Polyendocrine Metabolic Ovarian Syndrome

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

PMOS — Polyendocrine Metabolic Ovarian Syndrome (formerly PCOS)

PMOS, the new name for PCOS since May 2026, is a common hormonal and metabolic condition. This sheet gives why it was renamed, how to diagnose it, what to screen for, and how to treat the periods, hair, metabolic effects and fertility.

🎯 AT A GLANCE — PMOS (FORMERLY PCOS)

Polyendocrine Metabolic Ovarian Syndrome (PMOS) is the new name for polycystic ovary syndrome (PCOS), announced in May 2026 after a global consensus process published in The Lancet

Why the change: the old name suggested an ovarian cyst problem; the condition is really hormonal and metabolic, with no excess of abnormal ovarian cysts, and the narrow name contributed to missed diagnoses

About 1 in 8 women (over 170 million worldwide) are affected, and up to 70% are undiagnosed

Insulin resistance is present in up to 85%, including about 75% of women with a BMI of 25 or less

The diagnostic criteria have not changed; the name will be fully adopted in the 2028 international guideline update, after a three-year transition

PMOS affects periods, fertility, skin and hair, weight, blood sugar, mood and long-term health: assess and treat all of these.

🚨 THINK OF ANOTHER DIAGNOSIS OR ACT IF…

Rapid onset of virilisation (deep voice, clitoromegaly, rapid hair growth) or a very high testosterone — look for an androgen-secreting tumour of the ovary or adrenal and refer (from memory)

Amenorrhoea with milk discharge, headache or visual change — check prolactin and image the pituitary (from memory)

Bleeding after a gap of months, or heavy irregular bleeding, especially with obesity or over 45 — sample the endometrium; the risk of hyperplasia and cancer is higher in PMOS

Pregnancy with PMOS — treat as higher risk: screen for gestational diabetes at 24–28 weeks, and watch for hypertensive disorders

Low mood, anxiety, an eating disorder, or thoughts of self-harm — screen at diagnosis and refer for psychological support

STEP 1 · DIAGNOSE — two of three criteria

🧩 THE DIAGNOSTIC CRITERIA

First exclude other causes: pregnancy, thyroid disease, high prolactin, non-classic congenital adrenal hyperplasia, Cushing syndrome and androgen-secreting tumours (list from memory)

Hyperandrogenism: clinical (acne, excess hair growth, scalp hair loss) or biochemical (raised free testosterone or free androgen index)

Ultrasound: use a transvaginal scan when possible; the follicle and ovarian volume thresholds are from memory (at least 20 follicles in an ovary, or volume of 10 mL or more)

Adolescents: irregular cycles are normal in the first years after the first period; scans and AMH are poorly specific, so do not use them

🩺 HISTORY AND EXAMINATION

Ask about: cycle pattern, hair growth and acne, weight change, fertility plans, mood and sleep, snoring, and family history of diabetes (from memory)

Examine: BMI and waist, blood pressure, hirsutism score (Ferriman-Gallwey), acne, scalp hair loss, and dark velvety skin (acanthosis nigricans) (from memory)

Ask permission before weighing, and avoid weight stigma

Blood tests: testosterone or free androgen index, plus tests to exclude other causes; 75 g oral glucose tolerance test, lipids

STEP 2 · SCREEN — metabolic, mental and endometrial health

🩸 METABOLIC, MENTAL AND ENDOMETRIAL HEALTH

Area	What to do	How often
Glucose	75 g oral glucose tolerance test (the most accurate test)	At diagnosis, then every 1–3 years
Lipids and blood pressure	Lipid profile and blood pressure at diagnosis	Blood pressure every year
Sleep apnoea	Assess when symptoms are present, such as snoring and daytime sleepiness	When symptoms occur
Depression and anxiety	Screen every woman; offer psychological therapy such as CBT when needed; be aware of eating disorders and body image concerns	At diagnosis and as needed
Endometrium	Higher risk of hyperplasia and cancer (absolute risk is low); no routine screening; prevent with weight management, cycle regulation, and regular progestogen	Do not let her go months without a bleed

