#96 Alternatives To Hysterectomies In The Management Of Leiomyomas

Question 1

What are the two most common symptoms that women with fibroids seek treatment for?

Answer 1

AUB and pelvic pressure

Question 2

What is the typical pattern of bleeding seen with fibroids?

Answer 2

Prolonged and heavy menstrual bleeding

Question 3

What is prevalence of fibroids by age 50 in white and black population?

Answer 3

70% and 80%

Question 4

Are COC or progestin only use associated with increasing or decreasing fibroid size?

Answer 4

Studies are mixed. Recommend monitoring size during therapy

Question 5

What are pros and cons for Mirena type IUDs for treating AUB-L?

Answer 5

Decrease HMB

Higher rate of expulsion and vaginal spotting

Question 6

How does GnRH agonist affect fibroid size?

Answer 6

Decreases 35-65% in 3 months

Question 7

For what indication is the FDA approval for Lupron in regards to fibroids?

Answer 7

Pre op shrinkage of fibroids in patients with anemia. In conjunction with iron supplementation

Question 8

Will fibroids grow back to original size after cessation of gnrh therapy?

Answer 8

Yes, within several months

Question 9

After how many months of lupron treatment does add back therapy need to be added? Why?

Answer 9

6 months. Minimize continued bone loss and vasomotor symptoms

Question 10

Role of aromatase inhibitors for fibroids?

Answer 10

Overall little data, some case studies say decrease size and symptoms. No FDA approval for this indication

Question 11

What are potential side effects of mifepristone?

Answer 11

Endometrial hyperplasia without atypia (14 to 28 percent) and elevated transaminases (4%)

Question 12

What are type zero type one and type two leiomyomas?

Answer 12

Type zero is completely in the cavity
Type of one is less than 50% intramural
Type two is more than 50% intramural

Question 13

What is the success rate of removing fibroids at the initial hysteroscopy?

Answer 13

85 to 95%

Question 14

What are the potential complications of a hysteroscopic myomectomy?

Answer 14

Fluid overload with hyponatremia, pulmonary edema, gas embolism, uterine perforation, infection, bleeding, Cerebral edema

Question 15

What is the major complication rate for uterine artery embolization?

Answer 15

4.9%

Major = events were potentially life-threatening, could lead to permanent sequelae, or required surgical intervention

Question 16

What is the general complication rate for hysterectomy?

Answer 16

2.7%

Question 17

How does focused ultrasound therapy work for fibroids?

Answer 17

High intensity waves are directed at a specific region. Is produces focal areas of protein denaturization, irreversible cell damage, and tissue necrosis

Question 18

What are potential side effects from focused ultrasound treatment for fibroids?

Answer 18

Heavy menstrual bleeding requiring transfusion, persistent pain and bleeding, nausea requiring hospitalization, sciatic nerve pain

Question 19

What benefits are associated with preoperative GnRH agonist therapy for fibroid surgery?

Answer 19

When given 2-3 months pre op: improved hematologic parameters, shorter hospital stay, decrease blood loss, decrease operating time, decrease post op pain.

Question 20

Does pre op GnRH agonist decrease the risk of blood transfusion for fibroid surgeries?

Answer 20

No

Question 21

What is a disadvantage to pre op GnRH agonist (2-3 months) for fibroid surgery?

Answer 21

May make the leiomyomas softer and the surgical planes less distinct

Question 22

What are the effects of GnRH antagonists on leiomyoma volume?

Answer 22

Transient reduction in leiomyoma volume by 25-40% in 19 days (more rapid effect that agonist without initial steroidal flare.

Question 23

What are intraoperative measures that can be taken during myomectomy to decrease blood loss?

Answer 23

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).

Question 24

What percentage of women with infertility have leiomyomas?

Answer 24

5-10%

Question 25

What percentage of women with infertility have fibroids identified as the sole factor?

Answer 25

1-2.4%

Question 26

How can intramural and submucosal leiomyomas affect fertility and pregnancy complications?

Answer 26

Can distort the uterine cavity, obstruct tubal ostia or cervical canal.

Question 27

What pregnancy rates are reported (in 1-2 years) after abdominal myomectomy with otherwise unexplained infertility?

Answer 27

40-60%. Similar results with hysteroscopic and laparoscopic myomectomies.

Question 28

Do leiomyomas that cause distorted uterine cavity significantly lower IVF pregnancy rates?

Answer 28

Yes

Question 29

Is there a role for routine prophylactic myomectomy before IVF for women with leiomyomas and normal uterine cavities?

Answer 29

No

Question 30

What are potential negative impacts on fertility from myomectomy?

Answer 30

Can cause pelvic adhesive disease, which could cause tubal impairment or obstruction leading to infertility

Question 31

Can women get pregnancy after uterine artery embolization?

Answer 31

Yes

Question 32

Does uterine artery embolization affect ovarian function?

Answer 32

Yes, causes decreased ovarian reserve.

Question 33

Does hysterectomy have an effect on AMH?

Answer 33

Yes, decreases AMH (to the same extent as UAE)

Question 34

What pregnancy risks are associated with previous UAE?

Answer 34

12% risk of placenta problems (previa & accreta).

Question 35

Does hormone replacement therapy increase the risk of AUB?

Answer 35

Yes. Study showed that people with structural abnormalities of the cavity (polyps, fibroids), had increased likelihood of AUB if taking HRT.

Question 36

Should hormone replacement therapy be withheld from women with fibroids?

Answer 36

No

Question 37

What percentage of women with a uterus >12wks size have ureteral dilation?

Answer 37

56%

Question 38

What is rate of leiomyosarcomas per patient operated on for leiomyomas?

Answer 38

2-3/1000

Question 39

What are risk factors for leiomyosarcoma?

Answer 39

Increasing age, hx of prior pelvic radiation, tamoxifen use, rare genetic predisposition resulting in hereditary leiomyomatosis and renal cell carcinoma