Case report 1

Department of Obstetrics and Gynecology

TikurAmbessa Specialized Hospital
Addis Ababa University

Prepared by: kidest melkamu

MDR/3499/02

Identification:
Name: marta dereje
Age: 46
Sex: female
Address: kotebe, Addis Ababa
Occupation: housewife
Marital status: Married
Religion: Christian Orthodox
Date of admission: 28/02/05 E.C
Hospital: St.Paul
Ward: Obstetrics & Gynecology
Bed no 216/02
Date of clerking: 08/03/05 E.C

Chief complaint:
Irregular and heavy menses of 05 months duration

HPI:
This is a 46 years old gravid 1, Para 0, aborts 1 woman. Before 5 months, her menses used to come
regularly every 4 weeks and stays for 5 days. She used to use 02 pads per day and there were no clots.
Besides occasional headache she had no pain associated with the flow. And her menarche was at the age
of 13 years. But five months back, she started having irregular and heavy menses. The menses started
coming every 02/03 weeks and lasts for 7 days. The flow has clots and she uses 4 pads per day. She has
no pain associated with the flow.
She started experiencing lower abdominal pain which started 03 months ago. It is mild, dull, persistent
pain and it doesnt radiate to anywhere. It has no aggravating or alleviating factors. The severity does
not vary according to her menstrual flow and it does not prevent her from sleeping or doing physical
activities.
28years ago she had an induced abortion at the 2 nd month after absence of menses. It was elective,
because she thought she was not prepared to raise a child. It was induced in a hospital and she doesnt
recall any complications.
2

7 years back, she underwent pelvic surgery at St. Paul Hospital for inability to conceive with a diagnosis
of intrauterine adhesion. The procedure was adhesion lysis.After the surgery she was told she had a
small myoma but that there was no need to remove it.
She has no history of foul smelling vaginal discharge, Fever, chills, rigors, heat or cold intolerance,
Post-coital bleeding , bleeding from other sites, Loss of weight, loss of appetite, Dizziness, vertigo,
palpitation. And she has no history of trauma or other accidents to the genitalia or drug use.

Gynecologic history:
She has never used any contraception. She has no history of sexually transmitted diseases. She is no
more sexually active. She started coitus by the age of 17. She is monogamous. She had her last coitus 5
years ago. She has no history of circumcision.

Menstrual history:
Mentioned in the HPI

Past medical history:

She has a history of vaginal candidiasis 04 years back which was treated. She has not experienced
hypersensitivity to drugs. She has no history of infection with STD. and she has no history of DM, TB,
Hypertension or any other chronic illness.

Family/personal history:
The patient was born and raised in Addis Ababa. She is the second child to her family. She lives with
her husband and his sister. Her parents passed away from what she claims to be old age. They had no
history of DM, HTN or asthma. The patient is educated up to the level of 10 th grade. She has no habit of
smoking or drug use. She does not drink alcohol. She is a housewife supported by her husband who is a
shop owner in Merkato. Their house has 5 rooms with a separate kitchen and toilet. They have a clean
water supply. There is no family history of tuberculosis, allergies or mental disorders.

Review of systems:
H.E.E.N.T
Head: no headache, no head injury, no dizziness
Ears: no impaired hearing or discharge, no ringing in the ears
Eyes: no discharge, no redness, no blurred vision
Nose: no discharge, no stuffy nose, no runny nose, no sneezing
Mouth: no dental caries, no bleeding gums, no artificial dentures
Throat: no sore throat, no difficulty in swallowing, no hoarseness of voice
L/G: no mass in the neck, axillae, or groins. No breast enlargement. No discharge from the nipples. No
heat or cold intolerance

Respiratory: no cough, no expectoration, no chest pain, no wheezing, no cyanosis

Cardiovascular: no palpitations, no shortness of breath, PND or orthopnea, no chest pain, no fatigue
Gastrointestinal: no nausea and vomiting, diarrhea, no constipation, no abdominal pain or heart burn, no
change in stool color.
Genitourinary: no frequency, no dysuria, no urgency, no hesitancy, no dribbling, no reddish
discoloration of urine.
Integumentary: no rash, moist skin, no discoloration, no hair changes, no foot ulcer
Locomotor system: no history of pain, weakness or swelling of the joints,
Central nervous system: no history of numbness, no paralysis, urine incontinence, seizures or speech
defect

Physical examination:
General appearance:
The patient is comfortably lying on the bed. She is well communicating. She does not seem to be in
pain. She is not in cardiorespiratory distress. There is no gross dysmorphic feature.

Vital signs:
Blood pressure: 135/88 mmHg
Pulse rate:
84/min
right radial artery, full in volume and regular rhythm
RR:
19 breath/min
Temperature: 37.1c
Weight:
Height:
BMI:

72 kg
176cm
29.5 overweight

H.E.E.N.T
Head: no scar, no scalp infections, no tenderness, normal hair distribution, clean
Ears: normal contour, normal position, no discharge, no mastoid tenderness
Eyes: pink conjunctivae, non-icteric sclerae, no discharge, no conjunctival inflammation, no lid lag,
no proptosis, no peri-orbital edema, no strabismus, no nystagmus,
Nose: no discharge, central septum, no visible polyps or deformity
Mouth: non offensive breath order, wet buccal mucosa, no mucosal ulcers, no cyanosis, fissures on the
lips, no active gum bleeding or ulcers, no dental carries or fillings, tongue is not fissured or
coated,
Throat: tonsils not enlarged, non-tender

L/G:
No palpable lymph nodes. The breasts are symmetrical. They are soft. They are not tender there is no
lump. There is no discharge or inflammation over the nipple. Thyroid is not palpable.

Respiratory system:
Inspection: no peripheral or central cyanosis or digital clubbing, chest moves symmetrically with
respiration, no gross deformities, no use of accessory muscles, flaring of alanasi or grunting
Palpation: central trachea, no chest tenderness, symmetrical expansion, comparable tactile fremitus
Percussion: resonant over the lung fields, diaphragmatic excursion no done due to patient condition
Auscultation: bilateral good air entry, vesicular breath sounds heard over the lung fields, no crepitation,
no wheeze, no pleural friction rub

CVS:
Arteries: the pulse is regular rhythm and full in volume
Veins: JVP is 3 cm above sternal angle in 30inclination. No distended veins
Inspection: no pallor, no cyanosis, clubbing, Janeway lesion, splinter hemorrhage or Oslers nodes
Precordium is quiet, no bulge, apical impulse is visible in 5th left intercostal space, 1 cm lateral to midclavicular line
Palpation: PMI is palpable where apical impulse is visible. It is tapping, and localized. There are no
palpable heart sounds
Auscultation: S1 and S2 are well heard. There is a hash mid-systolic murmur at mitral and tricuspid
areas. It is grade III, does not radiate and it is crescendo type. No pericardial friction rub.

GIS:
Inspection: the abdomen is flat and symmetrical. There is no flank fullness. There is no localized
swelling. There are no distended veins. The abdomen moves upwards with inspiration and down with
expiration. Epigastric pulsations are not visible. Inguinal, epigastric, umbilical and femoral sites are free
of hernia. The umbilicus is inverted. There is lineanigra and striae gravidarum. No surgical scar.
Palpation: there is no superficial mass or tenderness. There is an abdominopelvic mass which does
not allow entry between it and the pubic symphysis. It is central and 18 week sized. It is firm,
irregular, mobile horizontally, non-tender. There is no hepatomegaly, no splenomegaly. The kidneys
are not palpable. No other deep mass.
Percussion: abdomen is dull over the mass, there is no shifting dullness. Total vertical liver span is 10
cmalong the mid-clavicular line.
Auscultation: active bowel sounds of 14/min, no renal arterial bruits.

GUS:
There is no costovertebral angle tenderness.

Pelvic:
Inspection: there is normal pubic hair distribution over the mons. The clitoris is 1.5 cm long. The labia
majora and minora are intact. There is no sign of genital cutting. There is no visible vaginal discharge.
There is no visible mass at introitus. There is no swelling over the labia, no ulcer.
Digital vaginal exam: cervix is regular, firm, closed. No mass over the cervix, there is no cervical
motion tenderness, no adnexal mass, no mass bulging from the vagina, no adnexal tenderness, smooth
vaginal mucosa.No blood on examining finger.
Bimanual vaginal exam: mass moves with cervix. The uterus is anteflexed and anteverted. It is
irregular.
Rectovaginal exam: rectovaginal wall is intact with a strong rectovaginal septum. The uterus is not
retroverted. There is no tenderness in the Pouch of Douglas

Integumentary:
no rash, no pallor, no jaundice, warm skin
normal hair distribution, soft texture and strength
pink nail beds, no inflammation around nails, no clubbing

Musculoskeletal:
No asymmetry of limbs, no gross deformities, no joint swelling, redness or tenderness. No edema. No
limitation in movement.

