STUDENT PROBLEM-BASED LEARNING SESSION
Benign Pelvic Mass
Clinical Case:
A 42-year-old G3 P3 female presents with a history of abnormal bleeding and pelvic pain. She was well until approximately age 35, when she began developing dysmenorrhea and progressive menorrhagia. The dysmenorrhea was not fully relieved by NSAIDS. Over the next several years, the dysmenorrhea and menorrhagia became more severe. She then developed intermenstrual bleeding and spotting, as well as pelvic pain, which she describes as a constant feeling of pressure. She also complains of urinary frequency. Past gynecological history is otherwise non-contributory. She delivered three children by caesarean section, the last with a tubal ligation at age 30. Her past medical history is unremarkable.
Physical Examination r eveals a well-developed, well-nourished woman in no distress. Vital signs and general physical exam are unremarkable. Abdominal examination reveals an irregular-sized mass into extending halfway between the pubic symphysis and umbilicus and to the right of the midline. Pelvic exam reveals a normal appearing vagina and cervix. The uterus is markedly enlarged and irregular, especially on the right side where it appears to reach the lateral pelvic sidewalls. The examiner is unable to palpate normal ovaries due to the mass.
Beta HCG is negative. CBC reveals hemoglobin of 10.3 and hematocrit of 31.2. Indices are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap smear is reported negative for malignancy, adequate for evaluation. Ultrasound shows a large irregular mass, filling the pelvis and extending into the lower abdomen. The mass does extend into the right side of the pelvis. There is mild hydronephrosis on that side. The ovaries are not visualized. Endometrial biopsy reveals proliferative endometrium.
Discussion questions:
- What are the likely causes of the mass?
- Describe the pathological changes?
- Discuss the appropriate management of women with fibroids?
- What are the indications for hysterectomy in women with fibroids?
References:
- Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 45 Uterine Leiomyoma and Neoplasia. Pages 448-454.
- ACOG Practice Bulletin 16. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas May 2000.
Uterine leiomyomas represent the most common gynecologic neoplasm and are often asymptomatic
The APGO Educational Objectives related to this topic are the following:
- Discuss the prevalence of uterine leiomyomas
- Describe the symptoms and physical findings in patients with uterine leiomyomas*
- Apply diagnostic methods to confirm uterine leiomyomas
- List the indications for medical and surgical treatment of uterine leiomyomas
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition