M would never forget the day when she collapsed in the bathroom at home with heavy menses. She was rushed to the hospital by the ambulance. When I saw her in the emergency room, she was barely conscious and her face was as pale as a sheet with a pulse that was weak and rapid at 120 per minute. Her blood pressure was low at 80 mmHg systolic and 60mmHg diastolic. Her blood haemoglobin, the oxygen carrying protein in red blood cells, was dangerously low at 6.6g/dl (normal range:12-15.5g/dl). M was in a state of shock. She was immediately given an intravenous drip and transfused with four pints of blood. Medications were also given to stop her menses. She gradually regained her consciousness. Her first words she uttered to me were “I should have listened to your advice”.
M, 40, was a marketing manager with 2 children. She was found to have a small 1 cm fibroid in her uterus during the postnatal check after her second delivery four years ago. I told her that the fibroid was usually non-cancerous and advised her to leave it alone since it was small and asymptomatic. But I told her to come back for review yearly to monitor its growth.
Due to work commitments and frequent travels, M forgot to return for regular review. Four months ago, she noticed that her menstrual flow was getting heavy. “I bleed a lot on the first 3 days of my menses. I have to use 8 to 10 pads a day, double the number I normally change and they are thoroughly soaked. I have to use an extra-large pad at night. Otherwise, my bed sheet will be stained,” she said. She also began to feel breathless and giddy while doing housework but she ignored these symptoms. She did not seek medical advice until the day when she passed out.
M’s condition was stable the next day. Ultrasound examination revealed that the fibroid detected four years ago had grown to 3cm in size and had protruded into the cavity of the uterus. This was probably the cause of her heavy menses. M was advised to have it removed through a hysteroscope- a thin, lighted tube that is inserted into the uterus which will enable one to visualise the womb lining. With her husband’s encouragement, M finally consented for the surgery which was successfully done. She was discharged well the next day.
M had a submucosal fibroid. Fibroids begin as growths in the muscle wall of the uterus. They are called intramural fibroids. With time, some may grow inwards towards the uterine cavity and form submucosal fibroids while others may expand outwards into the pelvic cavity and develop into the subserosal fibroids (Figure 1).
Because submucosal fibroids grow just beneath the inner lining of the uterus, they often cause more bleeding than other types of fibroids. This is because they increase the surface area of the uterine cavity lining. As in M’s case, the menstruation is usually heavy and prolonged. They can also lead to pregnancy and fertility problems such as repeated miscarriages, foetal growth restriction and premature delivery. Submucosal fibroids are usually removed through hysteroscopy. The procedure is done under general anaesthesia. Under the direct vision of the hysteroscope, fluid is introduced into the uterine cavity to lift the walls of the uterus. The fibroid is then shaved off in pieces by a resectoscope (Figure 2).
The outcome is usually good but patients may experience cramping and light staining a few days after the procedure. M recovered well. She was given iron tablets and her haemoglobin gradually returned to normal after a month.