CNS:
General:14/15 on Glasgow scale, conscious, oriented to place, time & person, communicating,
appropriate mood, judgment.
Cranial nerves: CN I
CN II

smells alcohol via each nostril

good visual field and acuity, direct and indirect pupillary light reflexes
are present
CN III, IV &VI patient looks in all directions with both eyes symmetrically, no
strabismus or nystagmus
CN V
intact tactile sensation over the face, corneal reflex present, intact
motor part
CN VII
face is symmetrical at rest and upon voluntary movements like smiling,
nasolabial folds are present bilaterally
CN VIII
good hearing on both sides,
CN IX & X
says ah, no hoarseness of voice
CN XI
shoulders shrug against resistance, neck turns against resistance
6

CN XII
no atrophy of the tongue, tongue is central upon protrusion
Motor: bilaterally comparable muscle bulk of limbs, no spontaneous or induced fasciculation,
Normal power and reflex
sensory: pain sensation is intact over all extremeties
Meningeal signs: no nuchal rigidity, absent kernigs and brudzinskys signs.

Summary:
Subjective

Objective

46 years old

Stable

Nulliparous

Abdominopelvic mass

1 abortion

-18 weeks sized

Menorrhagia

- Irregular, firm

Metrorrhagia
Low abdominal pain

Differential diagnoses:
Abnormal uterine bleeding 2 to uterine leiomyoma
AUB 2 to early pregnancy complications
AUB 2 to endometrial polyp
AUB 2 to adenomyosis
AUB 2 to endometrial CA
AUB 2 to endometrial sarcoma
Ovarian CA
Dysfunctional uterine bleeding

Discussion of the differential diagnoses

Dysfunctional uterine bleeding
DUB is a diagnosis by exclusion. It is an abnormal uterine bleeding that is not a result of an organic
disease involving the ovaries or the uterus. It is a result of disruption in the hypothalamo-pituitary-ovarian
axis. DUB is most common around the beginning and the end of menstrual age. It is mainly due to
annovulatory cycles. It may result from an immature HPO axis, insensitive ovarian follicles. Management
of DUB includes tranexamic acid, NSAIDS, COCs, progestins, androgens and Gn-RH agonists.
This patient is 46 years old, i.e, she may be in her perimenopausal age. She is also obese. These may
predispose her follicles to be less sensitive to gonadotropins, resulting in abnormal pattern of ovulation
and even anovulation with subsequent DUB. However, the concomitant presence of an abdomino-pelvic
mass makes an organic causes of the bleeding more likely. However, if all other diagnosis fail, DUB will
be the final diagnosis

Ovarian CA
The ovaries are the second most common site of pelvic malignancy in women. There are several types of
ovarian cancer. These are grossly divided based on origin as epithelial, germ cell, sex-cord stromal and
metastatic; the most common being epithelial. Incessant ovulation is thought to be the most important
factor behind the development of epithelial neoplasms.Some risk factors are low parity, infertility,diet rich
in saturated animal fat and genetics (BOC & Lynch II). Accordingly, protective factors include
multiparity, OCP, bilateral tubal ligation, and a low BMI.
A history of nonspecific gastrointestinal complaints, including nausea, dyspepsia and altered bowel habits
are common. Incarceration into the cul-de-sac may cause severe pain, urinary retention, rectal discomfort,
and bowel obstruction. Menstrual abnormalities are noted in 15%. AUB may be caused by a concomitant
endometrial CA, metastasis to the lower genital tract or estrogen secreting granulosa theca cell tumor.
Prognosis of ovarian malignancies is generally poor because of late diagnosis due to nonspecific
symptoms and lack of an effective screening technique. However, CA-125 is a well characterized tumor
marker in epithelial ovarian cancer and it can be used in high risk women.