STEP 3 · TREAT — target the problem she brings

🥗 LIFESTYLE FIRST

Healthy eating and physical activity are central at every life stage; aim to prevent weight gain, and to lose weight when needed

No single diet or exercise plan has been shown to be better than another; choose one she can keep up

Even a modest weight loss can improve cycles, androgen levels and fertility (from memory)

Anti-obesity drugs or bariatric surgery may be considered by general population guidelines

Offer support, not blame

💊 DRUG TREATMENT BY PROBLEM

Problem	First choice	Points to remember
Irregular periods and hyperandrogenism	Combined oral contraceptive pill; lower-dose preparations preferred	Also protects the endometrium; check the contraindications (last point from memory)
Metabolic features	Metformin	More effective than inositol; inositol has limited benefit
Unwanted hair	Cosmetic measures and laser; the combined pill	Antiandrogens only when other treatments fail or cannot be used; they need reliable contraception (last point from memory)
Needs a regular bleed but not the pill	Cyclical progestogen	Prevents endometrial overgrowth (from memory)

👶 FERTILITY

Line	Option
First	Letrozole for ovulation induction
Second	Clomiphene (alone or with metformin), gonadotrophins, or laparoscopic ovarian surgery
Third	IVF, possibly with in vitro maturation, when the other treatments have failed

Before conception: optimise weight, glucose and blood pressure; offer an OGTT before pregnancy where possible

In pregnancy: PMOS raises the risk of gestational diabetes, hypertension and pre-eclampsia, miscarriage, preterm birth and caesarean birth; repeat the OGTT at 24–28 weeks

Metformin does not prevent gestational diabetes or pre-eclampsia; it may reduce preterm birth

⚠️ COMMON PITFALLS

Telling a woman she “does not have PCOS” because her ultrasound shows no cysts

Diagnosing it in a teenager by ultrasound or AMH

Treating only the periods or the hair and missing glucose, mood and sleep

Using a glucose-only fasting test when an OGTT would find the problem

Leaving a woman with months of amenorrhoea and no endometrial protection

Giving clomiphene first when letrozole is the first-line drug

Blaming her weight

Memory Aid

PMOS

Four reminders for a woman with PMOS.

P

Periods, hair and scan: two of three — adults; teenagers need hyperandrogenism and irregular cycles

M

Metabolic check — OGTT, lipids, blood pressure, sleep

O

Offer help for her goal — cycles, hair, fertility (letrozole first) or weight

S

Support the mind — screen for depression and anxiety; protect the endometrium

Remember: PMOS is a lifelong hormonal and metabolic condition, not an ovarian cyst problem; screen, treat the whole woman, and follow up.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the Endocrine Society and AAFP reports on the May 2026 renaming of PCOS to PMOS (name, reasons, prevalence, transition to the 2028 guideline update, diagnostic approach), and a summary of the 2023 International evidence-based guideline on PCOS (diagnostic criteria, adolescents, lifestyle, combined pill, metformin, inositol, letrozole and later fertility lines, metabolic screening, psychological health, endometrial protection, pregnancy risks). Items marked “from memory” (ultrasound thresholds, conditions to exclude, history and examination details, anti-androgen and progestogen notes, red-flag situations) were not checked. Guidance is updated: follow your local protocol and the current international guideline.

 

