Uterine Myoma

What might you prescribe to decrease side effects of GnRH agonists?

"kick back therapy" of estrogen/progesterone

Indications for using myomectomy?

- women who have not completed childbearing and/or desire preservation of their uterus

What are the steps of pathogenesis of a myoma?

1. Transformation of normal myocytes to abnormal myocytes 2. Abnormal myocytes grow into tumors (monoclonal expansion)

For whom might Uterine artery embolization (UAE) be indicated?

For women who have completed childbearing, and desire preservation of the uterus

Why do myomas result in pelvic pressure and pain?

Generally due to size of myomas, forcing an irregularly shaped uterus and pressure on neighboring organs and ligaments

What options are there for medical management of myoma?

GnRH agonists Mifepristone (RU-486) DMPA Mirena or Skyla IUD

What is the recommend treatment for women in the menopausal transition?

LNG-IUS or endometrial ablation (for management of bleeding only)

Does myomectomy prevent growth of new lesions?

No. May be required for repeat procedure.

Who can not use IUD to treat myoma?

Not suitable for submucous myomas or large myomas that grossly distort shape of uterus

What is the primary clinical concern of mifepristone in treating myoma?

the association with possible endometrial hyperplasia

Where do intramural myomas develop?

within the myometrium

In what population is hysterectomy not recommended?

women in the menopausal transition

What is the standard confirmatory diagnostic for myoma?

transvaginal ultrasound

What type of myoma is most commonly implicated in menorrhagia?

Submucous

Is tenderness usually associated with myoma?

Tenderness may be due to pressure caused by a large myoma, but myomas, themselves, are characteristically non-tender.

When might you choose laparoscopic myomectomy over abdominal?

The advantage of a laparoscopic myomectomy is that several small incisions are used rather than one larger incision. The disadvantage is that only small myomas can be removed and it is not recommended if there are many myoma or if the myoma are deeply embedded in the uterine wall. Outpatient procedure, and recuperation is usually associated with minimal discomfort. After laparoscopic myomectomy, women usually return to normal activity within ten to fourteen days.

What are associated factors to myomas?

The epidemiology of myomas parallels the life-cycle of the reproductive hormones, estrogen (traditionally hypothesized to be the primary promoter of myoma growth) and progesterone

Who might not be a good candidate for UAE?

Women with large myomas

What labs should be done with suspected myoma?

a CBC should be done to r/o severe anemia; urine hCG

When is surgical management of myoma indicated?

abnormal uterine bleeding, bulk-related symptoms, infertility, recurrent pregnancy loss

By what are the monoclonal cells of a fibroid separated?

by fibrous connective tissue consisting of collagen, fibronectin, and proteoglycan

How does depo work in treating myoma?

causes significant improvement in bleeding pattern as well as a reduction in fibroid volume.

Pressure due to myoma may result in what associated symptoms?

constipation urinary frequency lower back pain

What is traditionally hypothesized to be the primary promoter of myoma growth?

estrogen

Where do transmural myomas develop?

extend from the serosal to the mucosal

Where do pedunculated subserous myomas develop?

extend into the abdomen

Where do pedunculated submucousal myomas develop?

extending into the uterine cavity, occasionally through the cervical os

What are some other words for myomas?

fibroids; leiomyomata; fibromyomas; leiomyofibromas; fibroleiomyomas

How to distinguish pedunculated myoma from polyps?

firm consistency of tissue

How is the size of a myomatous uterus measured?

in menstrual weeks, as with a gravid uterus.

Where do submucousal myomas develop?

in the uterine endometrium

What type of fibroid give the uterus an irregular contour?

intramural

What type of myoma is most common?

intramural

Where do subserous myomas develop?

just under the uterine serosa, outside the uterus.

Where do cervical myomas develop?

located in the stroma of the cervix

What are the side effects of GnRH agonists?

menopausal symptoms ie- hot flashes sleep disturbance, mood and cognition impairment, vaginal dryness, myalgias, arthralgias

What do you need to note during a bimanual exam if you suspect myoma?

size, contour, mobility of the uterus. Other findings such as cervical or adnexal mass should be noted.

From where do myomas develop?

smooth muscle cells of the myometrium

What type of fibroid are only palpable as an enlarged uterus?

submucousal

What type of fibroid can be palpated on abdominal exam?

subserous

Differential diagnosis for myoma?

