TVS detects a 4cm fibroid.
Discuss the further investigations and justify your management.

Posted by G. K.
Dear Dr. Paul:
This question appeared in the MRCOG exam paper Sept 2004. I have tried to answer it. Tell me what you think of it.

Further investigations include FBC to assess the degree of anemia secondary to bood loss. Out patient hysteroscopy+ D and C/ Pipelle to rule out endometrial pathology.Thyroid function tests.MRI to pinpont the exact location of the fibroid.
Treatment options depend on patient\'s preferences,whether child bearing is complete,location of fibroid, or if she\'s willing to go for surgery. Associated symptoms such as lower abdomonal presure and urinary frequency or constipation should be taken into account.
First Line of Mx: LNG-IUS. Although it is relatively contraindicated ,but at examination if the cavity seems regular enough, it can be tried.
Medical Mx:

Tranexamic acid, NSAIDs +COC and oral progestogens can be tried if there are no contraindications
GNRH analogues can be used to shrink the fibroid.
Progesterone receptor modulators cause amenorrhoea and shrinkage of fibroids without causing anovulation. a new drug. Still in research area. Short term administration seems safe.

Surgical Rx:
Endometrial ablation can be tried if the uterus is not too distorted.
Hysteroscopic resection if fibroid is submucous.
Myomectomy if the patient wants to retain her fertility.
Hysterctomy which can be abdominal vaginal or LAVH, depending on the pelvic examination and descent of the uterus and the availability of expertise in laparoscopic surgey.
MRI guided laser ablation of fibroid is a new technique which can be applied if the expertise and the equipment is available.

Posted by G. K.
Dear Dr. Paul:

Many thanks for your thorough guidance.Hopefully we will not get a vague question like this in the exam.