Uterine fibroids — structured SAQ (15 marks)

(a) FIGO classification and the location-symptom principle (3 marks)

One mark per point. [1][2]

• 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 3.6 mg SC 4-weekly) 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)

One mark per point. [4][6]

• 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]