Heavy Menstrual Bleeding With Fibroids and Iron-Deficiency Anemia
45-year-old G3P3 presents with 10 months of heavy menstrual bleeding lasting 9–10 days with clots, fatigue, and dizziness. She has completed childbearing but wishes to keep her uterus. BMI is 32; blood pressure 138/86 on amlodipine. Hemoglobin is 82 g/L, ferritin 6 ng/mL, platelets 240, TSH normal. Pelvic examination shows a 14-week-sized, irregular uterus. Transvaginal ultrasound shows a 5-cm intramural fibroid and a 3-cm submucosal fibroid, endometrial thickness 12 mm, and normal ovaries. She has no postcoital or postmenopausal bleeding and no family history of endometrial cancer. She takes iron intermittently but has not tolerated it. She is scheduled for follow-up in 2 weeks and wants to know whether she can avoid hysterectomy and whether she needs a biopsy.
1. Which findings drive the need for endometrial sampling, and how would you counsel her about the limits of imaging?
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Endometrial sampling is indicated because she is over 45 with abnormal uterine bleeding and has additional risk factors: obesity, hypertension, and a thickened endometrium of 12 mm. The submucosal fibroid plausibly explains the bleeding, but a fibroid does not exclude coexisting endometrial hyperplasia or carcinoma. Transvaginal ultrasound is good at measuring thickness but cannot reliably distinguish benign thickening from focal malignancy, and the office pipelle samples only part of the cavity. A negative pipelle therefore does not fully exclude disease when bleeding persists or when a focal lesion is seen. I would counsel her that hysteroscopy with directed biopsy is the most reliable way to evaluate the cavity and that it can be combined with hysteroscopic resection of the submucosal fibroid. Sampling should not be deferred simply because the fibroid is an obvious bleeding source.
2. Compare medical and surgical options for her bleeding and anemia, including a plan to correct iron deficiency before elective surgery.
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She has symptomatic iron-deficiency anemia (Hb 82 g/L, ferritin 6 ng/mL) and should receive intravenous iron, because oral iron has not been tolerated; transfusion is reserved for hemodynamic instability or severe symptomatic anemia. Medical options include tranexamic acid during menses, NSAIDs, progestins, and the levonorgestrel intrauterine system, although the submucosal fibroid may increase expulsion risk. Combined hormonal contraceptives are less attractive with hypertension. For a uterus-sparing surgical option, hysteroscopic myomectomy addresses the 3-cm submucosal fibroid and can be combined with endometrial sampling; pretreatment with a GnRH agonist for 2–3 months may shrink the fibroid and improve anemia but causes hypoestrogenic effects. Hysterectomy is definitive and appropriate if she no longer wants uterine preservation, but it is not the only option. Uterine artery embolization is another alternative, though it may not be ideal for a submucosal fibroid causing heavy bleeding. The plan should correct anemia first, then choose the least invasive durable option.
3. She asks whether hysteroscopic myomectomy can be done at the same time as endometrial sampling and what determines whether the submucosal fibroid is resectable.
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Yes, hysteroscopic sampling and myomectomy can be combined in one procedure after counseling and consent, and this is often efficient because it treats the likely bleeding source while excluding endometrial pathology. Resectability depends on the proportion of the fibroid within the cavity. A type 0 fibroid is entirely intracavitary, type 1 has less than 50% intramural extension, and type 2 has 50% or more intramural extension; type 0 and many type 1 fibroids are amenable to hysteroscopic resection, while type 2 lesions carry a higher risk of incomplete resection, fluid overload, and perforation. Size matters: a 3-cm lesion is generally approachable, but larger or deeply intramural lesions may require a staged procedure, preoperative GnRH agonist shrinkage, or an alternative route. Fluid distension media balance must be monitored, and the patient should understand the possibility of conversion to a more extensive procedure if malignancy is suspected or resection is unsafe.