A 34-year-old female, para 2, presented with the complaints of heavy menstrual bleeding and intermenstrual bleeding for 2 months. The patient had a history of hysteroscopic polypectomy 3 years before for similar complaints. Her vitals were normal, and abdominal and per speculum examination was unremarkable. On bimanual pelvic examination, a normal-sized, anteverted uterus, with free bilateral fornices. On transvaginal ultrasonography (USG), a well-defined hypoechoic lesion of approximately 2 cm was present in the anterior wall, as can be seen in Figure 1.Figure 1: Transvaginal ultrasound image showing anterior wall fibroid (green arrow)The diagnosis of fibroid uterus was made. The symptoms were disproportionately more with respect to the size of the fibroid. To guide the treatment, we decided to do fibroid typing. The patient has complaints of intermenstrual bleeding. This has raised suspicions of a submucosal fibroid. The saline infusion sonography (SIS) was performed, and it revealed a small 2 cm × 1.7 cm type 1 fibroid from the anterior wall, along with a small endometrial polyp, as can be seen in Figure 2.Figure 2: Saline infusion sonography image showing anterior wall fibroid (Red arrow- Polyp, Light brown arrow- fibroid, Yellow- Intrauterine saline)It was decided to do hysteroscopic polypectomy and fibroid resection. On hysteroscopy, around 2 cm, the anterior wall type 1 fibroid was present, as can be seen in Figure 3, resected using a resectoscope. Postoperative recovery period of the patient was uneventful, and she was free of symptoms on follow-up for 6 months. The histopathology report confirmed the fibroid uterus.Figure 3: hysteroscopy image showing anterior wall fibroid (blue arrow)DISCUSSION Abnormal uterine bleeding (AUB) is a significant clinical condition affecting women of reproductive age, and uterine fibroid is the common underlying cause. The treatment depends on symptoms, age, desire for fertility, and the number, size, and location of fibroids.1 Almost a third of women are symptomatic and need treatment.2 Medical treatment options such as progestogens, combined oral contraceptives, and gonadotropin-releasing hormone agonists or antagonists are generally used for short-term treatment of fibroid-induced bleeding.3 Current management strategies mainly involve surgical interventions, including myomectomy or more “radical” surgery, hysterectomy. Other nonsurgical approaches include uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.2 The International Federation of Gynaecology and Obstetrics (FIGO) classified the fibroids based on location4 (0 = pedunculated intracavitary fibroid; 1 = submucosal fibroid that is <50% intramural; 2 = submucosal fibroid that is ≥50% intramural; 3 = fibroid that is 100% intramural and in contact with the endometrium; 4 = intramural fibroid; 5 = subserosal fibroid that is ≥50% intramural; 6 = subserosal fibroid that is <50% intramural; 7 = sub-serosal pedunculated fibroid; 8 = other fibroids). Symptoms of small fibroids depend on their location, ranging from asymptomatic (where no treatment is required) in case of subserosal to heavy menstrual bleeding, intermenstrual bleeding, dysmenorrhea, infertility, and miscarriage in submucosal and need surgical treatment. Moreover, the route of surgery depends on the location; laparoscopic in case of large subserosal/intramural fibroid and hysteroscopic in case of submucosal fibroids. Again, in case of a pedunculated intracavitary fibroid (type 0) or an endometrial polyp, surgical treatment can be done simply by cutting the stalk or polyp with hysteroscopic scissors, whereas submucosal-intramural (types 1 and 2) may need a resectoscope. USG is the first-line imaging modality for their diagnosis and characterization. It can be used to locate the fibroid: subserosal, intramural, and submucosal. However, exact typing of the fibroid may not be possible with ultrasound in all cases, as the accuracy depends on the skill of the sonologist and the quality of the description in the report. Hence, errors in the classification and description of fibroids make the surgical planning difficult.5 SIS can help in the evaluation of the uterine cavity during the workup of infertility and abnormal uterine bleeding. It can be used for typing in case of submucosal fibroids and differentiating it from other intracavitary lesions such as polyps, and so, for pre-operative planning.6 We also acknowledge this is a report of a single case and thus is constrained by some limitations in generalizability. It though establishes application of universal diagnosis and treatment procedures based on standard guidelines such as FIGO classification. It further emphasizes individualized evidence-based management of abnormal uterine bleeding. Further personal experience of illness or a better understanding of what it is like for the patient to encounter illness also contributes to building empathy and better communication with patients and engaging in shared decisions. Detailed counselling and frank discussion of investigations and obtaining informed consent also evidenced empathetic, patient-centered practice. We present this case with the patient’s consent. Institutional Review Board (IRB) clearance is exempted as it is a single case, and consent from the patient is taken to publish the de-identified information and images. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions AS, AY, NG, and AK managed the case and collected relevant data (data curation, formal analysis, investigation). AS drafted the manuscript with direction from AY, NG, and AK (conceptualization, methodology, resources, supervision, project administration, software, writing). AS, AY, NG, and AK critically evaluated the manuscript (Writing – review and editing). All authors approved the final version of the manuscript (validation and visualization). Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sanap et al. (Wed,) studied this question.