Bolangir, Odisha

Clinical Quick Reference

Liver Function Tests

Reading the pattern: liver enzymes and bilirubin

Remember C · A · O Chronic hepatitis Acute hepatitis Obstructive jaundice

Test

C Chronic hepatitis Long-standing hepatocellular injury

A Acute hepatitis Sudden hepatocellular injury

O Obstructive jaundice Cholestatic / post-hepatic block

ALTAlanine aminotransferase

Mild ↑

Marked ↑↑

Mild ↑

ASTAspartate aminotransferase

Mild ↑

Marked ↑↑

Mild ↑

ALPAlkaline phosphatase

Normal to mild ↑

Mild ↑

Marked ↑↑

GGTGamma-glutamyl transferase

Normal to mild ↑

Mild ↑

Marked ↑↑

Bilirubin – DirectConjugated, water-soluble

Usually normal*

Moderate ↑

Marked ↑↑

Bilirubin – IndirectUnconjugated, albumin-bound

Normal

Mild ↑

Normal to mild ↑

Hallmark

Persistent mild ALT/AST rise, usually under 5× ULN, for more than 6 months

ALT/AST often over 10× ULN; ALT ≥ AST in viral hepatitis

ALP over 3× ULN with a matching GGT rise; direct bilirubin dominates

Direct vs Indirect bilirubin

Which fraction is raised points to where the problem is

Red cell breakdownHaem → bilirubin

IndirectUnconjugated, to liver on albumin

Liver conjugatesUGT1A1 enzyme

DirectConjugated, into bile

Bile ducts → gutStool colour

Indirect-predominant rise Direct fraction under 20% of total bilirubin

• Pre-hepatic: haemolysis, Gilbert syndrome, physiological neonatal jaundice
• Not water-soluble, so no bilirubin in urine; urobilinogen may rise
• ALT, AST and ALP usually normal

Direct-predominant rise Direct fraction over 50% of total bilirubin

• Hepatic or post-hepatic: hepatitis, drug-induced cholestasis, stones, stricture, tumour
• Water-soluble, so dark urine; pale stools when bile flow is blocked
• Pair with the enzyme pattern above to separate A from O

Normal Mild Moderate Marked

ULN = upper limit of normal. *Direct bilirubin rises when chronic disease decompensates.
Reference ranges vary by laboratory.

Swaraj Hospital and Research Institute Bolangir, Odisha

For education. Interpret LFTs with history, examination and imaging; not a substitute for clinical assessment.

Decoding Menopause

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menopause — Diagnosis, HRT & Care

Menopause is a natural stage that brings symptoms and long-term health risks. This sheet gives how to stage and diagnose it, how to choose hormone therapy, the options when hormones are unsuitable, and follow-up.

🎯 AT A GLANCE — MENOPAUSE

Menopause is the permanent end of menstruation, diagnosed after 12 months without a period (when she is not on hormonal contraception)

The transition (perimenopause) can last several years, with irregular periods and symptoms such as hot flushes, night sweats, poor sleep, low mood and vaginal dryness

In women over 45, diagnose perimenopause from the symptoms and the irregular periods; blood tests are not needed

Hormone therapy (HT or HRT) is the most effective treatment for hot flushes and night sweats, and for vaginal symptoms and bone loss

For most healthy symptomatic women under 60 or within 10 years of menopause, the benefits of HT outweigh the risks

Offer every woman information on symptoms, options, bone and heart health, and contraception, so that she can choose.

🚨 DO NOT ASSUME MENOPAUSE IF…

She is under 40 with no or infrequent periods — think of premature ovarian insufficiency; check FSH twice, 4–6 weeks apart, and refer

Bleeding after the menopause, or irregular heavy bleeding that does not fit the pattern — needs endometrial assessment; it can be hyperplasia or cancer

Unexplained weight loss, a breast lump, or pelvic mass or pain — examine and investigate; do not blame the menopause (from memory)

She has had breast cancer, active liver disease, undiagnosed vaginal bleeding or a past blood clot or stroke — do not start HT without specialist advice (from memory)

Mood symptoms with thoughts of self-harm, or severe depression — assess and refer; treat as depression, not only as menopause (from memory)

STEP 1 · RECOGNISE IT — stages, symptoms and diagnosis

🕰️ STAGES OF THE TRANSITION

Women over 45: diagnose perimenopause clinically from vasomotor symptoms and irregular periods; do not use AMH, inhibin, oestradiol or ovarian scans

Women aged 40–45 with symptoms, or under 40 where menopause is suspected: consider an FSH test

Do not use FSH when she is on a combined hormonal contraceptive or high-dose progestogen; hormonal treatment can mask the picture

