HEAVY MENSTRUAL BLEEDING

Resident(s): Adam Fang, MD

Attending(s): Devang Butani, MD
Program/Dept(s): University of Rochester Medical Center

CHIEF COMPLAINT & HPI

Chief Complaint
Heavy period

History of Present Illness

39 year-old, married, white female, G4/P2-0-2-2 noted a heavy period lasting for 16 days
associated with irregular vaginal bleeding, abdominal cramps and heavy menses.

RELEVANT HISTORY
Past Medical History
Bilateral tibial stress fractures.

Past Surgical History

No significant past surgical history.

Family & Social History

Family history of osteoporosis, hypertension, diabetes, dyslipidemia, anemia.
Does not smoke, drink alcohol, or use illicit drugs.
Medications
Ibuprofen and vitamin D

Allergies
NKDA

DIAGNOSTIC WORKUP
Physical Exam

BP: 120/62, HR: 62, RR: 20, O2Sat: 99% RA

General: Oriented to person, place, and time. She appears well developed and well nourished.
Cardiac: RRR, no murmurs, rubs, or gallops.
Pulm: CTAB. No wheezes, rhonchi or rales.
Abd: Soft and nontender abdomen. No distention or mass. No rebound or guarding.
Pelvic: Uterus, vulva, and cervix were normal. No adnexal abnormality.
Lymphadenopathy: No lymphadenopathy

Laboratory Data
Stool was guaiac negative.
Pregnancy test was negative.
INR 1.1, aPTT 28

7.3

10.2
32

207

DIAGNOSTIC WORKUP
A

Ultrasound:
Sagittal grey-scale (A) and color (B) transvaginal ultrasound (US) with Doppler and
spectral analysis (C) demonstrates an
anteverted uterus measuring 9.4 x 5.5 x 4.8cm.
Multiple serpiginous and anechoic tubular
structures (arrows) are seen within the
myometrium of uterus (A), which
demonstrate internal vascularity (B) on color
Doppler US.
Spectral Doppler US of this area (C) reveals
high peak velocity with low resistance arterial
waveforms and spectral broadening (arrow).

DIAGNOSTIC WORKUP
MRI:
Sagittal (A) and axial (B) T1-weighted MRI images demonstrate multiple serpiginous flow-related signal voids (arrows) involving the
posterior uterine body bulging towards the endometrial cavity and bowing the endometrium anteriorly (A).
The lesion (arrow) crosses the midline posteriorly, and appears to receive vascular supply via internal iliac vessels (arrowheads) as
depicted on contrast-enhanced magnetic resonance angiography (C).

DIAGNOSTIC QUESTION
1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.

C: Uterine hemangioma.
D: Retained products of conception.

CORRECT!
1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.

C: Uterine hemangioma.
D: Retained products of conception.

CONTINUE WITH CASE

SORRY, THATS INCORRECT.

1) Based on the US and MRI findings, what is the diagnosis?
A: Pelvic varicosities.
B: Uterine artery arteriovenous malformation.

C: Uterine hemangioma.
D: Retained products of conception.

CONTINUE WITH CASE

INTERVENTION
Right common femoral artery was accessed.
A 5F glide Omni-SOS catheter
(Angiodynamics, Latham, NY, USA) was
placed through a 5F sheath.
Aortogram was performed demonstrating a
uterine AVM (arrows) fed mainly by the left
(70% of supply) and the right (30% of supply)
uterine arteries with small branches from the
left internal iliac artery. Early venous
drainage is noted on delayed images.
LINK TO VIDEO

INTERVENTION
A
A: Selective embolization of left
uterine artery: Two 6 mm x 10 cm
hydrocoils (Terumo, Somerset,
NJ, USA), several 8 mm Gore-Tex
coils (L.W. Gore & Associates,
Flaggstaff, AZ, USA), and a small
piece of surgical gelfoam
sequentially deployed in the left
uterine artery with the help of a
renegade microcatheter (Boston
Scientific, Marlborough, MA,
USA).
C: Selective embolization of right
uterine artery: 4 mm and 6 mm
Gore-Tex coils were deployed in
the right uterine artery with the
help of a renegade microcatheter.

B: A repeat angiogram of the

left internal iliac artery
demonstrated the blood
supply of the uterine AVM
coming from the left uterine
artery was almost completely
shut down with very slow
minimal flow from some
small branches from the left
internal iliac artery.
D: Repeat arteriogram of the
abdominal aorta demonstrated
near-complete occlusion and
reduced flow of the uterine AVM
post-embolization.