Generally, an ovarian mass in reproductive aged women is more likely to be a functional cyst while in
premenarcheal and postmenopausal women, its more likely malignant. Malignant tumors of the ovary are
generally solid, fixed, bilateral and nodular.
. Surgical treatment includes primary debulking and cytoreduction which includes TAH, bilateral
salpingo-oophorectomy, para-aortic & inguinal lymphadenectomy, omentectomy, liver examination and
brushing of the diaphragm. Chemotherapy and radiation may be used.
This patient is a 46 years old nulliparous. She has irregular bleeding, a chronic lower abdominal pain and
an irregular abdomino-pelvic mass. These can all be explained by an ovarian tumor.

AUB 2 to endometrial sarcoma

ESSs are predominantly found in postmenopausal women and can be either endolymphatic stromal
myosis/low grade endometrial stromal sarcoma or high grade endometrial stromal sarcoma.
The most common manifestation of a uterine sarcoma in general is bleeding. Other complaints include
pelvic discomfort or pain, constipation, urinary frequency and the presence of a mass low in the abdomen.
Advanced disease manifests as a large omental mass or ascites secondary to abdominal carcinomatosis.
Chest x-ray, CT, pelvic ultrasonography, sigmoidoscopy, and cystoscopy may be indicated according to
presenting symptoms.
Complications include severe anemia from chronic blood loss or acute hemorrhage, uterine rupture from
rapid tumor growth, obstructed labor, postpartum uterine inversion, hemoptysis from lung metastasis and
ascites.Pressure effects on bladder and bowel may manifest as overflow incontinence in the former and
ribbon stools n the latter. Ureteral obstruction may result in kidney failure.
Treatment includes emergency management of hemorrhage, emergency D&C for biopsy. Definitive
therapy for low grade uterine sarcomas is radical hysterectomy and bilatleral salpingo-oophorectomy.
High grade uterine sarcomas are preferably managed by simple total abdominal hysterectomy & bilateral
salpingo-oophorectomy preceded or followed by adjunctive radiation therapy. Adjuvant chemotherapy
with doxorubicin is also recommended with LMS. Radiation therapy is also used as adjuvant.
This patient presented with the most common presenting symptom of uterine sarcomas. She has a
palpable mass that is firm and irregular and must be biopsied in order to perform patho-histological
studies. If diagnosed, management depends on the histology and prognosis on the extent.

AUB 2 to endometrial CA
Endometrial CA is the most common gynecologic malignancy. Unopposed estrogen induced proliferation
is thought to be the mechanism by which endometrial cells become hyperplastic and later undergo
malignant transformation. The type of hyperplasia determines the risk of progression to cancer.
Hyperplasia without atypia has a 1% chance of progression and that with atypia has a 10% risk if it is
simple and 30-40% risk of progression if complex. Simple and complex are differentiated with stromal
involvement of the proliferation.
Risk factors include old age (peak=70years), nulliparity, PCOS, chronic anovulation, late menopause,
Granulosa cell tumors, exogenous estrogens, metabolic syndrome (diabetes, obesity, hypertension,)
history of breast CA, tamoxifen therapy and genetic predisposition (HNPCC syndrome.)

It manifests as bleeding in the form of menorrhagia, metrorrhagia or postmenopausal bleeding. Diagnosis

is made by endometrial sampling.
Prognosis is generally good (75%) but depends on stage, histologic grade, cell type, depth of myometrial
invasion, lymph-vascular space involvement, node status, involvement of lower uterine segment and size
of the tumor. Dilatation and fractional curettage is the definitive procedure for diagnosis of endometrial
carcinoma.
The most important treatment modality is surgery with total simple or radical hysterectomy, bilateral
salpingo-oophorectomy and pelvic and peri-aortic lymphadenectomy. Radiation therapy may be used as
an adjuvant or as primary therapy in those unfit for surgery or with advanced disease. Refractory cases
may be treated with progesterone, tamoxifen or chemotherapy (cisplastin & doxorubicin).
This patient carries a number of risks for endometrial CA. She is old and nulliparous. She is also obese.
The increased peripheral conversion of androgens to estrogen from her body her fat places her
endometrium at increased risk of undergoing hyperplasia. She has an abdominopelvic mass which implies
a late stage if diagnosis is confirmed. Diagnosis can be made by either endometrial biopsy or D&C. If
diagnosed, management at this age (after considering patients fertility desire) will be surgical with
radical hysterectomy.

AUB 2 to adenomyosis
Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium of the
uterus. It may be diffuse or existing focally as an adenomyoma. Its incidence varies with the thoroughness
of the investigation used. Adenomyosis attains a large size due to surrounding smooth muscle hyperplasia
and hypertrophy.
Risk factors include a hx of child birth (risk does not increase with parity,) postpartum endometritis.
Mullerian cell arrest, prolactin and FSH are thought to play a role in pathogenesis.
Unlike myomas, adenomyosis is symptomatic in 70%. It manifests most commonly between ages 40-50.;
Physical findings include a uniformly enlarged, boggy uterus..
Clinical manifestation includes menorrhagia in 60% and dysmenorrhea in 25%. The typical presentation
is a parous, middle aged, woman with menorrhagia and dysmenorrhea with a symmetrically enlarged
uterus.
Transvaginal sonography has a 83% sensitivity and 67% specificity for diagnosing adenomyosis. MRI is
the most accurate but because of the cost, it is an option only in doubtful sonograms and coexisting
leiomyomas.
This patients age falls within the range of peak incidence of adenomyosis. She has never had child birth
but had an abortion which may still play the similar role as parity as far as predisposition to adenomyosis
is concerned. The induced abortion is a surgical assault to the endometrium with potential implantation of
endometrial cells into the myometrium.
If confirmed, hysterectomy is a definitive therapy as it can cure the disease. Hormonal therapy is
generally ineffective.

AUB 2 to endometrial polyp

An endometrial polyp is a hyperplastic overgrowth of endometrial glands visible as a spheroidal or
cylindrical structure that may be either pedunculated or sessile. Incidence of benign endometrial polyps
increases with age, peaking in the 5 th decade. Risk factors are hypertension, obesity and tamoxifen
therapy. 10-24% of women have asymptomatic polyps. The potential for malignant transformation is very
low (0.8%). In addition, prognosis is favorable with early diagnosis because of relative ease of removal.

Metrorrhagia is the most common presentation of symptomatic polyps, occurring in 50% of patients.
Menorrhagia, postmenopausal bleeding, or a prolapsed mass may also be the presenting complaint.
Presumably, a large polyp, with its central vascular component, contributes to menstrual bleeding and
adds greatly to the total blood loss..
Among imaging modalities, sonohyterography is considered the best as it is better than TVS in both
sensitivity and specificity.
Treatment is surgical and involves hysteroscopic resection followed by D&C. This is reserved only for
symptomatic patients and those with infertility. Medical management consists of GnRH agonists and
progestin. Hysterectomy is unnecessary unless malignancy is detected.
This patient has metrorrhagia and menorrhagia. In addition, she is obese. These evidences require further
diagnostic workup like hysteroscopy with endometrial biopsy to make a definitve diagnosis,

AUB 2 to early pregnancy complications

Pregnancy and its complications is a common cause of AUB in reproductive aged group women and its
misdiagnosis may have potentially serious outcomes. So, it should be the first to be considered and ruled
out.
Early pregnancy bleeding may be caused by abortion, gestational trophoblastic disease or ectopic
pregnancy. Abortion may be in any of the clinical stages of threatened, inevitable, incomplete, complete,
missed or septic. The clinical manifestations vary with each type, ranging from minimal bleeding, viable
fetus and a closed cervix in threatened abortion, to the expulsion of all products of conceptus including
the fetus, placenta & membranes in complete abortion. Management of abortion consists of five elements
including medical management of the abortion & its complications, counseling the patient, family
planning service, establishing a community-provider relationship and integrating abortion with other
health related problems.
Gestational trophoblastic disease is an aberrant product of gametogenesis and fertilization that results in
excessive trophoblastic proliferation. Its a spectrum of diseases encompassing hydatidiform mole
(complete or incomplete,) invasive mole, choriocarcinoma and placenta site trophoblastic tumor. It
manifests as exaggerated pregnancy symptoms like hyperemesis gravidarum, theca lutein cysts,
preeclampsia in 1st trimester, big for date uterus, expulsion of vesicles, -hCG greater than expected,
absent fetal heart tones and uterine bleeding in 1 st trimester. Risk factors include ages <20 and >40yrs,
nulliparity, low socioeconomic status and diets deficient in protein, folate & carotene. In addition, blood
group A women impregnated by group O men have a 10x risk. Treatment is complete evacuation of
uterine contents with chemotherapy as necessary.
Ectopic pregnancy is an implantation that occurs outside the uterine cavity proper. Tubal being the most
common, it can be ovarian, intraligamentous, abdominal, or cervical. Risk factors are mostly factors that
alter the fallopian tubes. Salpingitis in utero DES exposure, endometriosis, leiomyomas, ovulation
induction, assisted reproductive technology, tubal sterilization or anastomosis. Zygote abnormalities,
ovarian factors, exogenous hormones, and other factors like IUD, smoking and increasing age are also
implicated as increasing the risk. Presentations of ectopic pregnancy are severe pain, bleeding,
amenorrhea and/or syncope. On examination, there may be tenderness, an adnexal mass, uterine changes