After hysterectomy without removal of the ovaries, diagnose from symptoms, since periods cannot be used

Premature ovarian insufficiency (under 40): symptoms with a raised FSH on two samples 4–6 weeks apart; offer hormone replacement until at least the natural age of menopause unless contraindicated

🩺 SYMPTOMS TO ASK ABOUT

Vasomotor

Hot flushes

Night sweats

Palpitations

Genitourinary (GSM)

Vaginal dryness and soreness

Pain with sex

Urinary urgency and recurrent infections

Mind and sleep

Low mood and anxiety

Poor sleep and tiredness

Poor concentration (“brain fog”)

Body

Joint and muscle pain

Low sexual desire

Bone loss, later fractures

Symptoms vary a lot between women; ask about the effect on work, sleep and relationships.

STEP 2 · BEFORE YOU TREAT — check the woman first

📋 ASSESS AND COUNSEL

History: symptoms, last period, bleeding pattern, personal and family history of breast cancer, clots, stroke, heart disease, liver disease (from memory)

Examine: blood pressure, weight (BMI), breasts and pelvis as due, and check cervical screening is up to date (from memory)

Contraception: she can still conceive in perimenopause; offer advice on contraception until the menopause is confirmed

Bone health: calcium, vitamin D, weight-bearing exercise, no smoking, little alcohol; consider a bone scan when risk factors are present (from memory)

Lifestyle for symptoms: regular exercise, cool clothing, avoiding triggers such as spicy food, alcohol and caffeine (from memory)

Explain the benefits and risks of each option, then let her decide.

STEP 3 · TREAT — hormone and other options

💊 HORMONE THERAPY: CHOOSING THE REGIMEN

Situation	What to offer	Points to remember
Has a uterus	Oestrogen plus a progestogen (sequential if still having periods, continuous when postmenopausal)	The progestogen protects the endometrium; oestrogen alone is not given
No uterus	Oestrogen alone	No progestogen needed after hysterectomy (unless she had endometriosis, from memory)
Vaginal symptoms only	Vaginal oestrogen; moisturisers and lubricants	Safe to use alongside systemic HT; symptoms return when it stops; routine endometrial thickness checks are not advised
Raised risk of blood clots (for example BMI over 30)	Transdermal (patch or gel) rather than oral	Standard-dose transdermal HT carries no greater risk than baseline; refer high-risk women for haematology advice
Premature ovarian insufficiency	HT or a combined hormonal contraceptive until at least the age of natural menopause	Protects bone, heart and mood
Low sexual desire despite HT	Consider testosterone	Specialist-led; unlicensed in many places

Doses and products differ by country; use the lowest dose that controls symptoms and follow your local formulary. Compounded “bioidentical” hormones are unregulated and are not advised.

⚖️ BENEFITS AND RISKS OF HT

Outcome	What the guidance says
Hot flushes and night sweats	HT is the most effective treatment
Bone	Lowers the risk of fracture while taken; the benefit fades after stopping
Heart disease	Does not raise the risk when started under 60; heart risk factors are not a bar when well managed
Stroke	Oral oestrogen gives a small increase; transdermal does not
Blood clots (VTE)	Oral HT raises the risk; standard-dose transdermal does not
Breast cancer	Oestrogen alone: little or no effect. Oestrogen with a progestogen: the risk may rise with duration and falls after stopping
Dementia	The effect is unknown
Diabetes	Does not raise the risk of type 2 diabetes

🌿 WHEN SHE CANNOT OR WILL NOT USE HORMONES

Cognitive behavioural therapy can help hot flushes, low mood and sleep

Drugs such as SSRIs, SNRIs (for example venlafaxine) and clonidine are not first-line for flushes alone, but are options when hormones are unsuitable; do not give paroxetine or fluoxetine with tamoxifen

Newer non-hormonal drugs and gabapentin exist for hot flushes; follow your local guidance (from memory)

Herbal products such as isoflavones and black cohosh may help, but their safety is uncertain and they can interact with other medicines; St John’s wort has interaction risks

