Case 17: Heavy periods

 

Case 17: Heavy periods

CASE 17: HEAVY PERIODS

History

A 39-year-old woman complains of increasingly long and heavy periods over the last 5 years.

Previously she bled for 4 days but now bleeding lasts up to 10 days. The periods still occur

every 28 days. She experiences intermenstrual bleeding between most periods but no postcoital bleeding.

The periods were never painful previously but in recent months have become extremely

painful with intermittent cramps. She has had four normal deliveries and had a laparoscopic

sterilization after her last child. Her smear tests have always been normal, the most recent

being 4 months ago. She has never had any previous irregular bleeding or any other gynaecological problems.

Examination

The abdomen is soft and non-tender with no palpable masses. Speculum examination shows

a normal cervix. On bimanual palpation the uterus is bulky (approximately 8-week size),

mobile and anteverted. There are no adnexal masses.

INVESTIGATIONS

Normal range

Haemoglobin 9.2 g/dL 11.7–15.7 g/dL

Mean cell volume 75 fL 80–99 fL

White cell count 4.5×109/L 3.5–11×109/L

Platelets 198×109/L 150–440×109/L

Findings at hysteroscopy are shown in Fig. 17.1.

Questions

• What is the diagnosis?

• What further preoperative non-invasive investigation might have allowed the

same diagnosis?

• How would you manage this patient and counsel her about the management and its

potential risks?

Figure 17.1 Hysteroscopy (see colour insert).100 Cases in Obstetrics and Gynaecology

42

ANSWER 17

The hysteroscopy shows a submucosal fibroid. Ultrasound scan would have provided a

preoperative diagnosis too. At hysteroscopy a submucosal fibroid appears as a solid, pale,

smooth, relatively immobile (unless pedunculated) structure, whereas a polyp appears pink,

fleshy and highly mobile. Submucosal fibroids are a common cause of menorrhagia and can

cause, as in this case, intermenstrual bleeding. The cramp-like pain occurs as the uterus tries

to expel the fibroid. In some cases this eventually occurs with the fibroid becoming pedunculated and extending through to the vagina on a pedicle.

Management

The management is by hysteroscopic (transcervical) resection of the fibroid (TCRF). This can

be performed as a day case under general anaesthetic (or even local anaesthetic if the fibroid

is small). The important points in counselling the patient are as follows.

• Description of the procedure: the procedure involves stretching (dilatation) of the

cervix and insertion of an endoscope into the uterus (hysteroscopy) to view the

fibroid. The fibroid is ‘shaved’ away with a hot wire loop (diathermy). Fluid is circulated through the uterine cavity to enhance the view and allow cooling.

• What are the risks?

• Bleeding: it is rare to bleed heavily but in the extreme situation blood transfusion could be required, or even a hysterectomy to control the loss

• Infection

• Fluid overload: during the procedure, irrigation fluid is absorbed into the circulation. Excessive absorption can cause breathing difficulties (pulmonary

oedema) and the need for hospital admission

• Uterine perforation: rarely the hysteroscope perforates the wall of the uterus,

and if this occurs or is suspected then laparoscopy is needed immediately to

confirm it, secure any bleeding and check for damage to surrounding bowel or

bladder.

• What to expect afterwards: most women experience bleeding, discharge and passing

of ‘debris’ for up to 2 weeks after the procedure.

KEY POINTS

• Ultrasound is critical in the diagnosis of menorrhagia.

• Submucosal fibroids are more likely to cause menorrhagia than those that are

intramural or subserous.

• Transcervical resection of fibroids is a relatively simple procedure but is associated

with important risks.