Week 6 - Fibroids

Question 1

Define leiomyoma

Answer 1

aka uterine fibroids

A leiomyoma (plural leiomyomas or leiomyomata) (leio- + myo- + -oma, “smooth-muscle tumor”) is a benign smooth muscle neoplasm that is very rarely (0.1%) premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.

As other leiomyomata, they are benign, but may lead to excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility.

• Most common benign tumor of the uterus - often found on routine gynecological exam or abdominal exam
• Genetics is a factor; increased incidence (2-3x) in women of African decent
• Benign, with less than 0.5% rate of malignant transformation
• Arise from myometrium of uterus
• increased blood supply can be dangerous during surgery

Question 2

estimated incidence of fibroids

Answer 2

• Estimated incidence is 1 in 5 women over 30-40 years of age

Question 3

Describe physical characteristics of fibroids

Answer 3

• firm, spherical tumour growing in various locations throughout the uterus
• appear as single or multiple tumours
• uterus may remain symmetric (but enlarged) or may be enlarged and distorted in contour

Question 4

Typical size of fibroid?

Answer 4

microscopic to 20 lbs

Question 5

7 types of fibroids

Answer 5

• subserosal
• intramural
• submucosal
• pedunculated
• intraligamentous
• cervical
• parasitic

Question 6

describe pedunculated fibroids

Answer 6

Pedunculated uterine fibroids occur when a fibroid tumor grows on a stalk, resulting in pedunculated submucosal or subserosal fibroids. These fibroids can grow into the uterus and also can grow on the outside of the uterine wall. Symptoms associated with pedunculated fibroid tumors include pain and pressure as the fibroids can sometimes twist on the stalk.

Question 7

clinical presentation of uterine fibroids

Answer 7

• usually asymptomatic

Can present as:

• menorrhagia (& associated symptoms)
• dysmenorrhea
• pelvic pain
• pressure on adjacent structures
• infertility

Question 8

define menorrhagia

Answer 8

Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding. Although heavy menstrual bleeding is a common concern among premenopausal women, most women don’t experience blood loss severe enough to be defined as menorrhagia.

With menorrhagia, every period you have causes enough blood loss and cramping that you can’t maintain your usual activities.

Question 9

Symptoms of fibroids

Answer 9

• sensation of lower abdominal mass/abdominal enlargement
• pelvic pressure, congestion, bloating, feeling of heaviness in lower abdomen
• constipation
• lumps in abdomen
• dyspareunia
• menorrhagia
• secondary dysmenorrhea
• passage of large clots
• backache, lower abdominal pain
• infertility, miscarriages
• anemia, weakness, dizziness, dyspnea, CHF from chronic blood loss

Question 10

Signs of fibroids

Answer 10

Bimanual exam:

• firm irregularly shaped uterus with smooth and rounded protrusions
• non-tender uterus
• consistency: rock hard or soft and cystic
• if mass moves w the cervix, likely a fibroid

Other:
- signs of anemia

Ultrasound

Question 11

4 worst-case scenarios for fibroids

Answer 11

• compromised fertility
• compression of ureter (causing compromised function of kidneys)
• severe anemia
• disruption of blood supply to fibroid or torsion causing acute abdomen

Question 12

8 investigate hx questions

Answer 12

• when was your last period?
• what are your periods like?
• have you suffered from any inter menstrual spotting or postcoital bleeding?
• what form of contraception are you using?
• do you have any pelvic pain? Do you experience any pain w intercourse?
• have you had any abnormal vaginal discharge?
• have you noticed any other symptoms such as extreme tiredness, constipation, or urinary disturbance?
• are you trying to conceive? have you had any problems with conceiving? are you planning to have any children in the future?