Vaginal symptoms: moisturisers and lubricants; local oestrogen may be used after specialist advice even in women who cannot take systemic HT

After breast cancer: give information on all options and refer to a menopause specialist

STEP 4 · FOLLOW-UP — review, stop and stay healthy

📅 REVIEW AND STOPPING

Review at 3 months for effect and side effects, then every year

Irregular bleeding is common in the first 3 months of HT; tell her to report it at the review, or promptly if it starts later

Refer if symptoms do not improve, side effects persist, or the choice is uncertain

She need not stop HT at age 60 or 65; review the risks and benefits regularly and continue while the benefit is clear

Stopping: she can stop gradually or at once; gradual stopping may limit a short-term return of symptoms

Keep up cervical and breast screening as for her age, and check blood pressure, weight and bone health (from memory)

⚠️ COMMON PITFALLS

Sending blood tests to diagnose menopause in a woman over 45

Giving oestrogen alone to a woman with a uterus

Forgetting contraception during the transition

Missing premature ovarian insufficiency in a young woman with irregular periods

Using oral HT in a woman at high clot risk, when a patch or gel would do

Not offering vaginal oestrogen, or stopping it when she has improved

Labelling every symptom as menopause without looking for other causes

Memory Aid

CHANGE

Six reminders for the woman in menopause.

C

Clinical diagnosis — symptoms and periods, no blood tests over 45

H

HT is the most effective — for flushes, vaginal symptoms and bone

A

Add a progestogen — whenever she has a uterus

N

Non-hormonal options — CBT and others when HT is unsuitable

G

GSM: vaginal oestrogen — safe alongside systemic HT

E

Evaluate yearly — benefits, risks, bleeding and bone health

Remember: menopause is a normal stage of life; treat the symptoms that trouble her, protect her bones and heart, and decide together.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the NICE NG23 menopause guideline (diagnosis, FSH use, premature ovarian insufficiency, HT choice and route, vaginal oestrogen, risks and benefits, non-hormonal and herbal options, review and stopping, contraception) and a report of the 2022 NAMS hormone therapy position statement (who benefits, duration beyond 60 or 65, genitourinary syndrome, unregulated compounded hormones). Items marked “from memory” (early menopause age, history and examination points, bone and lifestyle advice, contraindications, newer non-hormonal drugs) were not checked. Guidance differs between countries and is updated: follow your local protocol and refer complex cases to a menopause specialist.

FIBROID UTERUS (LEIOMYOMA) Revised

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Fibroid Uterus — FIGO Classification & Treatment

Uterine fibroids are very common benign tumours that cause heavy bleeding and pressure symptoms in some women. This sheet gives how to assess them, the FIGO classification, the medical options, the procedures and surgery, and care when she wants to conceive.

🎯 AT A GLANCE — FIBROID UTERUS (LEIOMYOMA)

Fibroids are benign smooth-muscle tumours of the uterus, and the commonest solid pelvic tumour in women; at least 70% of women develop them by late reproductive age

Many cause no symptoms and need no treatment

When they do cause symptoms: heavy or prolonged periods and anaemia, and bulk symptoms such as pelvic pressure, frequent urination and constipation

Treatment depends on symptoms, size and position of the fibroids, and whether she wants to keep her fertility and her uterus

Medicines control bleeding but do not remove large fibroids; surgery or embolisation is needed for bulk

Ask before choosing: what bothers her most, does she want children, and does she want to keep her uterus.

