uterine myoma and myomectomy

reasons to say "sex steroid-responsive"

(a) are not noted prior to puberty, (b) typically regress after menopause, (c) possess sex steroid receptors (EST and PRO), (d) often dramatically enlarge during pregnancy when EST and PRO levels are very high, and (e) can be made to shrink with medically induced hypogonadism

investigations to identify uterine sarcoma (Tl, 12th)

- even the most diligent preoperative assessment cannot completely exclude the possibility of leiomyosarcoma or other malignancy - fibroid size and rate of growth are not predictive - there are no imaging or laboratory tests such as serum markers or histology from endometrial sampling that can reliably predict a uterine sarcoma

preoperative use of (SPRM)

- selective progesterone-receptor modulator (SPRM) agonists also shrink myoma volume and diminish menstrual bleeding

androgens danazol and gestrinone and myoma

- shrink leiomyoma volume and improve bleeding symptoms - Unfortunately, their prominent side effects, which include acne and hirsutism, preclude their use as first·line agents.

LNG IUS in myomatous uterus

- significantly improved leiomyoma related bleeding scores - However, for women with myomas, LNG IUS expulsion rates are higher and range from 10-15% - Placement into the large cavities of enormous uteri is also avoided, as the device and its strings may migrate cephalad to make retrieval difficult. Although not a strict clinical limit, many studies have included only uteri measuring </= 12 week size

age for uterine myoma

- uncommon before 30 yrs. but all occur after puberty - By 50 years of age, 70% of white women and 80% of African American women will develop a uterine leiomyoma. (TL, 12th)

pathophysiology/mechanisms of HMB in myoma

- vasodilation of endometrial vessles - altered hemostasis

MRI in leiomyomas (TL, 12th)

- when numerous fibroids, it may be used for more detail - to identify and map out leiomyoma before laparoscopic or robotic myomectomy - differentiating a leiomyoma from adenomyosis or an adenomyoma (but this test is not conclusive) - can also help determine whether the patient is a candidate for uterine artery embolization (UAE) and specifically to assess the arterial supply to the myomas

importance of FIGO classification system for myomas (TL, 12th)

- considered the accepted best approach for communicating the site of leiomyoma - The classification is important for determining the surgical approach (how?) - Submucosal leiomyomas are further subdivided into three more categories. This classification of submucosal leiomyomas assists in selection of the best treatment approach. (PROLOG, 8th)

conversion rates to hysterectomy during myomectomy

Fortunately, conversion rates to hysterectomy during myomectomy are low and range from 0 to 2%. (W, 4th)

High-frequency magnetic resonance-guided ultrasound (TL, 12th)

thermoablative technique that can be used to ablate fibroids - used for easily accessible fibroids - cannot be used if bowel and bladder are not interposed - Leiomyomas of greater than 10 cm are difficult to treat with this modality - Contradictions include: interposed bowel and bladder, >10cm, presence of more than four leiomyomas, poor vascularity (nonenhancement with gadolinium), and severe adenomyosis - Leiomyoma size reduction with this method is similar to UAE at about 37% to 40%. - approved for use in women who desire future fertility

Irregular vaginal bleeding (oligomenorrhea), regardless of the amount, or intermenstrual bleeding (metrorrhagia) does not suggest fibroids but rather an underlying endocrine abnormality (e.g., anovulation)

true

symptom risk rises with myoma size and number

true (W, 4th)

each leiomyoma is drived from a single progenitor myocyte

true (W, 4th) - Uterine leiomyoma (myoma; fibroids) are benign monoclonal tumors arising from smooth muscle tissue. (TL, 12th) - Leiomyomas arise from a single muscle fiber—the myocyte—of the uterine smooth muscle under the influence of reproductive hormones, namely estradiol as a primary growth promoter. (PROLOG, 8th)

There is no specific leiomyoma size that requires intervention in women who are asymptomatic.

Surgery is not indicated for prophylactic symptom prevention as there are no reliable predictors of symptom development. (TL, 12th)

Myomectomy is associated with a reintervention rate of 15% and subsequent hysterectomy rate of 11%.

