Pelvic Masses

Question 1

What is the most common indication for hysterectomy (both worldwide and in Canada)?

Answer 1

Uterine fibroids

Question 2

True or false: estrogen alone stimulates fibroid growth

Answer 2

False - estrogen is insufficient (progesterone is needed as well)

Estrogen stimulates expression of progesterone receptor, which responds to progesterone and promotes cell proliferation and survival

Question 3

List five risk factors for fibroid development.

Answer 3

Nulliparity
Dysmenorrhea
Obesity
Early menarche
Family history of fibroids
Age 40-50
Frequent menses (short cycle)
Black race
HTN
DM

Question 4

Describe the natural history of fibroids in pregnancy.

Answer 4

Fibroids tend to stay the same size or get smaller during pregnancy

Question 5

Describe some of the pros and cons of using the following imaging modalities to assess fibroids:

• US
• CT
• MRI

Answer 5

US: generally easier/faster to access, no radiation exposure, can typically visualize uterus, fibroids & adnexa very well, may also be able to see hydronephrosis or hydroureter if associated with large fibroids, can use sonohysterography to assess submucosal fibroids

CT: unable to delineate fibroids from endometrium & myometrium, not a good imaging tool for this purpose

MRI: may be particularly helpful in differentiating fibroids from adenomyosis, leiomyomas from adenomyomas

Question 6

List two medical options for treatment of bulk symptoms related to fibroids, and five medical options for treatment of heavy bleeding related to fibroids.

Answer 6

Bulk symptoms: GnRH agonist, UPA, androgens (danazol)

Bleeding: OCP, progestins, LNG-IUS, GnRH agonist, UPA

Question 7

What is the only indication for hysterectomy in a woman with asymptomatic fibroids?

Answer 7

Fibroid enlargement following menopause (in the absence of HRT use)

Question 8

What are the benefits to treating fibroids with a GnRH agonist prior to:

• Hysterectomy
• Abdominal myomectomy
• Hysteroscopic myomectomy

Answer 8

Hysterectomy: improved post-op Hb, reduced intra-op bleeding, decreased complications, decreased LOS, reduce uterine & fibroid volumes, reduced OR time, fewer vertical incisions, fewer laparotomies in general

Abdominal myomectomy: reduced intra-op bleeding, improved post-op Hb, fewer vertical incisions

Hysteroscopic myomectomy: no benefits

Question 9

What non-medical treatment options can you offer to a woman who does not desire fertility, but wants to retain her uterus?

Answer 9

Myomectomy
UAE
MR-guided focussed ultrasound
Radiofrequency myolysis