🚨 URGENT REVIEW OR SPECIALIST REFERRAL IF…

She is severely anaemic or has heavy bleeding with dizziness or fainting — admit, resuscitate and treat as for acute heavy bleeding

Rapid growth of a “fibroid”, or growth after menopause — think of a sarcoma; image with MRI and refer; avoid morcellation

Sudden severe pain in a woman with a fibroid — think of torsion of a pedunculated fibroid or red degeneration, mostly in pregnancy; check for other causes

Retention of urine, hydronephrosis or severe pressure symptoms — refer for surgery /span>

She wants to conceive and has a submucosal or large fibroid, or repeated miscarriage — refer to a fertility or gynaecology service before treatment

STEP 1 · RECOGNISE IT — presentation and assessment

🧬 THE FIGO CLASSIFICATION OF FIBROIDS

Type	Position	Description
0	Submucosal: pedunculated intracavitary	Attached by a stalk and lying inside the cavity
1	Submucosal: less than 50% intramural	Mostly in the cavity; less than half is inside the muscle
2	Submucosal: 50% or more intramural	Mostly in the muscle wall, but touching the endometrium
3	Contacts the endometrium, 100% intramural	Entirely in the muscle, touching the endometrium; does not distort the cavity
4	Intramural	Entirely in the muscle, away from both the endometrium and the outer surface
5	Subserosal: 50% or more intramural	Mostly in the muscle, reaching the outer surface
6	Subserosal: less than 50% intramural	Mostly outside the muscle, less than half inside
7	Subserosal: pedunculated	Attached by a stalk to the outer surface
8	Other	Elsewhere, for example the cervix or a parasitic fibroid; state the site

Types 0–3 touch the endometrium (submucosal); types 4–8 are the rest. A hybrid fibroid touching both surfaces is written with two numbers, the endometrial side first (for example 2-5).

🧭 WHY THE TYPE MATTERS

Types 0, 1 and 2 can usually be removed through the hysteroscope (hysteroscopic myomectomy is highly effective for these types)

Submucosal fibroids (0–3) are the ones that most often cause heavy bleeding and affect fertility

Type 3 does not distort the cavity but touches the lining; it may still cause bleeding

Types 4–7 give bulk symptoms and need laparoscopic or open surgery, or embolisation, when treatment is required

Type 7 can twist, and type 8 (cervical or parasitic) needs a specialist plan

Write the type in the notes and the scan report so the whole team plans the same operation

🔬 TYPES AND SYMPTOMS

Fibroids are classified by position: submucosal (inside the cavity), intramural (in the muscle) and subserosal (on the outer surface); the FIGO types 0 to 8 are shown above

Submucosal fibroids cause the most bleeding and affect fertility most

Heavy menstrual bleeding and anaemia: tiredness, breathlessness and pallor are the main complaints

Bulk symptoms: pelvic pressure or heaviness, frequent urination, constipation, and a lump felt in the lower abdomen

Other effects: pain, pain with sex, and sometimes infertility or pregnancy complications

Women of African descent develop clinically significant fibroids earlier, with larger uteri

🩺 INVESTIGATION

Examination: a firm, irregular, enlarged uterus, usually non-tender

Pelvic ultrasound (transvaginal and abdominal) shows size, number and position; use MRI when more detail is needed, for example before embolisation or myomectomy

Hysteroscopy for submucosal fibroids, and when the cavity needs to be seen

Full blood count and ferritin to look for anaemia and iron deficiency

Pregnancy test, and endometrial sampling if she is over 45 or has risk factors for hyperplasia (from memory)

STEP 2 · TREAT THE BLEEDING AND BULK — medical treatment first

💊 MEDICAL OPTIONS

Option	Dose and use	Points to remember
Tranexamic acid	1.3 g three times a day, at least 6 hours apart, for up to 5 days a cycle, started when heavy bleeding begins (trial dose, maximum 3.9 g a day)	Non-hormonal; reduces bleeding but not size. Avoid with a history of thrombosis (last point
NSAIDs	Taken during the period	Help pain; can be offered while investigations or treatment are arranged
LNG-IUS 52 mg	One device, up to 5 years (duration	Treats the bleeding; expulsion is more frequent with fibroids, and it may not suit a distorted cavity
Combined hormonal contraceptives or progestogens	As for heavy menstrual bleeding	May help bleeding; evidence is limited
Oral GnRH antagonist with add-back (relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg once daily; elagolix combination also exists)	Up to 24 months (FDA limit)	Reduce bleeding and may shrink fibroids; bone loss risk, hence the limit. Availability varies by country
GnRH agonist (for example leuprolide)	Short-term, up to 6 months without add-back, or 12 months with add-back (oestrogen with norethindrone)	Shrinks fibroids and raises haemoglobin before surgery; fibroids regrow within 6–9 months of stopping; menopausal side effects
Ulipristal acetate (and mifepristone)	Short courses only where available	Not approved for daily use in the USA; use limited in Europe because of rare serious liver injury

Doses are from the ACOG summary and the NICE pathway; check the local product label. Treat iron deficiency anaemia with iron, and correct it before surgery.

