Gynaecology Outpatient Clinical Note and GP Letter

• Age: 46 years

• BMI: 27.4 kg/m²

• Obstetric history: G2P2

  • 2012: SVD at term, uncomplicated.
  • 2015: Emergency LSCS for fetal distress, complicated by primary PPH (800 mL).

• Family complete: Yes.

• Presenting complaint: Referred with a 9-month history of worsening heavy menstrual bleeding (HMB) and secondary dysmenorrhoea.

• History of presenting complaint:

  • Onset 9 months ago, progressively worsening over the past 3 months.
  • Passing large clots and experiencing flooding during days 1 to 3 of menses.
  • Associated lethargy and exertional dyspnoea.

• Menstrual history:

  • Regular cycle.
  • 28-day interval.
  • 7 to 8 days duration.
  • Heavy flow with flooding.
  • Occasional erratic intermenstrual bleeding (IMB) over the last 2 months.
  • Denies postcoital bleeding (PCB).

• Pain history:

  • Suprapubic cramping pain.
  • Dull, aching nature with sharp exacerbations.
  • Intensity 7/10 at peak.
  • Radiates to the lumbosacral region.
  • Commences 2 days prior to menses, subsides by day 4.
  • Exacerbated by passing clots; partially relieved by oral NSAIDs and heat application.

• Bowel symptoms:

  • Bowel habit normal, opens daily.
  • No constipation, diarrhoea, rectal bleeding, or tenesmus.

• Urinary symptoms:

  • Mild daytime urinary frequency.
  • Denies urgency, dysuria, nocturia, incontinence, or haematuria.

• Vaginal discharge:

  • Physiological clear mucoid discharge only.
  • Non-offensive, no pruritus.

• Vulval symptoms:

  • Nil reported; no itching, pain, oedema, or lesions.

• Effect on quality of life:

  • Requires double sanitary protection and frequent changes every 1–2 hours on heavy days.
  • Missed 4 days of work over the past 2 months due to severe dysmenorrhoea and flooding.
  • Avoids social and sporting activities during menses.
  • Reports low mood secondary to chronic fatigue.

• Cervical screening history:

  • Last cervical smear: 14/05/2023.
  • Result: HPV negative, cytologically normal.
  • Follow-up: Routine 3-yearly recall.

• Previous gynaecological history:

  • Copper IUD inserted in 2016, removed in 2021.
  • No previous pelvic infections or gynaecological surgeries.

• Sexual history and contraception:

  • Sexually active in a monogamous relationship.
  • Current contraception: Male barrier methods (condoms) used for the past 3 years.
  • No deep dyspareunia.

• Medical history:

  • Iron deficiency anaemia, currently under treatment.
  • Primary hypertension, well controlled.

• Surgical history:

  • 2015: Emergency lower segment Caesarean section (complicated by 800 mL PPH, managed medically).
  • 2019: Laparoscopic cholecystectomy, uncomplicated.

• Current medicines and supplements:

  • amlodipine 5 mg PO OD
  • ferrous fumarate 210 mg PO BID

• Allergies:

  • Penicillin: Generalized maculopapular rash.

• Social history:

  • Employed as a primary school teacher.
  • Non-smoker (never smoked).
  • Alcohol: 4–6 units per week.
  • Denies recreational drug use.
  • Lives in a house with husband and two children.

• Family history:

  • Mother: Uterine fibroids (underwent hysterectomy aged 48) and T2DM.
  • Maternal aunt: Breast cancer diagnosed at age 62.

Examination

• Vital signs:

  • BP: 128/78 mmHg
  • Pulse: 76 bpm, regular
  • Temp: 36.7 °C
  • RR: 14 breaths/min
  • SpO2: 99 % on room air

• General physical examination:

  • Alert, comfortable at rest.
  • Mild conjunctival pallor noted.

• Abdominal examination:

  • Pfannenstiel scar well-healed.
  • Soft, non-distended.
  • Mild suprapubic tenderness on deep palpation; uterus palpable just at the pelvic brim (approx. 12-week size).
  • No guarding or rebound; no hepatosplenomegaly.

• Pelvic examination:

  • Speculum: Vulva and vagina healthy; cervix appears macroscopically normal, parous os, no polyps or ectropion; minimal old blood in vault.
  • Bimanual: Uterus bulky, anteverted, mobile, equivalent to 12-week gestation size, regular contour; no cervical motion tenderness; adnexa non-palpable and non-tender bilaterally.

• Laboratory tests (current consultation):

  • Urine dipstick: Blood +, Protein nil, Leucocytes nil, Nitrites nil.
  • Urine hCG: Negative.
  • Endometrial Pipelle biopsy obtained and sent for urgente histopathology.

• Ultrasound findings (current consultation):

  • Transvaginal ultrasound not repeated today as recent community scan available.

Investigations

• Earlier blood results:

  • FBC (02/10/2024): Hb 104 g/L, MCV 76 fL, Platelets 310 x 10⁹/L.
  • Ferritin (02/10/2024): 9 µg/L.
  • TFTs (02/10/2024): TSH 1.8 mU/L (normal).
  • Coagulation screen (02/10/2024): Normal.