TL, 12th

sex stroid sensitivity of fibroids vs vascular supply

While fibroids are stimulated to grow by sex steroids but the vascular supply is not, this is the limiting factor for the growth of individual tumors.

rate of recurrence of leiomyomas

after 5 years approximate 60% (W, 4th) - rates of leiomyoma recurrence in women treated with GnRH agonists prior to myomectomy are higher (W, 4th)

UAE in leiomyomas (TL, 12th)

effective nonsurgical treatment of leiomyoma-associated symptoms such as abnormal bleeding - After UAE, uterine size is typically reduced 30-45% with associated improvements in quality of life - Relief of symptoms from UAE occurs in 75-80%, similar to results following myomectomy. - Unfortunately, in comparison with myomectomy, UAE has higher reintervention rates, subsequent hysterectomy rates, and complications from the index procedure. - UAE is an excellent option for women who do not desire future fertility and have medical disorders that increase surgery risk

myoma: prevalence

generally 10-20% of women - as high as 70-80% sonographically - By 50 years of age, 70% of white women and 80% of African American women will develop a uterine leiomyoma.

"Uterine Fibroids : Causes, Risk factors, Signs and symptoms, Complications, Diagnosis and Treatment" at https://youtu.be/mBeRnzKX-z4

https://t.me/ProjectTGM/1880

forms of myoma degeneration

hyaline, calcific, cystic, myxoid, red, and fatty

clinical importance of the thin outer connective tissue layer of leiomyoma

its important cleavage plane that allows leiomto be easily "shelled" from the uterus during surgery

the MC benign tumors of female genital tract

leiomyomata - Uterine leiomyomas are the most common benign tumor of the female genital tract. (PROLOG, 8th)

other names for uterine myoma

leiomyomata, fibroids

most frequent symptom for uterine myoma

menorrhagia

menorrhagia

menstruation at regular cycle intervals but with excessive flow (more than 80ml per cycle) and duration (longer than 7 days)

preop optimization for anemia (TL, 12th)

- CBC, possible iron studies, and exclusion of sickle cell or other hemoglobinopathies - blood type and screen, possible cross match for blood and urine pregnancy test - Correction of anemia rather than transfusion is the optimal approach - Oral iron supplementation (with vitamin C to enhance absorption) can increase hgb by 2 g/dL within 2-3 weeks if bleeding is controlled. - Occasionally, IV iron may be necessary to improve preoperative hgb - GnRH agonists are not generally recommended to use GnRH agonist pretreatment solely to decrease interoperative blood loss, but it may be advantageous for correction of preoperative anemia - attempts to resolve anemia and heavy menstrual bleeding prior to surgery: oral iron therapy, GnRH agonists, and PRO antagonists (W, 4th)

hormonal contraceptives: types and roles (TL, 12th)

- COCs and progestin-only contraceptives, can be used to control AUB, as these medications do not cause leiomyomas to grow - LNG-IUD can be used in women with fibroids and a normaluterine cavity to decrease heavy menstrual flow

prolapsing pedunculated submucosal leiomyoma

- Compared with other uterine locations, prolapsing vaginal fibroids are the least common. - Classic prodromal symptoms of a prolapsing uterine fibroid may include leukorrhea, colicky pelvic pain, foul-smelling vaginal discharge, menstrual bleeding with variable flow, anemia, pressure, lower abdominal discomfort, "labor-like pain," bulge in the vagina, and difficulty with urination. Vaginal hemorrhage may occur, and the duration of symptoms is variable. - When prolapsing leiomyomas appear at the introitus, it may be mistaken for a fetal head (if large), or uterovaginal prolapse, including cystocele or rectocele. - the cervix can be effaced, softened, dilated, or barely seen - Hysteroscopy performed after removal of the prolapsed leiomyoma is beneficial as it permits complete resection of residual leiomyoma and coagulation of the base of the leiomyoma. - Due to a concern about colonization of the upper genital tract in the setting of a prolapsed myoma, patients are usually empirically treated with broad-spectrum antibiotics perioperatively and postoperatively. - If the patient is febrile, blood cultures and cervical/vaginal cultures are obtained, broad-spectrum antibiotics are administered, and the surgery is typically not performed until the patient is clinically improved

single vs multiple incisions

- Excision of multiple myomas through a single incision can make effective closure challenging as the tunnel created may make access to deep tissue difficult. Separate incisions can be made with myomas directly under the incision removed. (TL, 12th)

surgical approach vs FIGO class (TL, 12th)

