Uterine Fibroids – AFP 1/15/17

Epidemiology:  most common benign tumors in reproductive-age women; prevalence age-dependent, up to 80% by 50 yo.  Account for 39% of all US hysterectomies.

Etiology and Pathophysiology:  smooth-muscle origin; growth estrogen and progesterone dependent.  Fibroid tissue produces aromatase and endogenous estrogen/progesterone, and stem cells express estrogen- and progesterone receptors.

Increase risk:  African descent, age > 40, early menarche (<10yo), fam hx, nulliparity, obesity.  Decrease risk:  increased parity, late menarche (>16yo), smoking, OCP use.

Location:  subserosal, intramural and submucosal (out to in).

Clinical features:  most common symptom – abnormal uterine bleeding, usu heavy menstrual bleeding.  

  • Other symptoms:  pelvic pressure, bowel dysfunction, urinary frequency/urgency/retention, LBP, constipation, dyspareunia.
  • Can be associated with infertility (submucosal), but no RCT evidence that removal helps completion of pregnancy or live birth.
  • In pregnancy:  increased risk of C/S, breech presentation, PPROM, preterm delivery, intrauterine fetal death and growth restriction, and PPH.  So…fibroids in pregnancy are a high-risk condition!

Diagnosis:  Preferred imaging (in US):  ultrasound.  TVUS is 90-99% sensitive.  Adding sonohysterography or hysteroscopy can find smaller, submucosal fibroids.

DDx:  adenomyosis, ectopic pregnancy, endometrial carcinoma, endometrial polyp, endometriosis, metastatic disease, pregnancy, uterine carcinosarcoma (epithelial neoplasm), fibroids, sarcoma (leiomyosarcoma, others).

Predictors of malignancy (leimyosarcoma) on MRI:

  • age > 45
  • intratumoral hemorrhage
  • endometrial thickening
  • heterogeneity on T2 weighted imaging
  • menopausal status
  • non-myometrial origin

Risk factors for leiomyosarcoma:

  • hx pelvic radiation
  • increasing age
  • use of tamoxifen

Management:  Depends on size, location of the tumors; pt age, symptoms, desire for fertility, access to treatment and physician experience.

  • Expectant therapy:  Watchful waiting preferred for asymptomatic fibroids, no surveillance imaging needed.
  • Medical therapy:
    • Contraceptives: OCPs help, but Mirena helps even more compared to OCPs.  Expulsion rate <20%.
    • Tranexamic acid:  reduces menstrual blood loss vs placebo.  May increase fibroid necrosis, but debatable.
    • NSAIDs:  reduce blood loss and provide pain relief.  Less effective for blood loss than Mirena or tranexamic acid at 3 mos.
    • Hormonal:
      • GnRH agonists (leuprolide, goserelin, others)
      • SPRMs (selective progesterone receptor modulators): mifepristone, others.  Less hypoestrogen sxs than GnRH agonists.
      • Most useful peri-op or nearing menopause.
      •  Hypoestrogenic symptoms (hot flashes, vaginitis, sweating, breast changes).
    • Other options:  aromatase inhibitors (letrozole, anastrozole), estrogen-receptor antagonists, SERMs.  Not enough evidence to be standard yet.
  • Surgery:
    • Hysterectomy:  Definitive cure for women not wanting to preserve fertility.
      • Vaginal hyst is preferred technique, shorter surgery time, decreased blood loss, shorter hospital stay, shorter paralytic ileus time.  Limited by size of the uterus and fibroids.
      • Laparoscopic removal requires morcellation (cutting uterus up).  Concerns about spreading malignant cells.
      • 1/10 women have new symptoms after hyst with BSO.
    • Myomectomy:  preferred for submucosal fibroids wanting to preserve fertility (fibroids ❤ cm, 50%+ intracavitary).  15-33% recurrence rate, 10% of pts have a hyst within 5-10 yrs.
    • Uterine artery embolization:  shorter hospital stay, less blood loss, quicker recovery than both of the above.  20-33% reoperation rate in 18mos – 5y.  Fertility outcomes unclear – may be okay, may increase risk of miscarriage and C/S.
    • Myolysis:  heat, laser or MRgFUS – focal energy delivery systems. Well-tolerated, risks are local pain and bleeding.  Fertility effects unknown.
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