Uterine adenomyoma (benign) Leiomyoma (malignant) Pregnancy Hematometra Endometrial carcinoma Uterine sarcoma Uterine carcinosarcoma Constipation IBS Urinary tract disorders Ovarian masses Neoplasia of the abdomen Ascites

Indications for hysterectomy in tx myoma?

- For women with acute hemorrhage who do not respond to other therapies - For women who have completed childbearing, and have current or increased future risk of other diseases of the uterus that would be eliminated or decreased by hysterectomy - For women who have failed prior minimally invasive therapy for myomas - For women who have completed childbearing and have significant symptoms, multiple myomas, and desire for an end to symptoms

What are the aspects of expectant management of a myoma?

- initial u/s to confirm - annual pelvics - women with anemia / menorrhagia get a CBC and txed as necessary - screen for hypothyroid ordered for those experience menorrhagia - f/u with increasing size or worsening symptoms

When are GnRH agonists recommended?

3-6 months to reduce myomas and improve anemia prior to surgery or attempting pregnancy. Interval assessment is recommended due to variability of response

Incidence of myoma?

Actual incidence/prevalence is unknown, as myomas are often asymptomatic. However, they are thought to develop in the majority of American women by age 50-- >80% of African American women and almost 70% of white women

What is Mifepristone?

An antiprogestin

Who is eligible for expectant management of myoma?

Asymptomatic women with leiomyoma of the uterus of less than 12 weeks size may be suitable candidates for expectant management, especially those approaching menopause.

What is a myoma?

Benign monoclonal tumors that develop from smooth muscle cells of the myometrium

Protective factors for myoma?

DMPA Late menarche (>16) Parity Prolonged duration of breastfeeding High intake of green vegetables Smoking Menopause

How do myomas arise?

Each myoma arises from a single cell in the myometrium that replicates itself.

What is the leading indication for hysterectomies performed in the US?

Fibroids

Clinical effects of myomas?

Fibroids are usually asymptomatic. Some women may experience: - dysemenorrhea and/or menorrhagia - pelvic "fullness" - lower abdominal pressure - chronic pelvic pain - abnormal uterine bleeding - infertility or repetitive SAB

Why is race thought to be a risk factor for myoma?

Likely because: earlier menarche higher rates of obesity PCOS over expression of hormone receptors in WAD

What is the most common symptom of myoma?

Menorrhagia

Affect of UAE on menses?

Most women continue to have regular menses. But early menopause after the procedure is an increased risk for women over 45 years old

What will GnRH agonists accomplish?

Most women will develop amenorrhea, improve anemia, and experience uterine reduction 35-60% within 3 months of therapy (minimum period recommended)

What are the surgical options for tx of myoma?

Myomectomy Hysterectomy

How does Uterine artery embolization (UAE) work?

Performed by an interventional radiologist who injects polyvinyl alcohol particles into the uterine artery, causing myoma devascularization and infarction.

What might you notice on speculum exam with myoma?

Prolapsed pedunculated submucous myoma may be visible at cervical os.

Risk factors for myoma?

Race: WAD more likely than CW. Early menarche (≤10 years old) Late reproductive age Pre-menopausal status First degree relative with myoma Early OCP use Obesity Nulliparity Current ETOH use Diet high in red meat

What are the benefits of using IUD to treat myoma?

Reduces menstrual bleeding Improves anemia and its sypmtoms effective form of contraceptive

How does mifepristone work in treating myoma?

Reduces uterine volume by 26-74% in women with myomas

What is laparoscopic myomectomy work?

Removal of fibroids through by laparoscopy using 2-3 half-inch incisions. This procedure only works on small fibroids.

What is laparotomy/abdominal myomectomy?

Removal of one or more of the fibroids by an incision made in the abdomen to reach the uterus.

What will happen after GnRH agonists are ceased?

There is rapid resumption of menses and pretreatment uterine volume.

How to GnRH agonists work?

They create a hypogonadotropic, hypogonadal state, clinically resembling menopausal symptoms

What is the most serious complication of GnRH agonists?

osteoporosis after 12+ months of use

What type of myoma is most commonly implicated in inter-menstrual bleeding?

pedunculated

What are some other symptoms of myoma other than menorrhagia?

pelvic pressure and pain