- For example, types 0 and 1 leiomyomas are generally managed hysteroscopically. - A type 1 myoma (<50%intramural involvement) can be managed hysteroscopically depending on the size of the myoma. A myoma size greater than 3 to 5 cm may require medical therapy to decrease fibroid volume and be more amenable to hysteroscopic intervention. - Type 2 submucosal fibroid myomas with more than 50% intramural component require a high level of hysteroscopic skill and are generally approached abdominally. - Types 3 to 7 fibroids should not be approached hysteroscopically.

four symptom catagories myoma

- Heavy or prolonged menstrual bleeding - Bulk symptoms (abdominal protrusion, bowel or bladder dysfunction, early satiety) - Reproductive dysfunction (infertility or recurrent pregnancy loss) - Pain, including painful menses or nonmenstrual pain

The role of progestins in the development of leiomyomas seems to be less clear (PROLOG, 8th)

- In some reports, in vitro use of progestin in human leiomyoma cell culture stimulated leiomyoma cell proliferation. In other reports, use of in vitro progestin inhibited leiomyoma cell growth. - Clinical studies also have shown that leiomyoma growth was greater when estrogen and progesterone were used in combination compared with estrogen-only use. - In other studies, high-dose progestin use led to the atrophy of leiomyomas. - With the use of ulipristal, an antiprogestin, leiomyomas were noted to decrease in size, thus supporting the potential stimulating role of progestins on leiomyoma growth. - DMPA in young African-Americans lowers myoma risk (W, 4th)

uterine leiomyoma: definition

- benign smooth-muscle neoplasms that typically originate from myometrium - benign monoclonal tumors arising from smooth muscle tissue (TL, 12th)

myomectomy by laparatomy

- Laparotomy is suggested if there are a high number of myomas, typically more than 3, or myomas larger than 10-12cm - patient should be placed in lithotomy position: allows a uterine manipulator to be used and dye injected to correctly identify the uterine cavity during excision of myomas - Most myomas can be removed through a Pfannenstiel incision; however, for a very large uterus, a Cherney, Maylard, or midline incision should be made - With exteriorization of the uterus, surgical retractors are not typically needed. - Incision on the bladder peritoneum and dissected downward to visualize the parametrium - A catheter is placed around the lower uterine segment in order to occlude the uterine vessels (tied anteriorly or posteriorly) and a clamp is placed on the knot. - opening is then made in the posterior leaf of the broad ligament, and a tourniquet is passed - vascular clamp on the ovarian vessels can also be useful in decreasing bleeding - Dilutedvasopressin is then injected into the pseudocapsule - incision is made and carried to the pseudocapsule at which level dissection and coagulation should occur to minimize blood loss - Diluted methylene blue dye is injected transcervically. - towel clamp can be applied to the myoma - Entry into the uterine cavity requires a separate repair with fine sutures that should not be placed into the cavity - In cases of disruption of large or multiple segments of the endometrium, narrow lower uterine segment, or cervical canal, a pediatric Foley catheter can be placed and left in place for 1 wk to prevent stenosis - incisions are quickly closed with braided delayed absorbable sutures (e.g., 0-Vicryl or Polysorb) - At least 2 myometrial layers are required followed by a serosal layer of finer suture - The tourniquets are then removed.

leiomyoma vs leiomyosarcomas

- Leiomyosarcomas do not arise from preexisting leiomyomata and present much later in life, well after menopause. (W, 4th) - Leiomyosarcoma is found in approximately 1 in 495 to 1 in 1,100 women undergoing surgery for myomas (TL, 12th)

uterine myoma: symptoms

- Menorrhagia, Dysmenorrhea, Pelvic pressure (Urinary frequency, Constipation, Dyspareunia), Infertility, RPL, Abdominal Distension - Severe symptoms develop in about 30% of patients of women with leiomyomas. - The main symptoms associated with leiomyoma are abnormal uterine bleeding, bulk symptoms, pelvic pain or pressure, and urinary symptoms - Among symptomatic women, myomectomy results in significant improvement in symptoms and restores health-related quality of life - negatively impact pregnancy outcomes, cause infertility, and lead to recurrent miscarriages

roles of EST and PRO on myoma

- PRO is critical mitogen for uterine leiomyoma growth and development - EST functions to upregulate and maintain PRO receptors - myoma has higher densities of both EST and PRO receptors compared with their surrounding myometrium (W, 4th) - myoma formation is not induced by COCs (W, 4th) - DMPA in young African-Americans lowers myoma risk (W, 4th) - estradiol is a primary growth promoter, and the role of progestins in the development of leiomyomas seems to be less clear (PROLOG, 8th)

