O&G SAQs · Gynaecological health — benign gynaecology
Uterine fibroids — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on uterine fibroids: FIGO classification, the location-symptom principle, the structured workup, the medical-management ladder, and the EMA ulipristal hepatotoxicity restrictions. Per-sub-part marking rubric included.
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Prompt
A 38-year-old nonpregnant woman, family incomplete, presents with heavy regular menstrual bleeding for 8 months, a palpable pelvic mass and iron-deficiency anaemia (haemoglobin 88 g/L, ferritin 8 micrograms/L). Transvaginal ultrasound shows an enlarged uterus with one submucosal fibroid projecting into the cavity on a stalk with no intramural component, and three further intramural fibroids. (a) Classify the submucosal fibroid by the FIGO leiomyoma subclassification and state the principle that links fibroid location to symptom. (3 marks) (b) Outline your initial workup before any treatment decision. (4 marks) (c) Describe the medical-management ladder you would discuss, naming each agent class with its rationale. (5 marks) (d) The patient asks about ulipristal acetate, which a friend took. State the current EMA restrictions on ulipristal acetate and your counselling. (3 marks)
How this SAQ is marked
Marks come from the verbatim FIGO type, the location-symptom principle, a structured workup, a complete medical ladder, and precise EMA counselling. Write in short labelled points. [1]
Reveal model answer and mark schemeShowHide
(a) FIGO classification and the location-symptom principle (3 marks)
- The stalked intracavitary submucosal fibroid with no intramural component is FIGO type 0 (pedunculated submucosal). The three intramural fibroids are FIGO type 4.
- The cardinal principle: FIGO type (location), not size, predicts the symptom.
- Submucosal fibroids (FIGO 0-2) bleed most (distorted endometrial venules, impaired myometrial contractility) and reduce fertility by distorting the cavity; intramural (4) are commonest; subserosal (5-7) cause bulk and pressure.[2][3]
(b) Initial workup (4 marks)
One mark per point, maximum four. [1][3]
- Exclude pregnancy first (beta-hCG) before any hormonal therapy or imaging assumption.
- Confirm uterine origin and map the fibroids: TVUS first-line; saline-infusion sonography to define the cavity component and distinguish a submucosal fibroid from a polyp.
- Baseline bloods: FBC and ferritin (iron-deficiency anaemia is present here and needs correction); coagulation and von Willebrand panel if bleeding has been heavy since menarche.
- MRI for complex or multiple fibroids before surgical planning, and to raise or lower sarcoma suspicion (diffusion-weighted restricted diffusion). Endometrial sampling if bleeding pattern raises malignancy concern.[1]
(c) Medical-management ladder (5 marks)
One mark per agent class named with rationale, maximum five. [1][7]
- Tranexamic acid and NSAIDs (antifibrinolytic / prostaglandin inhibition) — cyclic, for women wanting no hormonal method.
- Levonorgestrel intrauterine system (LNG-IUS) — the most effective non-surgical option for heavy menstrual bleeding (ECLIPSE trial evidence), and contraception.
- Combined hormonal contraception and oral progestins — cycle regulation and endometrial suppression.
- GnRH analogue (e.g. goserelin depot per local dosing schedule) with add-back — short pre-operative course for volume reduction and anaemia correction; limit unopposed to 6 months (bone density).
- Relugolix combination therapy (relugolix 40 mg + oestradiol 1 mg + norethindrone acetate 0.5 mg once daily) — the modern oral GnRH antagonist, no flare, long-term without separate add-back.[5]
- Note: surgery (hysteroscopic myomectomy for the FIGO 0 lesion, with myomectomy or UAE for the intramural fibroids) is the definitive route and lives in the surgical-management topic; here the question is medical.[1]
(d) EMA restrictions on ulipristal acetate (3 marks)
- Ulipristal works (PEARL showed around 90 per cent bleeding control), but the EMA reviewed it in 2018, suspended it in 2020, and in 2021 recommended restricted reintroduction after reports of serious drug-induced liver injury including transplant cases.[4][6]
- It is now second-line and short-course: take a baseline liver function test, repeat it on treatment, and contraindicate it in pre-existing liver disease.[6]
- It is not recommended in women seeking fertility (RANZCOG C-Gyn 27). I would not choose it first-line for this family-incomplete woman.[1]
References7ShowHide
- [1]American College of Obstetricians and Gynecologists (ACOG) Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228 Obstet Gynecol, 2021.PMID 34011888
- [2]Bajaj S, Gopal N, Clingan MJ, Bhatt S. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas Abdom Radiol (NY), 2022.PMID 34581926
- [3]Puri K, Famuyide AO, Erwin PJ, Stewart EA, Laughlin-Tommaso SK. Submucosal fibroids and the relation to heavy menstrual bleeding and anemia Am J Obstet Gynecol, 2014.PMID 24080304
- [4]Donnez J, Tatarchuk TF, Bouchard P, et al. Ulipristal acetate versus placebo for fibroid treatment before surgery N Engl J Med, 2012.PMID 22296075
- [5]Al-Hendy A, Lukes AS, Poindexter AN 3rd, et al. Treatment of Uterine Fibroid Symptoms with Relugolix Combination Therapy N Engl J Med, 2021.PMID 33596357
- [6]Gatti M, Poluzzi E, De Ponti F, Raschi E. Liver Injury with Ulipristal Acetate: Exploring the Underlying Pharmacological Basis Drug Saf, 2020.PMID 32748236
- [7]Gupta JK, Daniels JP, Middleton LJ, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial Health Technol Assess, 2015.PMID 26507206