Download Fibroids

Fibroids
Ch 20
2009-2010 Academic Year
MSIII Ob/Gyn Clerkship
Self-Directed Study
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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 14week irregular shape, mobile uterus and
normal adnexa bilaterally.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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)
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Symptoms
• Menorrhagia, metrorrhagia,
menometrorrhagia  anemia
• Pelvic mass
• Pelvic pressure
• Bloating (clothes fit tighter)
• Feeling of heaviness
• Low Back Pain
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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)
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
US Images of fibroids
www.lakeridgehealth.on.ca
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Treatment
When 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)
Medical Tx is sometimes first line, followed
by surgical Tx for medical Tx failures.
2009-2010
Hysterectomy
• Premenopausal
• No future fertility
desires
• Large uterus (>12-14
week size)
– Could consider
myomectomy if fertility
• Concern for cancer
• Renal obstruction
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Treatment Options
Fibroids
Main Symptoms
Desires Future
Fertility
Bleeding
Pressure / Pain
Bleeding
Pressure / Pain
OCP’s
Progesterone
GnRH Agonists
OCP’s
Progesterone
GnRH Agonists
OCP’s
Progesterone
GnRH Agonists
OCP’s
Progesterone
GnRH Agonists
Myomectomy
Myomectomy
Hysterectomy
Hysterectomy
UAE
Only if pre-menopausal
UAE
More successful for
Bleeding sx’s
Cannot achieve pregnancy
during this Tx
2009-2010
No Future Fertility
Desires
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies