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Uterine Fibroids
Uterine Fibroids
Amber M. Shiflett MD
Bryan D. Cowan MD
Basics
Description
Uterine myomas are benign, smooth muscle cell tumors, also called fibroids
and leiomyomas.
Described by location, although most myomas involve >1 layer of the uterus:
o
Age-Related Factors
Develop during hormonally active reproductive years; ~70% of women at age 45
demonstrate fibroids on sonography.
Staging
Based on the location of the fibroid:
Submucous location: Type 0, I, II
Intramural location (confused with Submucosal Type II)
Subserous location
Epidemiology
True incidence and prevalence are unknown because myomas are usually
asymptomatic
If symptomatic, typically in women between the ages of 30 and 40
Black women are 23 times more likely to develop myomas than white
women
Risk Factors
Nulliparity
Obesity
Black race
Genetics
Family and twin studies suggest a genetic predisposition
Associated with hereditary syndromes:
o
Pathophysiology
Abnormal uterine bleeding:
o Increased vascularity and venous congestion
o
Impaired fertility:
o
Associated Conditions
Iron-deficiency anemia
Endometritis
Adenomyosis
Impaired fertility
Diagnosis
Signs and Symptoms
History
Menstrual, sexual, obstetric histories
Quantify blood loss during menses
Review of Systems
Pelvic/Reproductive:
o Heavy, prolonged, painful menses (submucosal myomas):
GI:
Urinary:
o
Physical Exam
Enlarged, firm, irregular uterus
Peritoneal signs (infarcted myoma)
Tests
Lab
hCG, CBC, type and cross before surgery
Imaging
TVU to confirm diagnosis, evaluate for ovarian neoplasm
Sonohysterogram to locate intramural lesions
Differential Diagnosis
Abnormal uterine bleeding:
o Anovulation
o
Pelvic pain:
o
Endometriosis
Adenomyosis
Ectopic pregnancy
PID
Pelvic mass:
o
Pregnancy
Adenomyosis
Uterine polyp
Ovarian mass:
Functional cyst
Benign neoplasm
Malignancy
Leiomyosarcoma
Treatment
General Measures
Control severe bleeding and pain
Treat iron-deficiency anemia
Medication (Drugs)
Can reduce myoma size and uterine volume as well as bleeding
Goal is to temporarily reduce symptoms and myoma size
GnRH agonists:
o
GnRH-antagonists are not FDA approved for treatment of myomas in the US.
P.193
Surgery
Indications for surgery:
o Contraindication to or intolerance of drug therapy
o
Hysterectomy:
Definitive treatment
Abdominal myomectomy:
o
Laparoscopic myomectomy:
o
Hysteroscopic myomectomy:
o
Myolysis:
o
Coagulation/Freezing of myoma
Associated with significant pain and fever; sepsis and death have been
reported
No surgery is required.
Alert
Rapid growth (increase in uterine size by 6 weeks in 1 year) in a nonpregnant woman,
growth in a menopausal woman, or new pain suggest malignancy and should prompt
surgical removal
Followup
Disposition
Issues for Referral
Refer to fertility specialist if infertility
Urology if ureteral obstruction
Pregnancy Considerations
Most myomas do not grow in pregnancy; when they do, most of the growth is
in the 1st trimester.
Large myomas may be associated with pain and premature labor.
Prognosis
Most symptomatic women require surgery
May recur after myomectomy:
o
Patient Monitoring
Serial exam or US every 612 months to determine growth pattern if
asymptomatic:
o Examine at same time in cycle to limit effects of hormonal stimulation
on tumor size
Annual bone mineral density studies if GnRH agonist are continued >6
months; consider calcium and bisphosphonate therapy
Bibliography
ACOG Committee on Gynecologic Practice. Uterine artery embolization. Obstet
Gynecol 2004;103:403404.
de Kroon CD, et al. Saline infusion sonography in women with abnormal uterine
bleeding: An update of recent findings. Curr Opin Obstet Gynecol 2006;18(6):653
657.
Griffiths A, et al. Surgical treatment of fibroids for subfertility. Cochrane Database
Syst Rev. 2006;3:CD003857.
Practice Committee of the American Society for Reproductive Medicine. Myomas
and reproductive function. Fertil Steril. 2006 Nov;86(5 suppl):S194-49.
Speroff L, et al. Clinical Gynecologic Endocrinology and Infertility, 7th ed.
Lippincott, Williams, & Wilkins 2005: 136140, 10431044.
Stewart EA, Morton CC. The genetics of uterine leiomyomata: What clinicians need
to know. Obstet Gynecol. 2006;107(4):917921.
Sudarshan S, et al. Mechanisms of disease: Hereditary leiomyomatosis and renal cell
cancera distinct form of hereditary kidney cancer. Nat Clin Pract Urol.
2007;4(2):104110.
Wallach EE, et al. Uterine myomas: An overview of development, clinical features,
and management. Obstet Gynecol. 2004;104:393406.
White AM, et al. Uterine fibroid embolization. Tech Vasc Interv Radiol. 2006;9(1):2
6.
Miscellaneous
Synonym(s)
Fibroid
Fibroleiomyoma
Fibroma
Fibromyoma
Leiomyofibroma
Myofibroma
Myoma
Leiomyoma
Clinical Pearls
Most women undergo hysterectomy to treat symptomatic uterine fibroids.
Myomectomy is selected to preserve the uterus for women who wish future
pregnancies, or women who desire retention of the uterus.
Endoscopy is used to treat easily accessible uterine fibroids by laparoscopy, or
pedunculated submucous fibroids (hysteroscopy).
Less invasive treatments are now available, but must be considered
developmental; include uterine artery embolization, HIFU, cryolysis, and radio
frequency ablation.
Abbreviations
GnRHGonadotropin-releasing hormone
HCGHuman chorionic gonadotropin
HIFUHigh-intensity focused ultrasound