Benign gynaecology, endometriosis and pelvic floor disorders
Introduction
Benign gynaecology covers abnormal uterine bleeding, leiomyomas, adenomyosis, endometriosis and pelvic organ prolapse - everyday presentations where classification drives the treatment choice.
Abnormal uterine bleeding
- Use FIGO PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified.
- Premenopausal heavy bleeding: check ferritin, TSH and coagulation; ultrasound first, then hysteroscopy with biopsy if there is a structural lesion or risk factor.
Leiomyomas and adenomyosis
- FIGO leiomyoma subclass 0–8: submucosal 0–2 (0 pedunculated intracavitary, 1 less than 50% intramural, 2 at least 50%), intramural 3–5, subserosal 6–7.
- Submucosal fibroids cause heavy bleeding and impaired implantation; hysteroscopic resection suits types 0–2 under about 4–5 cm.
- Adenomyosis: globular bulky uterus, asymmetric thickening, junctional zone over 12 mm on MRI; treat hormonally (levonorgestrel IUD, GnRH analogue) or by hysterectomy.
Endometriosis
- Symptoms: dysmenorrhoea, deep dyspareunia, cyclical bowel or bladder symptoms, chronic pelvic pain, infertility.
- Diagnosis is clinical and empirical treatment may start on history and examination; laparoscopy remains the reference standard but is not a prerequisite for treatment.
- First line: continuous combined hormonal contraceptives or progestins; second line GnRH agonists with add-back; deep lesions are excised in a specialist centre.
Pelvic organ prolapse
- POP-Q stages 0–IV: stage II reaches the hymen, stage III passes beyond it, IV is complete eversion.
- Asymptomatic prolapse is observed; a ring pessary or pelvic floor muscle training is first line; surgery (anterior or posterior colporrhaphy, vaginal hysterectomy with apical suspension) for symptomatic women.
Worked example
A 44-year-old has heavy periods, Hb 98 g/L and a 3-cm submucosal fibroid distorting the cavity (type 2). She wants to conceive. Hysteroscopic myomectomy is offered rather than hysterectomy: resection restores the cavity and improves implantation, while a GnRH analogue pre-treatment shrinks the fibroid and corrects anaemia. A levonorgestrel IUD is inappropriate while she is trying to conceive.
Traps
- Treating every fibroid - most are asymptomatic and need only review.
- Withholding analgesia and hormonal treatment while waiting for diagnostic laparoscopy.
- Missing a coagulopathy in a teenager with heavy bleeding since menarche.
- Operating on stage I–II prolapse that causes no symptoms.