Uterine Fibroids — SAQ

Stem

A candidate is asked to manage a classic presentation of Uterine Fibroids in an exam setting. Use precise definitions, scores, doses, and decision thresholds. [1]

Core knowledge (model answer backbone)

Uterine fibroids (leiomyomas) are benign, monoclonal, oestrogen- and progesterone-responsive smooth-muscle tumours of the myometrium — the commonest benign tumour of women (up to 70 to 80 per cent by age 50). Most are asymptomatic; when symptomatic the leading complaint is abnormal uterine bleeding (heavy/prolonged menses), followed by bulk/pressure symptoms (pelvic heaviness, urinary frequency, constipation) and infertility (predominantly submucosal). Classified by location (FIGO 0 to 8): submucosal cause bleeding and subfertility, intramural are commonest, subserosal cause pressure. Diagnosis is clinical plus transvaginal ultrasound; MRI maps submucosal extent and excludes sarcoma. Management is goal- and fertility-directed: observe if asymptomatic; medical (tranexamic acid, NSAIDs, LNG-IUS, GnRH agonist with add-back, GnRH antagonist); surgery (myomectomy for uterus/fertility preservation, hysterectomy definitive cure for completed family); and uterus-sparing radiological options (uterine artery embolisation, MRgFUS, radiofrequency ablation). [1]

Red flags

• Heavy menstrual bleeding with a uniformly enlarged, irregular, firm, mobile, non-tender uterus in a reproductive-age woman - uterine fibroids until proven otherwise
• Acute, severe, unprovoked heavy vaginal bleeding with anaemia - severe AUB; IV tranexamic acid plus high-dose IV conjugated oestrogen, fluids and transfusion; exclude pregnancy
• Rapidly enlarging pelvic mass in a postmenopausal woman or any woman NOT exposed to oestrogen stimulation - suspect leiomyosarcoma, NOT a benign fibroid
• Acute pelvic pain in pregnancy with a known fibroid - red (carneous) degeneration; conservative analgesia, the diagnosis of exclusion after ectopic/abruption

High-yield structure examiners expect

Cover: Overview & Definition, Classification, Epidemiology & Risk Factors, Pathophysiology, Clinical Presentation, Differential Diagnosis.

Key doses / thresholds (from topic teaching)

• Hb below 70 g/L or symptomatic):**
• Tranexamic acid 1 g IV three times daily** (or 1 to 1
• if Hb below 70 g/L or symptomatic anaemia; **IV iron (fe
• if iron-deficient and Hb 70 to 100 g/L (faster repletion than oral, better t
• goserelin 3.6 mg SC) — to induce amenorrhoea while plann
• Tranexamic acid 1 g oral three times daily for up to 4 days [1]

Questions

a) Define the condition and give the most important classification or severity framework used in exams. (3 marks) [1]

• Clear one-line definition matching standard teaching.
• Named classification / stages / types with discriminating features.
• One sentence on why classification changes management. [1]

b) Outline pathophysiology in a mechanism chain that explains the main clinical features. (3 marks) [1]

• Initiating insult → intermediate pathway → end-organ effect.
• Link at least two symptoms/signs to mechanism.
• Mention one complication pathway (e.g. shock, perforation, herniation, arrhythmia). [1]

c) List discriminating clinical features and bedside assessment. (3 marks) [1]

• Classic presentation plus one atypical group (elderly, pregnancy, child, immunocompromised).
• Named signs/manoeuvres if relevant.
• What must never be missed on exam/bedside (pregnancy test, airway, glucose, etc.). [1]

d) Investigations with thresholds and one named score if applicable. (3 marks) [1]

• First-line tests and what positive findings mean.
• Gold-standard or definitive investigation when needed.
• Score components reproduced exactly if a named score is standard for this topic. [1]

e) Immediate resuscitation and definitive management with doses where standard. (3 marks) [1]

• ABC / time-critical steps first.
• First-line drug(s) with agent + dose + route (or procedure steps).
• Escalation triggers (theatre, ICU, thrombolysis window, antidote, etc.).
• Disposition and safety-netting. [1]

Marking tips

Full marks require specificity (numbers, names, doses) not generic "give antibiotics/fluids." Regional practice (ICMR / NICE / AHA) may be cited as alternative where relevant. [1]

References

1. [1]Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review BJOG, 2017.PMID 28296146
2. [2]Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future Hum Reprod Update, 2016.PMID 27466209
3. [3]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
4. [4]Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids N Engl J Med, 2007.PMID 17251532
5. [5]Al-Hendy A, Lukes AS, Stewart EA, et al. Treatment of Uterine Fibroid Symptoms with Relugolix Combination Therapy N Engl J Med, 2021.PMID 33596357
6. [6]American College of Obstetricians and Gynecologists (ACOG) Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228 Obstet Gynecol, 2021.PMID 34011888
7. [7]Liver Injury with Ulipristal Acetate: Exploring the Underlying Pharmacological Basis Drug Saf, 2020.PMID 32748236
8. [8]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
9. [9]Islam MS, Protic O, Giannubilo SR, et al. Uterine leiomyoma: available medical treatments and new possible therapeutic options J Clin Endocrinol Metab, 2013.PMID 23393173