Successful Total Lap Hysterectomy with B/L Salpingo-Oophorectomy for Endometrial Hyperplasia in a 51 Y.O. Female

Chief Complaints

A 51-year-old female patient with a body mass index (BMI) of 21 presented to the Gynaecology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of perimenopausal menorrhagia (heavy or prolonged menstrual bleeding) with passage of clots and intermittent dysmenorrhea (painful menstrual periods), which was not relieved with medications.

The patient was a known case of uncontrolled diabetes mellitus and hypertension and had been on treatment for these conditions.

The patient was a multiparous woman (P2L2), with both deliveries conducted by normal vaginal delivery, and had undergone tubal sterilization (tubectomised).

On examination, the patient was conscious, coherent, and oriented. Systemic examination revealed normal air entry bilaterally in the respiratory system, normal first and second heart sounds on cardiovascular examination, and a soft, non-tender abdomen. Breast examination was normal with no palpable lumps. Per vaginal examination showed a bulky cervix with no fornicial tenderness. The patient was hemodynamically stable on general examination.

Upon admission to PACE Hospitals, the patient was evaluated by the Gynaecology team, which included a detailed review of her medical history and a comprehensive clinical examination. The examination revealed a bulky cervix with no fornicial tenderness, and the patient was found to be hemodynamically stable on assessment.

Ultrasound findings were suggestive of endometrial hyperplasia in the case of abnormal uterine bleeding in the perimenopausal age group. Evaluation and investigations revealed uncontrolled diabetes mellitus and hypertension, along with elevated glycaemic parameters, while renal function tests, electrolytes, and cardiac evaluation were within acceptable limits for surgery.

Based on the confirmed findings, the patient was advised to undergo Endometrial Hyperplasia Treatment in Hyderabad, India, under the expert care of the Gynaecology Department.

After a detailed consultation with Dr. Mugdha Bandawar, a Gynaecologist, a comprehensive evaluation of the patient was undertaken in coordination with cross consultations from Dr. Tripti Sharma, Endocrinologist, and Dr. Seshi Vardhan Janjirala, Cardiologist. Considering her history of perimenopausal abnormal uterine bleeding with menorrhagia and clots, associated dysmenorrhoea not relieved with medical management, and ultrasound findings suggestive of endometrial hyperplasia, along with known uncontrolled diabetes mellitus and hypertension, the multidisciplinary team reviewed her clinical condition in detail. Clinical examination revealed a bulky cervix, and investigations demonstrated poor glycaemic control, while renal, electrolyte, and cardiac assessments were optimized and deemed suitable for surgery with medical management.

Further assessment confirmed abnormal uterine bleeding (perimenopausal) secondary to endometrial hyperplasia in a high-risk metabolic background. Based on multidisciplinary evaluation, it was determined that total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was identified as the most appropriate definitive management to control bleeding, address the underlying endometrial pathology, and reduce the risk of progression to endometrial hyperplasia-associated complications, including malignancy.

The patient and her family members were counselled in detail regarding the diagnosis, planned surgical procedure, associated risks, benefits, and expected postoperative recovery, following which informed consent was obtained.

Following the decision, the patient was scheduled to undergo a Bilateral Salpingo-Oophorectomy with Total Laparoscopic Hysterectomy Surgery in Hyderabad at PACE Hospitals under the supervision of the expert Gynaecology Department.

The following steps were carried out during the procedure:

• Exploration and Assessment of Pelvic Structures: Intraoperatively, the uterus was found to be bulky, while both fallopian tubes and ovaries appeared normal. A thorough assessment of the abdominal cavity was performed, and the rest of the abdomen was noted to be normal with no visible pathology.

• Dissection and Mobilization of Uterus and Adnexa: The uterus along with bilateral fallopian tubes was carefully dissected and mobilized laparoscopically, ensuring preservation of surrounding structures and maintaining meticulous surgical planes.

• Removal of Uterus with Cervix and Adnexa: The uterus with cervix and both fallopian tubes was retrieved vaginally as a single specimen and sent for histopathological examination (HPE) for further evaluation.

• Vaginal Vault Closure: Following specimen retrieval, the vaginal vault was closed securely using standard laparoscopic suturing techniques to ensure anatomical restoration and prevent postoperative complications.

• Hemostasis and Completion of Procedure: Meticulous hemostasis was achieved throughout the surgical field, and the procedure was completed without complications, ensuring a stable operative outcome.

Postoperatively, the patient was kept in the Surgical Intensive Care Unit (SICU) for close monitoring and later shifted to the ward after achieving hemodynamic stability. Postoperative management included infection prevention, pain control, gastric protection, control of nausea, maintenance of hydration, and optimization of blood glucose levels. Ultrasound screening showed no abnormal findings in the postoperative period. She was also reviewed by the endocrinology team for glycaemic management and showed steady clinical improvement. The biopsy revealed a benign uterine fibroid (Leiomyoma) with associated changes in the endometrial lining, likely due to pill use, and no evidence of malignancy. The patient was discharged in a hemodynamically stable condition.

Upon discharge, the patient was prescribed medications for infection prevention following surgery, pain control, reduction of postoperative inflammation and swelling, gastric protection, and supportive care to aid recovery. Additional medications were advised for local wound care application and nutritional and metabolic support during the recovery period.

In view of uncontrolled diabetes mellitus, she was also prescribed medications for strict blood glucose control, including agents targeting fasting and postprandial glucose levels and combination therapy to improve glycaemic regulation and insulin sensitivity. 

The patient was advised to follow a diabetic diet and to avoid heavy lifting and strenuous physical activities during the recovery period.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as abdominal pain, fever, vomiting, or any abnormal vaginal bleeding.

The patient was advised to return for a follow-up appointment with the Gynaecologist in Hyderabad at PACE Hospitals after 10 days. A subsequent review was scheduled after 1 week with the Endocrinologist for assessment of fasting and postprandial blood sugar levels and ongoing diabetes management.

This case highlights a perimenopausal woman with abnormal uterine bleeding due to endometrial hyperplasia, managed by total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The patient had uncontrolled diabetes mellitus and hypertension, which were optimized with multidisciplinary care before surgery. The procedure was uneventful, and the postoperative recovery was stable. She was discharged in a hemodynamically stable condition with advice for follow-up and glycaemic control.