Progesterone receptor modulators in leiomyomas

- PRO receptor modulators, such as mifepristone or ulipristal acetate, are used to reduce menstrual bleeding. - ulipristal acetate versus GnRH agonists: equally effective - Due to a concern that PRO receptor modulators may result in endometrial changes (e.g., from unopposed estrogen), intermittent (rather than continuous) use of the drug is recommended.

surgery is not indicated in ___ (TL, 12th)

- Surgery is not indicated for prophylactic symptom prevention as there are no reliable predictors of symptom development. - not indicated solely to exclude the possibility of sarcoma - There is an association of intracavitary or cavity-distorting myomas and infertility or recurrent pregnancy loss. However, it is not clear when surgery would be beneficial to improve reproductive outcomes.

management of myoma causing infertility (Prolog 8th) - 2

- UAE involves injecting PVC particles thru femoral artery into uterine arteries to occlude flow to myoma or uterus or both, resulting in devascularization, necrosis and subscquent involution of the myoma - UAE is not recommended for patients interested in future pregnancy as it is associated with increased miscarriage rate and higher risk of PPH, placenta previa and accreta because of ischemia to endometrium and myometrial defects from infarcted myomas - UAE also may cause decreased ovarian reserve and permanent amenorrhea because of compromised blood flow to ovaries - necrosis of myoma that communicates eith endometrial cavity may cause fetid vaginal discharge - MRI-guided focused US surgery: is outpatient procedure that doesnt require anesthesia where high intensity US besms travel thru abdominal wall and converge on a targeted myoma, producing heat, protein denaturation, cell death, and coagulative necrosis, and contraindications include desired fertility, adenomyosis, and pedunculated myoma (may detach into abdominal cavity) - radiofrequency ablation using laparoscopic direction or TVS to achieve coagulation necrosis of myoma - myomas contain high conc of PRO receptors, and SPRMs decreas myoma size, and are associated with slowr regrowth of myoma after discontinuation of therapy compared to GnRH agonists, but cant get pregnant while taking them just like eith GnRH agonists

imaging in leiomyoma (TL, 12th)

- Ultrasound is considered the gold standard to diagnose uterine leiomyoma as well as to assess location and number. - saline ultrasonography can help delineate the penetration of a submucosal myoma into the myometrium and in this way aid in the surgical approach to management. - A hysteroscopy can be used to appropriately assess the resectability of the lesion - what is the place of MRI? - On ultrasonography, leiomyomas appear as hypoechoic or hyperechoic masses depending on the ratio of smooth muscle to connective tissue. (PROLOG, 8th) - In some cases, a central cavity may be seen within the tumor if the leiomyoma has degenerated. Calcified leiomyomas may appear hyperechoic with a rim of calcification surrounding the tumor. (PROLOG, 8th)

management of myoma causing infertility (Prolog 8th)

- fibroids affect 70% of women by the time they reach menopause - present in 5-10% of women with infertility - MC surgical treatment for symptomatic leiomyomas in want to preserve fertility is myomectomy - less invasive options include UAE and MRI-guided focused US surgery - myomas with a submucosal component commonly cause menstrual spotting and heavier bleeding - FIGO classification types 0, 1 and 2 (those with submucosal component) are associated with decreased in clinical pregnancy rates, hysteroscopic myomectomy for these has been associated with increased pregnancy rates and decreased miscarriage rates - data is less clear regarding infertility incidence in myomas that do not distort endometrial cavity - 3 proposed mechanisms for association of leiomyomas and infertility a. submucosal myomas decrease blood supply to endometrium reducing successful implantation rates b. low EST environment within myomas can lead to atrophy and disruption of endometrial glands within endometrium, thereby decreasing implantation rates c. larger intramural or subserosal myomas cna change physical relationship between ovaries and fallopian tubes decreasing oocyte pickup - GnRH agonist is not ideal treatment for myoma in woman who has infertility and desires pregnancy because their effect is not permanent and myomas often regrow to thier pretreatment size within 3 mos after last dose of GnRH agonist and the patient can't attempt pregnancy during treatment - GnRH agonists shrink myoma size by as much as 35-65% within 3 mos, hence they maybe used to reduce uterine and myoma volume which may allow minimaly invasive surgical approach and decrease intraop blood loss, operation time and hospital stay - UAE involves injecting polyvinyl chloride particles (thru femoral artery) into uterine arteries to occlude blood flow to myoma or u

risk factors and protective factors for leiomyoma

- https://t.me/ProjectTGM/2236 - pregnancy above 20 wks. and smoking decrease prevalence

myomectomy vs hysterectomy

- hysterectomy should be discussed in women who have completed childbearing as this is associated with definitive management of symptoms and no recurrence - exception to this general recommendation would be any fibroid easily managed by hysteroscopy - myomectomy: reintervention rate of 15% and subsequent hysterectomy rate of 11% - myomectomy for women with no desire for future fertility but wish to keep their uterus - in a postmenopausal woman, a rapidly growing uterine mass increases the probability of malignancy so myomectomy is not recommended: refer to gynecologic oncologist for investigation and potential hysterectomy

GnRH agonists (W, 4th)

- inactive if taken orally - shrink leiomyomas by targeting the growth effects of EST and PRO - flare: stimulate receptors on pituitary gonadotropes to cause a supraphysiological release of both LH and FSH - flare typically lasts 1 wk - With their long-term action, however, agonists downregulate GnRH receptors in gonadotropes, thus desensitizing gonadotropes to further GnRH stimulation. - suppressed EST and PRO levels 1 to 2 weeks after initial GnRH agonist administration - dramatic decreases in uterine and leiomyoma volume - effectively relieve symptoms of HMB and decrease uterine size, although they are associated with a rapid return of symptoms and uterine size upon cessation of use (TL, 12th)

Perioperative Measures to Reduce Intraoperative Blood Loss (TL, 12th)

- laparoscopic surgery decreases blood loss compared with open surgery for similar size leiomyoma - medical measures: https://t.me/ProjectTGM/2237 - mechanical tourniquets such as the use of a Foley catheter tied around the cervix or placement of a polyglactin suture around both the cervix and the infundibulopelvic ligament - A loop ligation of the vessels of the myoma pseudocapsule can decrease blood loss but has not proven to reduce transfusion rate. - vascular clamps (e.g., Bulldog clamps) - use of an ultrasonic device rather than electrosurgery has also been shown to reduce blood loss by 50 to 60 mL - use of unidirectional and bidirectional barbed suture can decrease blood loss at laparoscopic or robotic myomectomy as well as decrease operative time where suturing is more challenging (https://t.me/ProjectTGM/2238) - Intraoperative blood salvage techniques are also useful to decrease operative blood loss.

conditions that create hyperESTnic environment

- leiomyomas themselves create a local hyperESTnic environment - early menarche, obesity, PCOS

myoma incidence vs age vs race

- rare in adolescent, increase during reporoductive years, and decrease after menopause - African American women are diagnosed at a younger age and with more severe symptoms than Caucasian women. (TL, 12th) - By 50 years of age, 70% of white women and 80% of African American women will develop a uterine leiomyoma. (TL, 12th and PROLOG, 8th) - Women of African descent typically present with larger and more symptomatic leiomyomas. (PROLOG, 8th)

observation in myoma

- regardless of their size, asymptomatic leiomyomas usually can be observed and surveilled with an annual pelvic examination - annual US if adnexal assessment is hindered by large or irregular uterus or patient obesity - leiomyomas typically shrink and symptoms improve in the postpartum and postmenopausal period

advantages vs disadvantages of use of preoperative GnRH agonists (W, 4th)

1. advantages: - control of AUB (W, 4th). 3-4 mos of pretreatment led to a significant positive impact on preoperative hgb and HCT levels secondary to improvement in HMB (TL, 12th) - significantly shrink uterine volume after several months of use leading to less invasive surgery (W, 4th). It may allow a surgeon to accomplish an open procedure via a transverse rather than a vertical incision (TL, 12th) - Volume changes to the fibroid occur within the first 2-3 mos (TL, 12th) - also diminish leiomyoma vascularity and uterine blood flow 2. disadvantages - GnRH agonists can incite hyaline or hydropic degeneration which may obliterate the pseudocapsule connective tissue interface which may lead to tedious and lengthy tumor enucleation - rates of leiomyoma recurrence in women treated with GnRH agonists prior to myomectomy are higher. - leiomyomas treated with these agents may shrink in volume and be missed during surgical removal (W, 4th). They may regrow postoperatively, after return to normal menstrual function - GnRH agonists do cause side effects such as hot flashes - not generally recommended solely to decrease interoperative bloodloss, but it may be advantageous for correction of preoperative anemia (TL, 12th)