Question 13

aetiology of fibroids

Answer 13

• although a genetic component, lifestyle factors play a large role

Estrogen:

• believed to stimulate growth. Fibroids usually recede after menopause w decreased levels.
• rapid growth occurs in pregnancy, obesity
• postpartum and post-menopausally, fibroids can regress & degenerate (larger fibroids)

Progesterone:
- Shown to have a role in stimulating growth

Question 14

Lab work for fibroids

Answer 14

CBC
Ferritin

To determine if you have anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

Question 15

Imaging for fibroids

Answer 15

Ultrasound - abdominal and transvaginal

• usually quite accurate way to dx fibroids
• often found incidentally w other investigations

Question 16

Rapidly enlarging uterus/vaginal bleeding in a perimenopausal/postmenopausal women
R/O ??

Answer 16

endometrial sarcoma

Clinicians who are evaluating a woman with presumed leiomyomas are presented with the clinical challenge of deciding which rare patients may have sarcoma. While there are differences in the populations of the two disorders, there is some overlap. There are several histologic types of uterine sarcoma. The main type of sarcoma that may resemble a leiomyoma is leiomyosarcoma, which presents as a myometrial mass. In contrast, endometrial stromal sarcoma presents as an endometrial mass. However, this could potentially have a similar appearance to a submucosal leiomyoma.

Increasing age is a significant risk factor for uterine sarcomas. The average age at diagnosis is 60 years; thus, the majority of sarcomas occur after menopause. Young age does not exclude the diagnosis of uterine sarcoma, however, since it has been reported in women as young as their mid-20s.

Thus, particularly for postmenopausal women, a new or growing uterine mass warrants further evaluation for uterine sarcoma. The level of suspicion may be lower in women who are on postmenopausal estrogen therapy and have a small increase in the size of a fibroid known to present prior to menopause. In this subgroup, stopping postmenopausal estrogen therapy is also an option to see if regression occurs.

Abnormal uterine bleeding, pelvic pain/pressure, and a pelvic mass are the primary presenting symptoms and signs for both leiomyomas and sarcoma, making it difficult to differentiate between the two on this basis. Some women with sarcoma present with a foul-smelling vaginal discharge, but this is not a reliable indicator of malignancy since vaginal discharge is a common gynecologic symptom.

Question 17

6 naturopathic assessments

Answer 17

• 25 hydroxyvitamin D
• Ferritin
• CBC
• Thyroid function tests
• comprehensive stool analysis
• testing for celiac disease

Question 18

2 general options for allopathic treatment

Answer 18

Medical

• GnRH analogs/agonists - shrink size & help w symptoms (menorrhagia/anemia)
• combined OC - for dysfunctional uterine bleeding
• NSAIDS - decrease PGs in myometrium & endometrium, decreasing blood lost

Surgical

• when sxs can’t be controlled medically, enlarged uterine size, pressure sxs present, infertility cannot be controlled medically
• definitive treatment: hysterectomy
• endometrial ablation (for menorrhagia d/t submucosal fibroid)
• myomectomy - surgical or laparoscopic
• uterine artery embolization
• myolysis - destruction of fibroid in situ using electrosurgical heat, laser energy or cryotherapy

Question 19

Naturopathic treatment goals:

Answer 19

• r/o severe pathology
• relieve sxs (menorrhagia)
• stabilize or slow growth
• buy time until menopause & natural regression occurs
• recognize when its time for conventional medical intervention
• education regarding the variety of surgical options
• improve chances of future fertility
• decrease risk of endometrial cancer

Question 20

Top 3 dietary recommendations

Answer 20

• reduce fat
• increase fibre
• increase phytoestrogens & legumes

Question 21

Food to reduce

Answer 21

sugar
caffeine
alcohol
processed/junk foods

Question 22

Foods to increase

Answer 22

lycopene
vegetables and fruits
whole grains (brown rice, oats, buckwheat, millet, rye)
soy
fibre to 30gm/d

Question 23

Supplementation

Answer 23

• lipotrophic factors (inositol & choline)
• pancreatic enzymes: lipases, amylases, proteases

improve digestion to reduce pressure in abdomen

improve metabolism & detox of estrogen

• vitamin D - low levels can increase growth
• vitamin A - low levels can increase menorrhagia
• iron
• EGCG
• vitamin C & bioflavonoids - strengthens small blood vessels & reduce menorrhagia
• B vitamins