Heavy bleeding and menstrual cramps
For the past 2 years, G, 31, had been enduring menstrual pain and heavy bleeding with clots. She had become accustomed to the “stormy time of the month”.
“I did not seek medical help as I thought it was normal to have some discomfort or clots during menses after childbirth, ” she recalled.
After the birth of her son 4 years ago, her periods had become increasingly heavier and longer. There were clots on the first 3 to 4 days. About 2 year ago, she began to experience abdominal cramps on the first few days of menses as well. The pain was relieved by applying a hot pack to the lower abdomen and by taking painkillers. She also felt weak and exhausted during menstruation.
One morning, she was brought to the emergency department in the hospital when she collapsed and passed out in her office. It was the second day of her menstruation. She looked pale with a fast pulse rate of 110 beats per minute. Her blood pressure was low at 90/60mm Hg. Her uterus was enlarged and palpable in the lower abdomen, corresponding to about 14 weeks of pregnancy. A large amount of blood clot was noted in her vagina. Ultrasound examination revealed a large uterine mass about 8 cm in diameter, protruding into the uterine cavity. Her hemoglobin was low at 9.2 gm/dl. She was transfused with blood. Her bleeding was stopped with medication. G was having heavy bleeding and severe anemia due to a huge uterine fibroid.
What are uterine fibroids?
Uterine fibroids are common muscle growths of the womb. About 20 to 70 percent of women will have fibroids during their childbearing years. They are usually non-cancerous.
Fibroids can range in size from tiny seedlings to huge masses that can distort and enlarge the uterus. They can present either as a single lump or multiple ones. They are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids protrude outside the uterus.
What are the symptoms?
Majority of the fibroids do not present with any symptoms. If symptoms are present, they are dependent on the location, size and number of fibroids. Common symptoms include:
- Heavy menstrual bleeding
- Prolonged or painful periods
- Spotting or bleeding between periods
- Pelvic pressure or pain
- Frequent urination
- Difficulty emptying the bladder
What are the causes?
It is not clear why fibroids develop; but research and clinical experience suggest the following factors:
- Hormones: Fibroids are stimulated by ovarian hormones. They may develop and grow rapidly during pregnancy and tend to shrink after menopause.
- Genes: Fibroids may run in the family. If a woman’s mother had fibroids, her risk of having fibroids is about three times higher than average.
- Obesity: The risk of obese women having fibroids is two to three times higher than normal.
- Other factors: Ethnic origin; menstruation at an early age; vitamin D deficiency; drinking alcohol and a diet higher in red meat and lower in vegetables, fruit and dairy appear to increase the risk of developing fibroids.
What are the complications?
- Anemia: Heavy periods may lead to iron-deficiency anemia resulting in fatigue, dizziness and shortness of breath.
- Pregnancy problems: Preterm birth, intrauterine growth restriction, abnormal fetal position and pregnancy loss may occur.
- Infertility: Fibroids usually do not cause infertility. However, submucosal fibroids may be a factor as they may block the fallopian tubes or cause repeated miscarriages.
- Cancer: Cancerous fibroids, known as leiomyosarcomas, are rare. They occur in less than 1 in 1,000 cases.
How are fibroids diagnosed?
Uterine fibroids are frequently found incidentally during a routine pelvic examination or ultrasound scan.
Other imaging tests may include:
- Pelvic Magnetic resonance imaging (MRI). This test can show in more details the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options.
- Hysterosalpingography (HSG) and hysterosonography or saline infusion sonogram using sterile saline to expand the uterine cavity may help in the diagnosis of submucosal fibroids.
How are fibroids treated?
Fibroids can be treated in various ways. They include:
- Watchful monitoring: Many women with uterine fibroids have no symptoms. Watchful monitoring could be the best option.
- Medications; Nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, hormones and GnRH agonists have been used to reduce the menstrual bleeding. They do not reduce the size of the fibroids.
- Non-invasive procedure using ultrasound (Hifu) has been used to destroy fibroids. (see the article “Surgery without knife” in the website)
- Minimally invasive procedure: Embolic agents are injected into the uterine artery to block the blood supply of the fibroids (uterine artery embolization). This can destroy fibroids without actually removing them through surgery.
- Surgery: Removal of the fibroids (myomectomy) or the entire uterus (hysterectomy) can be done either by open surgery (laparotomy) or by minimally invasive surgery (laparoscopic surgery). Submucosal fibroids can be removed via hysteroscopy.
After G had recovered from her anemic state, we had a full discussion of the pros and cons of the various treatment modalities. She opted for the laparoscopic key-hole surgery to remove the fibroid as she was young and would like to start a family in future. Myomectomy was successfully performed. She was amazed of her quick recovery. Her menstruation had returned to normal and she has remained pain free since.