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 14-
week 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 Hysterectomy
• Desired fertility • Premenopausal
• Declines operative Tx • No future fertility
• Correct anemia prior desires
to surgery • Large uterus (>12-14
• Poor surgical week size)
candidate – Could consider
myomectomy if fertility
• Postmenopausal
(depending on sx’s) • Concern for cancer
Medical Tx is sometimes first line, followed • Renal obstruction
by surgical Tx for medical Tx failures.
2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
 Treatment Options
Fibroids
Main Symptoms

Desires Future No Future Fertility

Fertility Desires

Bleeding Pressure / Pain Bleeding Pressure / Pain

OCP’s OCP’s OCP’s OCP’s

Progesterone Progesterone Progesterone Progesterone
GnRH Agonists GnRH Agonists GnRH Agonists GnRH Agonists

Myomectomy Myomectomy Hysterectomy Hysterectomy

Cannot achieve pregnancy UAE

UAE
More successful for
during this Tx Only if pre-menopausal
Bleeding sx’s

2009-2010 USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies