Chief Complaint and characterization of Clinical Case.

History:
A 56 year-old G6P1051 woman, currently in prison, complains of heavy
vaginal bleeding of 14- month duration. She denies spotting between
periods. She states that around her early 50s she was diagnosed with
myomas and was treated with Provera. She takes 2 tables of tylenol,
without relief of her pelvic pain. She denies fatigue, cold tolerance
and galactorrrea.. Her past medical history is positive for COPD,
hypothyroidism and DM2. She does not want to have more children.
Patient underwent hysterectomy on 9/23/15.
Physical Examination:
On physical examination her BP is 130/82 mm Hg, HR is 80 bpm,
weight 167 lb and temperature of 36.6 C. The heart and lung
examination are normal. The abdomen reveals a lower abdominal
midline irregular mass approximate 21 weeks size move in conjunction
with cervix. . On pelvic examination, the cervix is anteriorly displaced
and uterine myomas prolapsed into vaginal canal. No adnexal masses
are palpated. Her pregnancy test is negative. Her hemoglobin level,
leukocyte count, platelet count, TSH are 8.2 g/dl, 8.12 x 10^3 u/L , 215
X 10^3 and 2.1 (mIU/L), respectively.
Discussion of diagnosis, differential diagnosis and diagnostic
modalities that were used in your patient:
Pregnancy:
It must be ruled out in patients with history of amenorrhea/overdue
periods prior to investigating other gynecological causes. Pregnancy
test was negative.
Adenomyosis:
Patients are often multiparous with complaints of menorrhagia and
dysmenorrhea. It usually does not exceed 14 weeks in size.
Malignancy of uterus:
As it usually presents in its early stages, such marked enlargement of
the uterus is rarely seen.
Menometrorrea by hypotiroidism or abnormal hematologic
values:
Normal TSH and coagulation test levels are seen.

Ovarian masses, tubo-ovarian masses or adnexal masses:

are Lateral, fixed, or fluctuant masses, with are not not typical for
myomas.
Myomas: Normally present with irregular, midline, firm, nontender
mass that moves contiguously with cervix. This presentation is 95%
accurate for diagnostic.
Diagnostic modalities to consider:
USG pelvis: is another way to diagnose myomas in uterus and role out
other differential diagnosis.
Clinical Management:
Treatment needs to be individualized depending on presentation age,
parity and others. For this case, the patients was at the end of her
reproductive age, have already had multiple pregnancy resulting in
only 1 living baby, wish not to have anymore children and was
previously treated for myoma with Provera.
Hysterectomy is
considered to proven treatment for symptomatic uterine fibroids that
fail pharmacologic treatment and when future pregnancy its not
desired. If the patient desire to have another pregnancy, but still
present with symptoms after drug therapy, then hysterectomy is the
best indicated option, which was the one done to patient.
Others alternative treatment for myoma would be:
1) Non invasive procedure: Magnetic resonance imaging guided
focused ultrasound surgery (MRgFUS)
2) Uterine artery embolization
4) Myomectomy open abdominal, laparoscopic, hysteroscopy and
robotic assisted.
Even though this patient did not want to have any more children, we
wanted to investigate what would be the most effective management
for women diagnosed with uterine myomas and wish to maintain
fertility. For this, we review 5 research articles to understand the
different types of myomas, their clinical significance for fertility and
how treatment correlates with pregnancy outcomes.

Papers:
Do submucous myoma characteristics affect fertility and menstrual
outcomes in patients who underwent hysteroscopc myomectomy
Ahmed Namazov M.D., Resul Karakus M.D., Ezgi Gencer M.D.,
Hamdullah Sozen M.D., Levent Acar M.D. Iran J Reprod Med Vol. 13.
No. 6. pp: 367-372, June 2015
Objective: The aim of this study was to determine the long term effects
of submucousal myoma resection on menorrhagia and infertility; also
to detect whether the type, size, and location of myoma affect the
surgical success and outcomes.
Pertinence to Clinical question: Learn of management of uterine
myomas and its effects on fertility
Limitations: Sample 98->47 infertilty so its a small sample size,
retrospective cohort no control over data recollected
Strengths: Excluded patients with previously diagnosed infertility
causes such as patients with multiple myomas, persistent anovulation
or bilateral tubal occlusion and those patients who received IVF in
order eliminate possible bias and strengthen conclusions.
Study Design

Total
patients
included
in
98 patients
study
with
Uterine
myomas

Chief
Infertility
complaint

Chief
complaint

Number
of
47 patients
patients

Menorrhagia

51 patients

Study Design: Retrospective cohort study

Database of hysteroscopic myomectomies in Zeynap Kamil Training

and Research Hospital
Data recollected included: demographics, pregnancy rates before
surgery, indications for surgery, duration of infertility, menstrual
bleeding pattern, causes of infertiliy, complications related to
procedures.

Results and Conclusions:

Table I. Mean size of excised myoma in menorrhagia and infertility groups

Groups
Menorrhagia group (n=51)

Myoma size (mm)

Improved

23.30 10

Recurred

29.88 5

p-value

0.141

Infertility group (n=47)

Conceived

30.38 4

Not conceived

29.95 5

p-value

0.961

Figure 2. Pregnancy rates in infertility group according to myoma type and location (ChiSquare test).

Women with cavity-distorting fibroids who undergo

myomectomy are more likely to conceive a pregnancy. In
addition, observational studies have reported that the presence
of intracavitary leiomyomas decreases pregnancy rates in
women undergoing in vitro fertilization. Thus, many IVF units
advise women with these lesions to undergo myomectomy.
Retrospective and
case control studies have demonstrated that submucous myoma resection improves
pregnancy rates in patients with infertility as 27-77% (14-18). Our data support these
findings: in present study in 2310 months postoperatively period the rate of
spontaneous conception was 60%.
Our results suggest that pregnancy rates after hysteroscopic
myomectomy are not significantly influenced by myoma location, type and
size. Tarek Shokeir et al in his prospective randomized trial showed no
difference in pregnancy rates according to myoma location and size (18).
Also Bernard et al reported that pregnancy rates were not affected by the
myoma location and size (19). In contrast, Varasteh et al reported that
hysteroscopy polypectomy and myomectomy of myomas larger than 2 cm
in diameter improves pregnancy rates (20). We suggest that even
myomas smaller than 2 cm in diameter can influence fertility. Because
there are many different mechanisms by which myomas may affect
fertility. Vercellini et al have reported retrospectively pregnancy rates after
hysteroscopy myomectomy (16). They found no statistical difference in
pregnancy rates according to myoma type.

Menorrhagia and pregnancy rates after hysteroscopic

myomectomy were not significantly affected by variations
in myoma size, type or location.
According to our study the myoma characetesitics do not affect improvement
rates after hysteroscopy myomectomy in patients with unexplained infertility

or excessive uterine bleeding. Large prospective randomized trials could be

designed, to assess the relationship between submucous myoma
characteristics and postoperative outcomes. But we think that in
symptomatic patients (menorrhagia and infertility) with submucous myoma,
an expectant management will not be ethical. So randomized-controlled trials
will be difficult to design.

Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus
Myomatosus

Aim of Study: To asses the fertility capability and pregnancy

outcome after operative removal of myomas by minilaparotomy
in a special patient collective.
Pertinence of aim to study question: They explore a possible
management for myomas to see if it has beneficial effects in the
fertility of the patients.

Study Design
332 patients were
operated for benign
myomas (June 2004June 2008)

89 were not
included

(endometriosis,
ovarian sterility,
andrological
sterility, and
sarcomatous
degeneration)

33 could not be
contacted

55 decided not to
anwser
questionnaires

160 were available

for evaluation

Greater than 45
years

Statistical Analysis: Used SPSS 18 and calculated by means of the

Wald test. The relationship between symptoms and complaints were
determined by the logistic regression method.
Average of 5.0 myomas were removed in the patients
The average of the maximum size was 6.6 cm- the biggest being 19
cm
82.5% intramural myomas were found in the patients of the studyimportant because it has been previously demonstrated that this can
lead to possibly sterility, infertility or seroius complications of
pregnancy.
Mini laparotomy helps maintain fertility

Strengths and limitations:

Strengths: Throughout the discussion of the paper they
compare constantly their results with previously published
data and both have similar results.
Limitations: Many of the women in the study were
overweight or with advanced maternal age.
Conclusion
Post operative pregnancy rate - 60.3% (28.4% were
vaginal delivieries & 71.6% were C/S)

The preoperative miscarriage rate of 75.6% was

reduced to 22.5%

Pregnancy Outcomes Following Robot-Assisted Myomectomy

Aim of Study: Pregnancy outcomes in women with symptomatic

leiomyomata uteri who underwent Robot-assisted laparoscopic
myomectomy (RALM)
Pertineance of aim to study question: They explore a possible
management for myomas to see if that management has
beneficial effects in the fertility of the patients.

Retrospective Cohort

872 women who underwent robotic

myomectomy
57.4% were overweight or obese
Majority of conceptions were
spontaneous
39.4% used ART (IVF was the most
common)
127 pregnancies
92 deliveries and 7 ongoing (during
analysis period)
RALM is Not Proven to Benefit Fertility Outcomes.

Strengths and limitations:

Strengths: Throughout the discussion of the paper they
compare constantly their results with previously published
data and both have similar results. Also, it utilized a large
group of people from different institutions (3 institutions).

Limitations: Dr. Pitter, one of the authors, is on the

Speakers Bureau for Intuitive Surgical. Also, since this was
a retrospective study, and not a prospective, it did not
include all women who attempted conception after surgery.
Majority of the women were overweight or obese (57.4%)
Conclusion
127 pregnancies / 872 underwent RALM = 14% of
pregnancy
RALM treatment may offer a minimally invasive alternative
for uterine preservation for women with uterine fibroids

Level 4: Observational studies without controls

All of the previously mentioned papers were retrospective studies

that could have possible confounding factors affecting the final
data.
Retrospective cohort studies are not generalizable to the general
population.
Ideally, large prospective randomized trials could be designed.
Assess the relationship between uterine myomas and
fertility post-surgery
It would provide information of whether the study could be
generalizable to the population
It would be considered unethical in symptomatic patients.

Conclusions

There is no consensus in specific management of uterine

myomas.
No treatment has been proven more effective than others.

Recommendations:

For post-menopausal women, hysterectomy is indicated.

For women interested in preserving their fertility:
Procedure depends on resources available in each hospital
setting.
Ideally, a minimally invasive procedure could be done in
order to maintain uterine preservation.

There was no statistical difference according to the myoma size (Table

I). 28 of 47 infertile women spontaneously experienced thirty
pregnancies, with an overall 2310 months postoperatively period

(60%). The mean period between myomectomy and conception was

51.5 months.
Pregnancy rates according to myoma location and type are such as
following: lower segment 50%, fundus 57%, and corpus 80%; type 0)
75%, type 1) 62%, type 2) %50. Those variations were not statistically
significant (Chi-Square test) (Figure 2). The mean myoma size in
patients who became pregnant was 30.38 mm, in patients who did not
conceive was 29.95 mm and no statistical difference was found
(p=0.961, Mann Whitney U test) (Table I).