PB 228: Management of Symptomatic Uterine Leiomyomas

Question 1

Uterine leiomyomas are common and estimated to occur in up to ____% of women by menopause.

Answer 1

70%

Question 2

What factors are associated with an increased risk of uterine leiomyomas?

Answer 2

Premenopausal status

Family history

Increasing interval since last birth

HTN

Obesity

The prevalence rate of uterine leiomyomas is 2-3x higher among Black women compared to White women.

Question 3

What factors are associated with decreased incidence of uterine leiomyomas?

Answer 3

Increasing parity

Use of hormonal contraceptives or DMPA for any duration

Question 4

What is the FIGO Leiomyomas Subclassification System?

Answer 4

Question 5

What are the symptoms of leiomyoma?

Answer 5

Prolonged or heavy menstrual bleeding, with or without anemia

Bulk symptoms: pelvic pressure, urinary frequency, constipation

Question 6

What imaging options are available for diagnosis of uterine leiomyoma?

Answer 6

• TVUS
• SIS - distinguish between Type 0, 1, 2
• HSC - distinguish between Types 2 and 3
• MRI - can be useful for surgical planning, determining vascularity and degeneration, and distinguishing between type 4 and type 5 leiomyoma

Question 7

In which patients is expectant management of uterine leiomyomas appropriate?

Answer 7

In patients who do not have bothersome symptoms or are experience perimenopausal symptoms because after menopause leiomyomas do not have the necessary levels of estrogen and progesterone to sustain their development and growth.

Question 8

What options are available for medical management of uterine leiomyomas? Which of these options is best for BULK and BLEEDING symptoms?

Answer 8

• GnRH antagonists/agonist
• LNG IUD
• Contraceptive steroids
• Tranexamic Acid
• Selective progesterone receptor modulators (ulipristal acetate and mifepristone)

** GnRH agonists and selective progesterone receptor modulators are best for BULK and BLEEDING symptoms **

Question 9

True or False:

Elagolix is an oral GnRH antagonist that results in reversible, dose-dependent, suppression of gonadotropins and ovarian sex hormones and can be used for treatment of AUB-L for up to 2 years.

Answer 9

TRUE

Add back therapy includes 1 mg estradiol and 0.5 mg norethindrone in order to offset the hypoestrogenic effects of elagolix, including hot flushes, increased mean serum lipid levels, and BMD loss.

Question 10

Treatment with GnRH agonists is typically limited to what time period?

Does this differ with and without add-back therapy?

Answer 10

6 months without add-back therapy

12 months with add-back therapy

GnRH agonists are used for SHORT term management to bridge to interventional procedures, surgical management, menopause or other medical therapies.

Question 11

What are the advantages of using an GnRH agonist before proceeding to definitive surgical treatment for AUB-L?

Answer 11

Reduce uterine volume, which may facility use of a minimally invasive surgical route, allow for small incision, increase in preoperative hemoglobin levels (by an avg of 0.88 g/dL)

Question 12

What procedural/surgical options are available for uterine leiomyoma?

Answer 12

• UAE
• Radiofrequency Ablation
• Focus ultrasound surgery
• Endometrial ablation
• Myomectomy
• Hysterectomy