Title
Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions. You will review the answers and the material covered during your next Continuity Clinic Session.
Fibroids
A 49-year-old woman, gravida 2, para 2, comes to your office for her annual well-woman examination. She has a known history of obesity and uterine leiomyomas. She reports monthly menses. She reports no bladder or bowel concerns. Physical examination reveals a 16-week size, lobular uterus. The uterus is nontender to palpation. Pelvic ultrasonography confirms multiple uterine leiomyomas with a homogenous appearance, essentially unchanged from last year. There are normal ovaries visualized bilaterally. The best next step in her management is
Show Explanation
• Uterine leiomyomas are present in approximately 70% of white women and 80% of Black women by the age of 50. Approximately 25% of women with leiomyomas become symptomatic.
• Common symptoms include abnormal uterine bleeding, pelvic pain or pressure, and infertility. In patients who are asymptomatic, expectant management is preferred.
• GnRH therapy can temporarily decrease heavy vaginal bleeding and can reduce leiomyoma size by 35% to 65% within 3 months of starting treatment. This can provide optimization prior to surgery, but symptoms often recur within several months after therapy is stopped. GnRH therapy can cause significant hypoestrogenic effects, including bone loss, so therapy is recommended for only 3-6 months for preoperative optimization.
• Uteirne artery embolization is performed via transfemoral catheterization with intervention radiology. Embolization leads to uterine leiomyoma devascularization and involution with up to 42% size reduction 3 months after the procedure. This procedure can decrease mean menstrual duration, dysmenorrhea, and life impact scores.
• Hysterectomy is the most invasive option and is reserved for patients who are symptomatic and have failed other therapies.
A 39-year-old healthy woman, gravida 1, para 1, presents with an enlarged uterus and heavy vaginal bleeding with each monthly period. She usually misses a few days of work each months. She is not interested in getting pregnant and wants to avoid surgery. Ultrasonography showed three leiomyomas located in the subserosal area (FIGO class 6) and one intramural leiomyoma (FIGO class 4), each measuring 2-3 cm. The endometrial cavity is not distorted. She did not respond to a trial of tranexamic acid. The best next medical therapy for her is
Show Explanation
• Heavy menstrual bleeding occurs more commonly with submucosal leiomyomas, but can be present with leiomyomas in other locations. It is not clear why heavy bleeding occurs with intramural and subserosal leiomyomas, but it may be related to the difficulty the uterus has contracting in order to provide pressure to stop the bleeding.
• Medical treatment of leioyomas is first line. NSAIDs, tranexamic acid, combined oral contraceptives and progestins can reduce bleeding and cramping, but do not affect leiomyoma size.
• Levonorgestrel-releasing IUDs limit menstrual blood flow by local progestin effect. It requires a normally shaped uterine cavity to be placed appropriately. There is a slightly higher risk of expulsion rate for patients with leiomyomas.
• Desmopression is a synthetic form of vasopressin (ADH) that is used to promoted hemostasis in patients with bleeding disorders by causing the release of von Willebrand factor by endothelial cells. There is no evidence that there is local clotting factor disturbance during heavy bleeding caused by leiomyomas, so desmopressin is not appropriate for use in this situation.
• GnRH agonists are effective in reducing blood loss and causing reduction in leiomyoma size. Leuprolide acetate can be used preoperatively to reduce the size of leiomyomas, improve hemoglobin, decrease intraoperative bleeding, decrease fluid absorption, and shorten operative time. Maximum duration of treatment is 6 months because of adverse effects on bone density.
• Selective progesterone receptor modulators, like ulipristal acetate, decrease cellular proliferation in leiomyomas without affecting normal myometrium. They block progesterone activity in the endometrium, so monitoring for hyperplasia is important. Ulipristal acetate is not approved by the FDA for treatment of leiomyomas but is approved as an emergency contraceptive.
A 63-year old woman with a known history of uterine leiomyomas presents with worsening pelvic pressure and fullness. Pelvic examination demonstrates an increase in uterine size from her previous examination. Repeat pelvic ultrasonography shows that her uterine leiomyomas have doubled in size and now measure 4cm (submucosal) and 10cm (intramural) with a thickened junctional zone suggestive of adenomyosis. She is hoping to avoid a hysterectomy and requests a uterine artery embolization. The factor in this patient's history that is a contraindication to uterine artery embolization is
Show Explanation
• Uterine artery embolization is a minimally invasive treatment approach for uterine leiomyomas. It is performed by an interventional radiologist, who uses fluoroscopy to guide percutaneous catheters from the femoral artery into the pelvis, allowing injection of embolic particles into the bilateral uterine arteries to occlude vessels feeding the leiomyoma.
• Compared to surgical management, uterine artery embolization offers uterine preservation, shorter recovery time, decreased blood loss, and similar beneficial clinical outcomes, especially for treatment of abnormal uterine bleeding.
• Absolute contraindications to this procedure include asymptomatic leiomyomas, pregnancy, active infection, and uterine malignancy. An enlarging fibroid in a postmenopausal patient is concerning for malignancy.
• There is not a clear size limit for a leiomyoma that may be targeted by embolization, but there is an increased risk of postprocedure pain and infection with larger leiomyomas. Submucosal leiomyomas with a large intracavitary component are at an increased risk of expulsion through the cervix, with an increased risk of pain, bleeding, and infection, but embolization is not contraindicated.