7. Fibroids Flashcards
Define: Leiomyomata/Fibroids (1)
Benign smooth muscle tumour of the uterus (most common gynecological tumour)
Describe epidemiology: Fibroids (5)
- diagnosed in approximately 40-50% of pre-menopausal women >35 yr
- more common in African Americans, where they are also larger and occur at earlier age
- common indication for major surgery in females
- minimal malignant potential (1:1000)
- typically regress after menopause
Describe pathogenesis: Fibroids (3)
- estrogen stimulates monoclonal smooth muscle proliferation
- progesterone stimulates production of proteins that inhibit apoptosis
- degenerative changes (occur when tumour outgrows blood supply)
- fibroids can degenerate, become calcified, develop sarcomatous component, or obtain parasitic blood supply
Describe clinical features: Fibroids (6)
- majority asymptomatic (60%), often discovered as incidental finding on pelvic exam or U/S
- abnormal uterine bleeding (30%): dysmenorrhea, heavy menstrual bleeding
- pressure/bulk symptoms (20-50%)
- pelvic pressure/heaviness
- increased abdominal girth
- urinary frequency and urgency
- constipation, bloating (rare)
- acute urinary retention (extremely rare, but surgical emergency!)
- acute pelvic pain
- fibroid degeneration
- fibroid torsion (if pedunculated subserosal)
- infertility, recurrent pregnancy loss
- pregnancy complications (potential enlargement and increased pain, obstructed labour, difficult C-section)
Name: Possible anatomic locations of uterine leiomyomata (6)
Describe investigations: Fibroids (6)
- bimanual exam: uterus asymmetrically enlarged, usually mobile
- CBC: anemia
- U/S: to confirm diagnosis and assess location of fibroids
- sonohysterogram: useful for differentiating endometrial polyps from submucosal fibroids, or for assessing intracavitary growth
- endometrial biopsy to rule out uterine cancer for abnormal uterine bleeding (especially if age >40 yr)
- occasionally MRI is used for pre-operative planning (e.g. before myomectomy)
Describe tx: Fibroids (6)
- only if symptomatic (heavy menstrual bleeding, menometrorrhagia, bulk symptoms), rapidly enlarging or intracavitary
- treat anemia if present
- conservative approach (watch and wait) if:…
- medical approach to treat AUB-L
- interventional radiology approach
- surgical approach
Name indications of conservation approach of fibroids (4)
- symptoms absent or minimal
- fibroids <6-8 cm or stable in size
- not submucosal (submucosal fibroids are more likely to be symptomatic)
- currently pregnant due to increased risk of bleeding (follow-up U/S if symptoms progress)
Describe medical approach to treat fibroids (5)
- antiprostaglandins (ibuprofen, other NSAIDs)
- tranexamic acid (Cyklokapron®)
- CHC, IUS or Depo-Provera®
- GnRH agonist: leuprolide (Lupron®)
- ulipristal acetate (Fibristal ®): a selective progesterone receptor agonist
In the tx of fibroids, describe use of:
- GnRH agonist: leuprolide (Lupron®) (3)
- often used for 3 mo preoperatively to increase Hb and reduce fibroid size
- reduces bleeding, shrinks fibroids, and corrects anemia
- can be used long-term to bridge to menopause in combination with add-back progestin or estrogen
In the tx of fibroids, describe use of: ulipristal acetate (Fibristal ®) (5)
- 5 mg daily for 3 mo
- reduces bleeding, shrinks fibroids
- repeat courses only if patient not eligible for surgery; patients must menstruate between courses
- associated with benign, non-physiological endometrial changes (selective progesterone receptor modulator-associated endometrial changes (PAEC)) which are reversible with discontinuation of therapy
- note: rare side effect of liver failure. Screen for liver disease prior to prescribing, and monitor liver function before, during, and after treatment courses. Do not prescribe in patients with underlying liver disorder
In the tx of fibroids, describe use of:
- interventional radiology approach (2)
- uterine artery embolization (UAE) occludes both uterine arteries, shrinks fibroids by 50% at 6 mo; improves heavy bleeding in 90% of patients within 1-2 mo; not an option in women considering childbearing
- higher risk of surgical re-intervention than with surgical approaches
In the tx of fibroids, name surgical approaches (4)
- myomectomy (hysteroscopic, transabdominal, or laparoscopic)
- hysteroscopic resection of fibroid and endometrial ablation for AUB-Lsm
- hysterectomy
- note: avoid operating on fibroids during pregnancy (due to vascularity and potential pregnancy loss); expectant management usually best
Compare Ulipristal Acetate vs. Leuprolide Acetate for Uterine Fibroids (1)
Oral ulipristal acetate (5 mg or 10 mg) is noninferior to intramuscular leuprolide acetate for control of uterine bleeding due to fibroids and has a better side-effect profile.
Compare outcomes of uterine artery embolization (UAE) to other medical or surgical therapies for symptomatic uterine fibroids. (1)
No significant differences in patient satisfaction or major complications in UAE compared to surgical intervention. UAE is associated with an increased risk of surgical re-intervention.