LINK TO VIDEO

MANAGEMENT QUESTION
2) What other potential treatment options are available for patients who fail
transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.

CORRECT!
2) What other potential treatment options are available for patients who fail
transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.

CONTINUE WITH CASE

SORRY, THATS INCORRECT.

2) What other potential treatment options are available for patients who fail
transcatheter arterial embolization?
A: Laparoscopic bipolar coagulation of uterine vessels.
B: Hysterectomy.
C: Unilateral uterine artery and ovarian artery ligament ligation.
D: All of the above.

CONTINUE WITH CASE

CLINICAL FOLLOW UP
Repeat pelvic US was performed 3 months
after bilateral uterine artery coil embolization.
Uterine AVM was stable in size and involved
the posterior and left side of uterus with
pronounced color flow signal (A and B).
Patient continued to have cramps and
sometimes heavy bleeding.
Multiple options were offered to the patient
including surveillance, repeat embolization,
and total hysterectomy with preservation of
ovaries.
Patient decided to undergo laparoscopic total
hysterectomy.

SUMMARY & TEACHING POINTS

Uterine arteriovenous malformations (AVMs) are rare, but
can be a source of potentially life-threatening bleeding

Classification

Characterized by multiple communications between arteries

and veins.
Classified as congenital or acquired
Clinical presentation:

Signs and symptoms: Severe uterine bleeding, lower abdominal

pain, dyspareunia, anemia, and symptoms due to blood shunting
(dyspnea, fatigue, and high-output heart failure)
Physical exam: Audible bruit, palpable thrill in groin, palpable
mass on manual examination, venous stasis and lower extremity
edema

Imaging:

Doppler US, CT, MRI, and angiography (gold standard)

Congenital

Dilation and
curettage

Acquired

Uterine
trauma

Endometrial
carcinoma

Uterine
surgery

SUMMARY & TEACHING POINTS

Treatment Options

Indications

Advantages

Disadvantage

Surgical Management
(ex: hysterectomy, uterine
artery ligation, laparoscopic
bipolar coagulation of
uterine vessels)

Fertility preservation is not

needed, limited access to
medical facilities, or
embolization therapy fails

Definitive treatment

Potential loss of fertility

Expectant and Medical

Management

Single episode of bleeding

and hemodynamically stable

Avoidance of surgical risks

and preservation of fertility

Unsuccessful in patients with

severe or recurrent bleeding

Transcatheter Arterial
Embolization

Recurrent bleeding,
severe bleeding, or
hemodynamically unstable

High success rates, low

complications, avoidance of
surgical risks, and
preservation of fertility

Side effects include lowgrade temperature, pelvic

pain, infection, insufficient
embolization, buttock and
lower-limb claudication

SUMMARY & TEACHING POINTS

Transcatheter arterial embolization technique:
Common femoral artery is accessed using Seldinger technique. Pelvic angiography followed by
selective internal iliac angiography and uterine angiography on the affected side. Embolization
of feeding arteries to the point of stasis. Repeat ipsilateral internal iliac angiography to exclude
additional feeding arteries.
Contralateral internal iliac artery and uterine artery angiography and embolization to prevent
cross-filling. Repeat contralateral internal iliac angiography.
Ovarian artery, inferior epigastric artery, or middle sacral artery are evaluated if bleeding does
not stop or the vascular abnormality does not disappear.

Treatment is usually successful after one or two sessions.

Embolization material used in previous cases include gelatin sponge, coils, isobutyl-2cyanoacrylate, detachable balloons, thrombin, and polyvinyl alcohol sponge.

REFERENCES & FURTHER READING

Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous
malformations: gray-scale and Doppler US features with MR imaging correlation.
Radiology. 1998;206:115123.
Meilstrup JW, Fisher ME. Women's health case of the day Uterine arteriovenous
malformation. AJR Am J Roentgenol. 1994;162:14571458.
Ghosh TK. Arteriovenous malformation of the uterus and pelvis. Obstet Gynecol.
1986;68:40S43S.
Vogelzang RL, Nemcek AA, Jr , Skrtic Z, Gorrell J, Lurain JR. Uterine arteriovenous
malformations: primary treatment with therapeutic embolization. J Vasc Interv
Radiol. 1991;2:517522.