myoma Flashcards
risk factors
- Genetics (2.5x inc in 1st deg relatives)
- Ethnicity (Black > white)
- Obesity
- Inc age
- HTN
- Food additives
- Soybean milk consumption
- Time since last birth / nulliparity
protective
- Smoker
- Lean
- Exercise
- Use of OCP
pathophysio
- Hyperestrogenic
- More E and P receptors
- Increased aromatase
- Peak mitotic activity occurs during luteal phase, progesterone increases mitosis (primary hormone for growth) while estrogen increases progesterone receptors
- Induction of BCL2 gene inhibits apoptosis and promotes cell replication; BCL2 inc in response to P
- Growth factors: EGF, IGF-1, IGF-2, PRL overly expressed in myomas, Inc VEGF, FGF, PDGF
infertility MOA
- Mechanical obstruction of FT/cx/EM
- Distortion of uterine cavity
- Altered uterine contractility affecting gamete/ovum transport & implantation
- Endometrial vascular disturbance, inflammation and endometrial glandular atrophy causing implantation failure
- Abnormal local hormonal milieu
AUB MOA
- increased surface area
- uterine venous ectasia
- fragile and engorged vessels
- impaired platelet action
- increase in TGFB3
- molecular changes (VEGF, MMP, bFGF)
- impaired myometrial contractility
- impaired vasoconstriction of spiral arterioles
pregnancy risk (8)
- PTB
- Malpres
- RPL
- Hemorrhage
- Previa
- Dysfunctional labor
- IUGR
- IUFD
FIGO
FIGO
0 - pedunculated SM
1 <50%
2 >50%
3 - contacts EM, SM
4 - IM
5 - >50% IM
6 - <50% IM
7 - pedunculated SS
8 - others: cervical, parasitic
diagnostics
TV-UTZ - best initial screening to diagnose
SIS - adjunct for SM myoma
MRI - best for mapping: detection, localization, characterization
CT- limited use kasi same color lang myoma and myometrium
cervical priming
Evening primrose gel 6 caps 12h, 4 caps 1h
OR
1 cap TID x 3 days
6 caps 12h, 4 caps 6h
Laminaria 12h
ESGE Classification
*based on penetration of myometrium
1- endometrial cavity
2- <50% myometrial penetration
3- >50% myometrial penetration
step-w
0-3 - I: easy peazy
4-6 - II: consider 2 stage, consider GnRH
7-9 - III: lap that bitch
Size
0 - <2 cm
1 - 2-5cm
2 - >5 cm
Topography
0 - Inferior
1 - Middle
2 - Upper
Extension
0 - 1/3
1 - in between
2 - 2/3
Penetration
0 - SM
1 - Figo 1
2 - Figo 2
Wall (lateral wall) - 1
adhesion barriers
reduce post-op adhesions but no evidence on future pregnancy or pain control
If hystero–insufficient evidence:
Hyaluronic acid gel fewer adhesions, balloon stent undetermined, hormone therapy no evidence
Goals of tx
Goal: 1) TEMPORARILY reduce symptoms, 2) reduce myoma size 3) improve anemia
Therapy of choice: GnRH agonist
Medical MGT
GnRHa 3.75mg IM qmonthly x 3-6 months (+ addback therapy)
GnRH antagonist (Elagolix)
SPRM (UPA 5mg/tab)
Levonorgestrel intrauterine device (LNG-IUS) 52mg
Uterine Artery Embolism
High intensity focused ultrasound (HIFU)
magnetic resonance guided focused ultrasound (MRg-FUS)
Sx
EL
HM - choice if SM
Lap - method of choice for SS and IM
Mini-lap - incision <8cm
Robot no advantage over lap
VM
Hysterectomy - permanent solution if completed family size
*No difference in PR and LBR between EL and OL, but OL has advantages: lower blood loss, faster recovery, less postop pain