STEP 3 · PROCEDURES AND SURGERY — choose by what she wants

📊 HOW OFTEN IS A SECOND PROCEDURE NEEDED?

🔪 PROCEDURES AT A GLANCE

Option	For whom	Points to remember
Hysteroscopic myomectomy	Submucosal fibroids (types 0, 1 and 2)	Highly effective; complications 1–3%; re-intervention about 7% at 60 months
Myomectomy (laparoscopic, robotic or open)	Wants to keep the uterus or conceive	Recommended when future pregnancy is wanted; recurrence about 25% by 40 months; transfusion risk 0–5%
Uterine artery embolisation	Wants to keep the uterus and is not planning pregnancy	Similar satisfaction at 2–5 years; more repeat procedures (15–38%); little data on later pregnancy
Radiofrequency ablation	Uterus-sparing, where available	Shrinks fibroids by 50–75%; access is limited; little pregnancy data
Hysterectomy	Family complete or other treatment failed or declined	Definitive; use the least invasive route, with vaginal preferred where possible

Endometrial ablation has too little evidence for fibroid bleeding. Consider a GnRH agonist before surgery if it helps (to raise haemoglobin or shrink the uterus for a minimally invasive route).

🤰 FERTILITY AND PREGNANCY

Most women with fibroids conceive and deliver normally (from memory)

Submucosal fibroids lower the chance of pregnancy and raise the risk of miscarriage; removal by hysteroscopy is advised when she is trying to conceive (from memory)

If she wants a pregnancy and the uterus kept, myomectomy is recommended, ideally minimally invasive

Fibroids in pregnancy can cause pain (red degeneration), malpresentation, and bleeding after birth; the obstetric team should plan the delivery (from memory)

Medicines that suppress ovulation are not used when she is trying to conceive

⚠️ COMMON PITFALLS

Treating asymptomatic fibroids because they look large on a scan

Missing anaemia and not giving iron

Offering hormonal treatment when she is trying to conceive

Using a GnRH agonist for months without add-back and without a plan for the next step

Choosing embolisation for a woman who wants a pregnancy

Morcellating a uterus without excluding a sarcoma (from memory)

Ignoring a fast-growing fibroid

Memory Aid

FIBROID

Six reminders for a woman with a fibroid uterus.

F

FIGO type — note it in every report

I

Image — ultrasound, MRI if surgery is planned

B

Bleeding and blood count — treat anaemia

R

Rapid growth is a red flag — think of sarcoma

O

Options match the goal — medicine, embolisation, myomectomy, hysterectomy

D

Decide together — and review often

Remember: fibroids are common and benign; treat the symptoms and the woman’s goals, not the scan.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: a summary of ACOG Practice Bulletin 228 (2021) on managing fibroids (prevalence, symptoms, tranexamic acid, GnRH agonist and antagonist regimens, LNG-IUS, ulipristal, embolisation, radiofrequency ablation, myomectomy, hysterectomy, re-intervention rates, fertility) the FIGO leiomyoma subclassification (types 0–8 and hybrid notation, from a published table), and the NICE NG88 heavy menstrual bleeding care pathway (investigation, options by fibroid size, GnRH agonist before surgery). Items marked “from memory” (red-flag situations, examination findings, blood tests, pregnancy effects, sarcoma and morcellation caution, LNG-IUS duration) were not checked. Availability of drugs differs between countries: follow your local protocol and involve a senior gynaecologist.