2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Fibroids Ch 20 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

FibroidsCh 20

2009-2010 Academic Year

MSIII Ob/Gyn Clerkship

Self-Directed Study


Case Study

41 yo G3P3 AAF presents to clinic with c/o abdominal bloating, pelvic pain, and pressure. C/o feeling her uterus through her abdomen as if she was pregnant, but she had a BTL 8 yrs ago. Menses are q28days with heavy bleeding and large clots, lasting 9 days. Exam reveals a 14-week irregular shape, mobile uterus and normal adnexa bilaterally.


Questions to Consider

1. What is your differential diagnosis?– Uterine Fibroids, adenomyosis, Endometrial cancer– Adnexal Ovarian cancer, ovarian cyst– Abdominal Colon tumor, intestine etiology

2. What are treatment options for women with fibroids?– Hormonal therapy (OCPs, Progesterone, GnRH

Agonists)– Myomectomy (hysteroscopic, laparoscopic,

abdominal)– Hysterectomy– Uterine Artery (Fibroid) Embolization (UAE/UFE)


3. If she was a 22 yo G0P0 how would your recommendations change?– Uterine conservation therapy (fertility desires)

4. What makes fibroids get bigger? Smaller?– Estrogen, progesterone, Pregnancy Menopause

5. What are risk factors for fibroids?– Increasing age, African Am, nulliparity, FMHx

6. How often can fibroids become malignant?– Less than 1 per 1000 uteri


APGO Educational Topic 53

• A. Describe the prevalence of uterine leiomyomas.

• B. Describe the symptoms and physical findings in patients with uterine leiomyomas.

• C. Apply diagnostic methods to confirm uterine leiomyomas.

• D. List the indications for medical and surgical treatment of uterine leiomyomas.


Prevalence

• 45% of women have fibroids by age 50– Many are asymptomatic

• Primary indication for hysterectomy– 200,000 – 300,000 surgeries per year in USA


Symptoms

• Menorrhagia, metrorrhagia, menometrorrhagia anemia

• Pelvic mass

• Pelvic pressure

• Bloating (clothes fit tighter)

• Feeling of heaviness

• Low Back Pain


Signs (Physical Exam)

• Abdominal palpation – uterus palpable if larger than 14 week size (correlate size of uterus to gestational sizing)

• Irregularly shaped uterus on BME, masses move with cervix

• Nodular uterus (firm, cystic, soft)

• Recto-vaginal exam – can palpate posterior fibroids



Diagnosis

• History and Physical Exam !!!!!!!!!!!

• Endometrial biopsy – Rule out endometrial cancer

• Ultrasound– Can usually identify fibroids on US – will NOT

r/o leiomyosarcoma (malignant fibroids)


US Images of fibroids

www.lakeridgehealth.on.ca

http://www.lakeridgehealth.on.ca/


TreatmentWhen to Operate and When to Wait?

Conservative Treatment• Desired fertility• Declines operative Tx• Correct anemia prior

to surgery• Poor surgical

candidate• Postmenopausal

(depending on sx’s)

Hysterectomy• Premenopausal• No future fertility

desires• Large uterus (>12-14

week size)– Could consider

myomectomy if fertility

• Concern for cancer• Renal obstructionMedical Tx is sometimes first line, followed

by surgical Tx for medical Tx failures.


Treatment OptionsFibroids

Main Symptoms

Desires Future Fertility

No Future Fertility Desires

Bleeding Pressure / Pain Bleeding Pressure / Pain

OCP’sProgesterone

GnRH Agonists

Myomectomy

OCP’sProgesterone

GnRH Agonists

Myomectomy

OCP’sProgesterone

GnRH Agonists

Hysterectomy

UAEOnly if pre-menopausal

OCP’sProgesterone

GnRH Agonists

Hysterectomy

UAEMore successful for

Bleeding sx’s

Cannot achieve pregnancy during this Tx

Documents

2009-2010USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Fibroids Ch 20 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study