#96 Alternatives To Hysterectomies In The Management Of Leiomyomas Flashcards
What are the two most common symptoms that women with fibroids seek treatment for?
AUB and pelvic pressure
What is the typical pattern of bleeding seen with fibroids?
Prolonged and heavy menstrual bleeding
What is prevalence of fibroids by age 50 in white and black population?
70% and 80%
Are COC or progestin only use associated with increasing or decreasing fibroid size?
Studies are mixed. Recommend monitoring size during therapy
What are pros and cons for Mirena type IUDs for treating AUB-L?
Decrease HMB
Higher rate of expulsion and vaginal spotting
How does GnRH agonist affect fibroid size?
Decreases 35-65% in 3 months
For what indication is the FDA approval for Lupron in regards to fibroids?
Pre op shrinkage of fibroids in patients with anemia. In conjunction with iron supplementation
Will fibroids grow back to original size after cessation of gnrh therapy?
Yes, within several months
After how many months of lupron treatment does add back therapy need to be added? Why?
6 months. Minimize continued bone loss and vasomotor symptoms
Role of aromatase inhibitors for fibroids?
Overall little data, some case studies say decrease size and symptoms. No FDA approval for this indication
What are potential side effects of mifepristone?
Endometrial hyperplasia without atypia (14 to 28 percent) and elevated transaminases (4%)
What are type zero type one and type two leiomyomas?
Type zero is completely in the cavity
Type of one is less than 50% intramural
Type two is more than 50% intramural
What is the success rate of removing fibroids at the initial hysteroscopy?
85 to 95%
What are the potential complications of a hysteroscopic myomectomy?
Fluid overload with hyponatremia, pulmonary edema, gas embolism, uterine perforation, infection, bleeding, Cerebral edema
What is the major complication rate for uterine artery embolization?
4.9%
Major = events were potentially life-threatening, could lead to permanent sequelae, or required surgical intervention
What is the general complication rate for hysterectomy?
2.7%
How does focused ultrasound therapy work for fibroids?
High intensity waves are directed at a specific region. Is produces focal areas of protein denaturization, irreversible cell damage, and tissue necrosis
What are potential side effects from focused ultrasound treatment for fibroids?
Heavy menstrual bleeding requiring transfusion, persistent pain and bleeding, nausea requiring hospitalization, sciatic nerve pain
What benefits are associated with preoperative GnRH agonist therapy for fibroid surgery?
When given 2-3 months pre op: improved hematologic parameters, shorter hospital stay, decrease blood loss, decrease operating time, decrease post op pain.
Does pre op GnRH agonist decrease the risk of blood transfusion for fibroid surgeries?
No
What is a disadvantage to pre op GnRH agonist (2-3 months) for fibroid surgery?
May make the leiomyomas softer and the surgical planes less distinct
What are the effects of GnRH antagonists on leiomyoma volume?
Transient reduction in leiomyoma volume by 25-40% in 19 days (more rapid effect that agonist without initial steroidal flare.
What are intraoperative measures that can be taken during myomectomy to decrease blood loss?
Infiltration of vasopression into my myometrium. Tourniquet around the lower uterine segment. For hysteroscopic myomectomy can inject vasopressin in cervix (decrease blood loss, fluid intravasation and operative time).
What percentage of women with infertility have leiomyomas?
5-10%
What percentage of women with infertility have fibroids identified as the sole factor?
1-2.4%
How can intramural and submucosal leiomyomas affect fertility and pregnancy complications?
Can distort the uterine cavity, obstruct tubal ostia or cervical canal.
What pregnancy rates are reported (in 1-2 years) after abdominal myomectomy with otherwise unexplained infertility?
40-60%. Similar results with hysteroscopic and laparoscopic myomectomies.
Do leiomyomas that cause distorted uterine cavity significantly lower IVF pregnancy rates?
Yes
Is there a role for routine prophylactic myomectomy before IVF for women with leiomyomas and normal uterine cavities?
No
What are potential negative impacts on fertility from myomectomy?
Can cause pelvic adhesive disease, which could cause tubal impairment or obstruction leading to infertility
Can women get pregnancy after uterine artery embolization?
Yes
Does uterine artery embolization affect ovarian function?
Yes, causes decreased ovarian reserve.
Does hysterectomy have an effect on AMH?
Yes, decreases AMH (to the same extent as UAE)
What pregnancy risks are associated with previous UAE?
12% risk of placenta problems (previa & accreta).
Does hormone replacement therapy increase the risk of AUB?
Yes. Study showed that people with structural abnormalities of the cavity (polyps, fibroids), had increased likelihood of AUB if taking HRT.
Should hormone replacement therapy be withheld from women with fibroids?
No
What percentage of women with a uterus >12wks size have ureteral dilation?
56%
What is rate of leiomyosarcomas per patient operated on for leiomyomas?
2-3/1000
What are risk factors for leiomyosarcoma?
Increasing age, hx of prior pelvic radiation, tamoxifen use, rare genetic predisposition resulting in hereditary leiomyomatosis and renal cell carcinoma