(implicating diagnosis of probable pregnancy) and hemodynamic instability. Ectopic pregnancy may
undergo resorption, abortion, rupture or re-implantation onto the abdomen. Symptomatic ectopic
pregnancy is a surgical emergency which can be managed by salpingotomy, salpingostomy or
salpingectomy.
This patient has bleeding that was not followed by a certain period of amenorrha. She is in the
reproductive age group but claims not to be sexually active for the last 05 years. She has an 18 sized
abdominiopelvic mass but without any of the other signs of probable pregnancy. This makes the
diagnosis of pregnancy related complications very unlikely. However, all the above complications are still
possible and can be ruled out with a simple serum hCG detection/quantification.

AUB 2 to uterine leiomyoma

Leiomyoma of the uterus, also known as fibromyoma, fibroid, myoma, is a benign clonal neoplasm
arising from smooth muscle cells in the uterine wall. It is the most common gynecologic tumor, if not the
most common tumor in humans. It is present in 20-25% of reproductive aged women and more so in
black women.
It has a pseudo-capsule which is composed of the areolar tissue& compressed muscle tissue, allowing
easy dissection during surgery. Estrogen receptors make this tumor sensitive to the hormone.
Most commonly asymptomatic, it may manifest as AUB in the form of menorrhagia or metrorrhagia,
pain, infertility, spontaneous abortion, or pressure effects on bowel & bladder. Even though the cause is
not known, risk factors identified include: early menarche, nulliparity, reproductive age, obesity or in
other words, anything that increases estrogen without progesterone to counterbalance.

Myomas are classified by their anatomic location as intramural, subserosal, submucosal, cervical,
intraligamentous, pedunculated intravaginal or parasitic. Clinical manifestation depends on location,
bleeding being the most common in submucosal myomas. This can be due to increased endometrial
surface area, hyperplasia of endometrium, thinning & ulceration in overlying endometrium from
interruption of blood its supply, interference with contractions and/or prostaglandin imbalance. Pain may
be acute from torsion of a pedunculated myoma, hemorrhage into the myoma (red degeneration,)
dyspareunia or infection (septic degeneration.) Chronic pain is due to pressure effect.
A leiomyoma can have a varied clinical course. It might undergo atrophy, hyaline degeneration, cystic
degeneration, calcify, septic degeneration, fat degeneration, red degeneration (common during pregnancy)
or advance into sarcoma (1%.) A myoma might rarely metastasize without malignant transformation. This
is more common with surgical manipulations such as D&C, myomectomy or hysterectomy.
Diagnosis may be made by from history and bimanual pelvic examination or sometimes abdominal
palpation supported by a pelvic ultrasound. Anemia is usually present in chronic cases of bleeding.
Polycythemia may sometimes be present from extra medullaryhematopoiesis, erythropoietin release due
to compressed kidney and renal artery.
This patient is at increased risk of developing leiomyoma because of multiple factors. She is old and in
the reproductive age, black, nulliparous and obese. In addition she was already previously diagnosed
during her surgery 7 years ago. She was asymptomatic during this stage. She now presented with
menorrhagia and metrorrhagia, which is the most common symptomatic presentation. She has a mass
which is irregular, firm and pelvic in origin. This makes the diagnosis of uterine leiomyoma very likely.

An imaging modality like pelvic ultrasound may be used to observe 1 or more smooth, spherical masses
to confirm diagnosis. However, considering her age, endometrial biopsy is still warranted in this patient
because of the increasing likelihood of malignancy with age.
If diagnosis is confirmed, management options are based on location, symptoms, size, age and fertility
desires. The options of therapy include expectant (if asymptomatic,) medical, surgical (myomectomy,
hysterectomy,) uterine artery embolization, myolysis and immunotherapy.

Investigations
CBC
Serum hCG
Transvaginal sonography

Hysteroscopy
Colposcopy
Endometrial biopsy