British Society for Gynaecological Imaging
On completing this case study, reading associated articles and answering related questions, you will;
A 43 year old lady presents to the gynaecology outpatient department with a 4 year history of regular heavy menstrual bleeding. She is otherwise asymptomatic. She has 4 children all of whom were delivered by caesarean section (and a tubal ligation at her 4th caesarean) and 12 months ago had a midline laparotomy and splenectomy following an RTA. She has no other medical conditions or contraindications to therapy. She has failed to respond to medical management and an endometrial ablation. An ultrasound reads:
An AV uterus with an ET of 2mm on day 2 is seen. The cavity is not distorted but within the myometrium are multiple small fibroids with the largest measuring 3cm. Left ovary normal. Right ovary normal. No free fluid.
She has been counselled appropriately and has opted for uterine artery embolisation.
The diagnosis is symptomatic fibroids. This is made by a combination of clinical history and utrasound examination. In addition to diagnosis, ultrasound imaging of the uterus is essential in treatment planning and follow up for UAE. Accurate description of fibroid location and size can also aid counselling in terms of treatment success.
Appreciate the indications and contraindications of uterine artery indication.
Understand the importance of patient selection and the role of ultrasound in doing so.
HMB caused by a fibroid uterus can cause significant morbidity for the patient and severely affect her quality of life. In this case it was correct to begin with medical management before moving to surgical management strategies. Her operative background puts her at high risk of operative complications and all options should be discussed before offering an open procedure. Ultrasound assessment can assess suitability for endometrial ablation by estimating uterine size and cavity length and ensuring that the fiborids’ do not cause an endometrial defect thereby reducing the effectiveness of the procedure. Ultrasound scans can be used in patient follow up to ensure fibroid reduction and treatment success.
Joint RCOG/RCR 3rd edition: Uterine artery embolisation for the management of fibroids
http://www.rcog.org.uk/files/rcog-corp/23-12-2013_RCOG_RCR_UAE.pdf
NICE guidance: Heavy menstrual bleeding
http://guidance.nice.org.uk/CG44/QuickRefGuide/pdf/English
MR-guided focused ultrasound MRgFUS for symptomatic uterine fibroids: predictors of treatment success. Hum. Reprod. (2012) 27(12): 3425:3431
Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids:
Stewart et al. Fertility and Sterility January 2006 pp22-29
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