myoma: management summery

1. nonsurgical management - observation - sex steroid hormones: COCs, continuous oral progestins, or DMPA, LNG IUD, androgens danazol and gestrinone - GnRH receptor agents - PRO receptor modulators - antifibrinolytic agents - UAE - High-frequency magnetic resonance-guided ultrasound 2. surgical management - myomectomy: hysteroscopic, laparoscopic, robotic, laparotomy, vaginal - hysterectomy

types of uterine myoma

1. serosal or subserosal (and pedunculated) 2. intramural 3. submucosal (and intracavitary) 4. cervical 5. parasitic (may or may not detach from parent myometrium)

Indications for Myomectomy (TL, 12th)

1. symptoms that interfere with quality of life: AUB, urinary symptoms, pelvic pressure or pain 2. asymptomatic women with infertility or recurrent pregnancy loss: after investigating all other causes in cases of cavity-distorting fibroid 3. previous adverse pregnancy outcome - considered in asymptomatic women who desire future fertility and have a submucosal leiomyoma amenable to hysteroscopic surgery - the presence of moderate or severe hydronephrosis from ureteral compression

TXA use in leiomyomas

Antifibrinolytic agents, such as tranexamic acid, are effective in treating idiopathic regular HMB. The response of patients with fibroids and heavy bleeding to tranexamic acid is variable, but this approach can be tried as long as the patient is not taking an oral contraceptive (TL, 12th)

The concern that morcellation may lead to the spread of an occult uterine sarcoma at the time of tissue extraction of a presumed uterine leiomyoma has led to an attempt to an increased recognition of the importance of identifying malignant uterine disease before surgery.

Despite the FDA stance on power morcellation and dissemination of occult uterine sarcoma, a cross-sectional study in the Healthcare Cost and Utilization Project databases supports myomectomy for the treatment of leiomyomas. (TL, 12th)

FIGO catagorization of leiomyoma

SUBMUCOSAL 0 pedenculated intracavitary 1 <50% intramural 2 >/=50% intramural - Submucosal leiomyomas are further subdivided into three more categories. This classification of submucosal leiomyomas assists in selection of the best treatment approach. (PROLOG, 8th) OTHER 3 100% intramural but contacts endometrium 4 intramural 5 subserous >/=50% intramural 6 subserous<50% intramural 7 subserous pedunculated 8 other (cervical, broad ligament, parasitic, ovary, fallopian tube, vagina or vulva) HYBRID: contacts both the endometrium and serosal layers https://t.me/ProjectTGM/2234

endometrial adenocarcinoma is the most common malignancy observed in women with fibroids and abnormal uterine bleeding

Therefore, endometrial sampling is recommended prior to surgery in the setting of abnormal bleeding. Endometrial sampling can also aid in detecting uterine sarcoma. (TL, 12th)

GnRH agonists are not used routinely in all patients undergoing myomectomy

They can be recommended for preoperative use in women with greatly enlarged uteri or preoperative anemia or in cases in which a decrease in uterine volume would allow a less invasive approach. (W, 4th)

Medical management is typically hormonal in nature. Which hormonal method is suitable for long term use? (PROLOG, 8th)

o COCs as well as progestins have been used with limited relief in patient symptoms. o GnRh agonists and antagonists also have been used with reports showing as much as 30-40% shrinkage in leiomyoma size in the first 3 mos of use. o Although DMPA and GnRH agonist use are effective, they may not be good options for women seeking long-term management. o Consideration for EST supplementation is important because of the potential risk of low bone mass and future osteoporosis after 3-6 mos of use. o Letrozole also is not a good long-term option because it induces a hypoestrogenism state and may contribute to ovarian cyst development o Mifepristone has been shown to decrease HMB but not leiomyoma volume. Adverse effects of mifepristone also prohibit its continuous use. o The LNG-IUD has been shown to reduce blood loss and improve hematocrit levels in women with leiomyomas. § The LNG IUD delivers 20 micrograms of hormone daily into the endometrial cavity for 3-5 years. § In the first 3-4 months of LNG-IUD use, endometrial atrophy occurs; some women experience irregular bleeding or spotting. By 6 months of use, most women experience amenorrhea.

attempts to resolve anemia and heavy menstrual bleeding prior to surgery

oral iron therapy, gonadotropin-releasing hormone (GnRH) agonists, and progesterone antagonists (W, 4th)