• Earlier imaging:

  • Pelvic Ultrasound (10/10/2024): Bulky anteverted uterus measuring 105 x 68 x 72 mm. A 32 x 28 mm FIGO Type 1 submucosal fibroid is indenting the endometrial cavity. Endometrial thickness 11 mm. Both ovaries appear morphologically normal.

• Other earlier investigations:

  • High vaginal swab and endocervical Chlamydia/Gonorrhoea NAAT (02/10/2024): Negative.

Assessment

• Diagnosis: Heavy menstrual bleeding and secondary dysmenorrhoea secondary to a FIGO Type 1 submucosal uterine fibroid, complicated by iron deficiency anaemia.

• Differential diagnoses:

  • Adenomyosis
  • Endometrial polyp
  • Endometrial hyperplasia

• Clinical impression: Symptomatic submucosal fibroid amenable to hysteroscopic resection alongside medical management of menstrual loss and endometrial protection.

Discussion

• Education and counselling:
  • Reviewed ultrasound findings demonstrating a 3 cm submucosal fibroid protruding into the uterine cavity, explaining its correlation with HMB and cramping.
  • Discussed medical management options (tranexamic acid, NSAIDs, levonorgestrel intrauterine system) versus surgical intervention (hysteroscopic transcervical resection of fibroid [TCRF]).
  • Patient keen on definitive removal of the fibroid via TCRF and insertion of a Mirena IUS at the same time to manage ongoing bleeding.
  • Discussed setting options for diagnostic/operative hysteroscopy and TCRF.

"Options reviewed:"

"Outpatient Hysteroscopy (Awake)" "- A brief procedure, generally taking 5–10 minutes, with the overall department visit usually under one hour." "- It tends to cause greater pain or discomfort, with typical pain ratings around 5–6/10; a small cohort experienced severe pain or felt unwell during or afterwards." "- Analgesia choices included Entonox (gas and air) and local anaesthetic; Entonox was favoured because it acts quickly and is straightforward to administer."

"Hysteroscopy under General Anaesthetic (Asleep)" "- This approach generally produces the least pain and discomfort." "- It involves a longer hospital attendance of about six hours and fasting beforehand." "- Procedural risks are slightly higher, including a small possibility of injury to the uterus or cervix."

Plan

• Treatment strategy:

  • Book for day-case Hysteroscopy, Transcervical Resection of Fibroid (TCRF), and insertion of levonorgestrel IUS (Mirena®) under general anaesthetic as per patient preference.
  • Chase histopathology results from today's Pipelle endometrial biopsy.
  • Continue oral iron supplementation to optimise preoperative haemoglobin.

• Medicines prescribed:

  • tranexamic acid (Cyklokapron®) 1 g PO TID for up to 4 days during menses
  • mefenamic acid (Ponstan®) 500 mg PO TID during menses with food

• Follow-up arrangements:

  • Pre-operative assessment clinic appointment prior to surgery.
  • Write to patient and GP with Pipelle biopsy results within 3 weeks.
  • Routine post-operative discharge to GP care if histology is benign and procedure is uncomplicated.

Dear GP,

Thank you for referring this 46-year-old G2P2 lady to the gynaecology outpatient clinic with a 9-month history of worsening heavy menstrual bleeding, flooding, erratic intermenstrual bleeding, and secondary dysmenorrhoea. Her symptoms have significantly impacted her quality of life and employment, and have resulted in iron deficiency anaemia (Hb 104 g/L, ferritin 9 µg/L on 02/10/2024), for which she takes ferrous fumarate 210 mg PO BID alongside amlodipine 5 mg PO OD for hypertension. Her cervical screening is up to date and normal (14/05/2023).

On examination today, she had mild conjunctival pallor and a bulky, mobile uterus equivalent to a 12-week gestation size, with a normal cervix on speculum examination. A urine pregnancy test was negative, and an outpatient Pipelle endometrial biopsy was obtained. Review of her recent pelvic ultrasound from 10/10/2024 confirmed a bulky uterus containing a 32 x 28 mm FIGO Type 1 submucosal fibroid indenting the endometrial cavity.

I have diagnosed heavy menstrual bleeding secondary to a submucosal uterine fibroid. Following a comprehensive discussion regarding conservative, medical, and surgical options—including the relative merits and risks of outpatient versus general anaesthetic hysteroscopy—she has elected to proceed with a day-case hysteroscopy, transcervical resection of the fibroid (TCRF), and insertion of a Mirena IUS under general anaesthetic. In the interim, I have prescribed tranexamic acid 1 g PO TID and mefenamic acid 500 mg PO TID to be taken during menses, and advised her to continue her oral iron supplementation. I will write to confirm the histology results from today's endometrial biopsy once available.

Yours sincerely,

Miss Eleanor Vance, MRCOG, Consultant Gynaecologist