Alternatives to hysterectomy for fibroids Flashcards
What are other options to hysterectomy for treatment of fibroids?
Medical:
- OCPs
- NSAIDs
- GnRH agonists or antagonist
- LNG IUDs
- Aromatase inhibitors
- Progesterone modulators
Procedural
- Myomectomy
- UAE
- UFE
- MR focused ultrasound ablation
What are efficacy and considerations of OCPs?
- Likely short term, high cross over to surgery
- Need to monitor uterine and myoma size with OCPs
IUD -what are efficacy and considerations?
- small studies show it can be effected
- higher risk of vaginal spotting and IUD expulsion
GnRH agonists and antagonist - what are efficacy and considerations?
in pre-op setting: GnRH agnoist (leuprolide/lupron) - decreases fibroid volume by 35-65% - improves hematologic parameters - decreases EBL, OR time, postop pain - downside is it makes surgical planes less distinct, softens fibroids - if more than 6 months, need add-back therapy (ex: premarin 0.625 mg and 5 mg norethindrone acetate) - dose depot leuprolide 11.25 mg IM
GnRH antagonist (Ganirelix)
- reduce fibroid volume by 25-40%
- not FDA approved
- added benefit of not causing steroid flare
progesterone modulators (i.e. mifepristone)
- not FDA approved for fibroids
- high rate of leiomyoma size reduction
- risk of hyperplasia with atypia
- transient transamnitis, requires liver function monitoring
abdominal myomectomy
rate of recurrent tumors?
rate of recurrent surgical intervention?
single fibroid:
- 27% recurrent tumor
- 11% subsequent hyst
multiple fibroids:
- 59% recurrent tumor
- 26% repeat surgery (hyst or myomectomy)
when would you consider laparoscopic/robotic?
- large fibroids (greater than 5-8 cm)
- multiple fibroids
- deep intramural
no hard and fast rule
what is the classification of submucosal fibroids? type relevant?
Type 0: completely intracavitary
Type 1: < 50% intramural
Type 2: > 50% intramural
important because gives you an idea how how likely you are to completely remove hysteroscopically
how do uterine artery embolization and TAH compare (i.e. EMMY trial)?
- efficacy: satisfaction of treatment at 2 years equal
- UAE had better 24 hour post-op pain control, quicker time to return to work (28 vs 63 days)
- UAE had higher minor complications (vaginal discharge, hematoma, fibroid expulsion) (58 vs 40%)
- UAE had higher rates of readmission (11% to 0%)
–
likely higher repoeration rate than myomectomy (20-30%)
what are potential complications of UAE
5-8%
- degeneration/necrosis of target lesion
- myometrial infarction/necrosis
- infection (myometritis, bacteremia)
- uterine perforation
- loss of ovarian function 5-14% of cases
what are documented benefits of UAE? what are not documented benefits?
Documented:
- reduced myometrial blood flow, reduced symptoms of fibroids
Undocumented:
- significance in reduction of myomata
- avoidance of hysterectomy
what intraoperative steps can be used to decrease blood loss in myomectomy?
- injection of vasopressin with saline into myometrium (4-6 u, 0.2/mL) -> decreases EBL, and LOS
- tourniquet may be help; not been compared with placebo
effect of HRT on fibroids?
- increases fibroid size
- may cause bleeding, along with other structural anomalies
- does not decrease QOL
what are RFs for leiomyosarcoma? what pre-op steps can you take if concerned?
- post menopausal
- prior pelvic radiation
- tamoxifen use
- rare genetic condition
*not rapidly increasing fibroid/uterine size
Get MRI and EMB if concerned
candidates for UAE?
- pre-menopausal
- done with childbearing (likely increased ~12% risk of abnormal placentation)
- desire to retain uterus
