03/09/2025
When magnetic resonance imaging MRI becomes the deciding factor.
* Warning: long post, with graphic operative photos.
A patient came for a second opinion. She was admitted as a walk-in in a private hospital due to dizziness. She has no missed period but her recent mentruation was heavy. Routine CBC revealed severe anemia. Work up done to establish cause of anemia. A transvaginal ultrasound revealed a large uterine mass, normal adnexae. The following day, CT of whole abdomen was done, read as a large pelvoabdominal mass probably ovarian in origin, probably malignant; uterus normal. Patient was discharged after receiving blood transfusion. Hours after discharge, she went to my clinic wanting a second opinion because she was confused of the diagnosis given her. After my history taking and pelvic exam, I was inclined to believe her pelvoabdominal mass was benign, maybe a huge degenerated myoma. I offered to request for a repeat transvaginal ultrasound with doppler studies to be done by an OBGyn sonologist to confirm my findings. But the patient refused. She said why would I request for another ultrasound when it was already done and it ran conflict with the ct scan findings. Oo nga naman 😅.
I listened to the patient’s opinion. And so I requested for an MRI of whole abdomen with contrast. I warned her she will be spending more for this than an ultrasound. But patient was adamant for another diagnostic imaging modality. She wanted peace of mind, so she can decide as a well-informed and satisfied patient for any further management.
MRI was done. The image clearly showed an enlarged uterus, an intramural mass with submucous component. The uterine mass had both solid and cystic areas. These features are usually associated with malignancy if it were ovarian in origin. But since the mass was uterine in origin, with defined borders, it is more associated with a benign degeneration. Endometrial cavity was compressed by the submucous mass. Surrounding bowels were likewise compressed. Ovaries normal in size. The MRI images were the good visual aids which helped me explain to the patient what she has and what must be done.
Patient consented to surgery after I explained that there was no other option but hysterectomy for an at least 20 cm uterine tumor, and she was past reproductive function. Patient is 45 y/o.
I did a total abdominal hysterectomy with bilateral salpingectomy. Removal of her uterus including cervix and both her fallopian tubes. Her ovaries are grossly normal so these remained to avoid menopause. There was minimal blood loss. No blood transfusion done though 2 units packed RBCs were set on standby. The enlarged uterus weighed almost 5 kg, showing a grossly degenerated myoma uteri, thin compressed endometrial cavity, with a large submucous component which was the cause of her monthly heavy mentrual bleeding of almost 2 years. Patient was discharged improved/relieved, and came back after a week, then after 1 month post surgery happy, gained weight, and able to sleep well.
Lesson learned: A physician must listen to her patient because a good treatment outcome is best expected when the patient is fully informed and understands her condition.
* Photos taken with consent for educational purpose, and may be viewed under your discretion.
* During the clinical interview (history taking), patient revealed she has been my patient 10 years ago due to abnormal vaginal bleeding. Her old medical record was still in my files. Upon review, she already had a 3 x 4 cm myoma uteri then. But she was lost to follow up after her mentrual cycle became normal with medical management.
.5T
