A 35yo lady who has been using IUCD for one year now complains of pelvic pain and heavy
painful periods. Select the most likely cause leading to her symptoms?
a. PID
b. Endometriosis
c. Adenomyosis
d. Fibroids
e. Asherman syndrome
answer D
FIBROIDS
Epidemiology
• diagnosed in approximately 40-50% of pre-menopausal women >35 yr
• more common in African Americans, where they are also larger and occur at earlier age
• common indication for major surgery in females
• minimal malignant potential (1:1,000)
• typically regress after menopause; enlarging fibroids in a postmenopausal woman should
prompt consideration of malignancy
ƒ 50% of leiomyosarcomas originate from within fibroids
Clinical Features
• majority asymptomatic (60%), often discovered as incidental finding on pelvic exam or U/S
• abnormal uterine bleeding (30%): dysmenorrhea, menorrhagia
• pressure/bulk symptoms (20-50%)
ƒ pelvic pressure/heaviness
ƒ increased abdominal girth
ƒ urinary frequency and urgency
ƒ acute urinary retention (extremely rare but surgical emergency!)
ƒ constipation, bloating (rare)
• acute pelvic pain
ƒ fibroid degeneration
ƒ fibroid torsion (pedunculated subserosal)
Adenomyosis
Epidemiology
• 15% of females >35 yr old; found in 20-40% of hysterectomy specimens
• mean age at presentation: 40-50 yr old (older age group than seen in endometriosis)
• adenomyosis is a common histologic finding in asymptomatic patients
Clinical Features
• often asymptomatic
• menorrhagia, secondary dysmenorrhea, pelvic discomfort
• dyspareunia, dyschezia
• uterus symmetrically bulky, usually <14 cm, mobility not restricted, no associated adnexal
pathology
• Halban sign: tender, softened uterus on premenstrual bimanual exam
Investigations
• clinical diagnosis
• U/S or MRI can be helpful
• endometrial sampling to rule out other pathology
Treatment
• iron supplements as necessary
• analgesics, NSAIDs
• OCP, medroxyprogesterone (Depo-Provera®)
• low dose danazol 100-200 mg PO OD (trial x 4 mo)
• GnRH agonists (e.g. leuprolide)
• definitive: hysterectomy (no conservative surgical treatment)
PID > there would be dyspareunia, discharge, fever
plus risk from IUCD only within the first 20days !
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