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2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies
FibroidsCh 20
2009-2010 Academic Year
MSIII Ob/Gyn Clerkship
Self-Directed Study
2009-2010 USUHS MSIII Ob/GynClerkship 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 14-week irregular shape, mobile uterus and normal adnexa bilaterally.
2009-2010 USUHS MSIII Ob/GynClerkship 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/GynClerkship 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/GynClerkship 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/GynClerkship 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/GynClerkship 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/GynClerkship 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/GynClerkship Self Directed Studies
2009-2010 USUHS MSIII Ob/GynClerkship 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/GynClerkship Self Directed Studies
US Images of fibroids
www.lakeridgehealth.on.ca
2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies
TreatmentWhen 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)
Hysterectomy• Premenopausal• No future fertility
desires• Large uterus (>12-14
week size)– Could consider
myomectomy if fertility
• Concern for cancer• Renal obstructionMedical Tx is sometimes first line, followed
by surgical Tx for medical Tx failures.
2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies
Treatment OptionsFibroids
Main Symptoms
Desires Future Fertility
No Future Fertility Desires
Bleeding Pressure / Pain Bleeding Pressure / Pain
OCP’sProgesterone
GnRH Agonists
Myomectomy
OCP’sProgesterone
GnRH Agonists
Myomectomy
OCP’sProgesterone
GnRH Agonists
Hysterectomy
UAEOnly if pre-menopausal
OCP’sProgesterone
GnRH Agonists
Hysterectomy
UAEMore successful for
Bleeding sx’s
Cannot achieve pregnancy during this Tx