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History:
A 56 year-old G6P1051 woman, currently in prison, complains of heavy
vaginal bleeding of 14- month duration. She denies spotting between
periods. She states that around her early 50s she was diagnosed with
myomas and was treated with Provera. She takes 2 tables of tylenol,
without relief of her pelvic pain. She denies fatigue, cold tolerance
and galactorrrea.. Her past medical history is positive for COPD,
hypothyroidism and DM2. She does not want to have more children.
Patient underwent hysterectomy on 9/23/15.
Physical Examination:
On physical examination her BP is 130/82 mm Hg, HR is 80 bpm,
weight 167 lb and temperature of 36.6 C. The heart and lung
examination are normal. The abdomen reveals a lower abdominal
midline irregular mass approximate 21 weeks size move in conjunction
with cervix. . On pelvic examination, the cervix is anteriorly displaced
and uterine myomas prolapsed into vaginal canal. No adnexal masses
are palpated. Her pregnancy test is negative. Her hemoglobin level,
leukocyte count, platelet count, TSH are 8.2 g/dl, 8.12 x 10^3 u/L , 215
X 10^3 and 2.1 (mIU/L), respectively.
Discussion of diagnosis, differential diagnosis and diagnostic
modalities that were used in your patient:
Pregnancy:
It must be ruled out in patients with history of amenorrhea/overdue
periods prior to investigating other gynecological causes. Pregnancy
test was negative.
Adenomyosis:
Patients are often multiparous with complaints of menorrhagia and
dysmenorrhea. It usually does not exceed 14 weeks in size.
Malignancy of uterus:
As it usually presents in its early stages, such marked enlargement of
the uterus is rarely seen.
Menometrorrea by hypotiroidism or abnormal hematologic
values:
Normal TSH and coagulation test levels are seen.
Papers:
Do submucous myoma characteristics affect fertility and menstrual
outcomes in patients who underwent hysteroscopc myomectomy
Ahmed Namazov M.D., Resul Karakus M.D., Ezgi Gencer M.D.,
Hamdullah Sozen M.D., Levent Acar M.D. Iran J Reprod Med Vol. 13.
No. 6. pp: 367-372, June 2015
Objective: The aim of this study was to determine the long term effects
of submucousal myoma resection on menorrhagia and infertility; also
to detect whether the type, size, and location of myoma affect the
surgical success and outcomes.
Pertinence to Clinical question: Learn of management of uterine
myomas and its effects on fertility
Limitations: Sample 98->47 infertilty so its a small sample size,
retrospective cohort no control over data recollected
Strengths: Excluded patients with previously diagnosed infertility
causes such as patients with multiple myomas, persistent anovulation
or bilateral tubal occlusion and those patients who received IVF in
order eliminate possible bias and strengthen conclusions.
Study Design
Total
patients
included
in
98 patients
study
with
Uterine
myomas
Chief
Infertility
complaint
Chief
complaint
Number
of
47 patients
patients
Menorrhagia
51 patients
Improved
23.30 10
Recurred
29.88 5
p-value
0.141
30.38 4
Not conceived
29.95 5
p-value
0.961
Figure 2. Pregnancy rates in infertility group according to myoma type and location (ChiSquare test).
Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus
Myomatosus
Study Design
332 patients were
operated for benign
myomas (June 2004June 2008)
89 were not
included
(endometriosis,
ovarian sterility,
andrological
sterility, and
sarcomatous
degeneration)
33 could not be
contacted
55 decided not to
anwser
questionnaires
Greater than 45
years
Retrospective Cohort
Conclusions
Recommendations: