Not all roads point to hysterectomy: treatment options for fibroids MAUREEN KOHI, MD DEPARTMENT OF RADIOLOGY JEANNETTE LAGER, MD DEPARTMENT OF OBSTETRICS, GYNECOLOGY AND REPRODUCTIVE SCIENCES A lady, recently married, wishing above all things to have a child underwent a hysterectomy on account of a single fibroid. Being a woman of strong character, she accepted the blow without complaint, and none but those who knew her well, perceived the tragedy. I was among this number and the grief of it is still keen in me today. Victor Bonney 1937 Overview Uterine Leiomyomas/Fibroids Overview of uterine fibroids Types and classification of fibroids Common presentation Discussion of treatment options Medication Radiology procedures Surgical treatments Hysterectomy is the 2 nd most common surgical procedure in the US 77-80% had fibroids on pathology Causes symptoms in 25% of women of reproductive age Terminology: fibroids=myomas=leiomyomas
Risk factors Appearance Race/Ethnicity 2-3 times increased rate in black women versus white women Medical and Obstetrical history Early menarche increases risk of fibroids Prenatal exposure to DES increases risk of fibroids Parity decreases burden of disease 80% were smaller following pregnancy Dietary habits and lifestyle Suspected increased risk with obesity, alcohol, high glycemic index and vitamin D deficiency Increased relative risk with consumption of red meat and ham Decreased relative risk with green vegetables and fruit (especially citrus) Genetics Familial disposition in some but not all women Increasing evidence of specific susceptibility genes for fibroids Classification of myomas Types of leiomyomas Submucosal Intramural Subserosal
Types of Fibroids Types of leiomyomas Submucosal Intramural Subserosal Submucosal Intramural Subserosal Types of Fibroids Symptoms
Symptoms Reproduction and Pregnancy Bulk symptoms Dysmenorrhea Dyspareunia Pain Heavy menstrual bleeding Infertility Pregnancy loss Pregnancy Malpresentation Placental abnormalities Fetal growth Postpartum hemorrhage Evaluation Ultrasound image History Physical exam Imaging U/S MRI CT Ultrasound image demonstrating 2 uterine fibroids
MRI image CT Large fibroid on this MR image Large fibroid depicted on the CT image CT Treatment options Fibroids can sometime calcify as shown on this CT image Expectant management Medical treatments Surgical treatments Radiological treatments
Expectant management Medical management Levonorgesterel IUD Combination oral contraceptive pills Tranexamic acid Promising medical therapies Letrazole Reduced fibroid volume by 46% in 12 weeks Mifepristone Reduces uterine volume by 26 to 74% Amenorrhea Increased blood count Regrowth occurs after stopping the drug Ulipristal acetate Higher resolution of menorrhagia (91% vs 19%) Significant reduction in fibroid volume 12-21% Case discussion MANAGEMENT
Case 1 Ultrasound/ SIS Kristine is a 35 year old who presents with 6 month history of heavy bleeding. Her menses has been regular but lasted 9 days with heavy bleeding and clots. Her bleeding is so heavy that she wears a super tampon and pad, and still has accidents at work on the first 2 days of her period. Additional hx? Imaging? Submucosal Fibroid on US Submucosal Fibroid on SIS MRI Hysteroscopic myomectomy Submucosal fibroid with >50% of its mass located in the uterine cavity Performed for submucosal fibroids Indications: Abnormal uterine bleeding Desired conception, recurrent miscarriage
Hysteroscopy Hysteroscopic myomectomy Techniques Hysteroscopic resection Using monopolar, bipolar electrosurgery, mechanical or vaporization Case 2 UAE Rebecca is a 40 year old who presents with increasing abdominal girth over the past 5 years. She notes urinary frequency, without dysuria. She also reports constipation. She had 2 normal spontaneous vaginal deliveries and a bilateral tubal ligation. On physical exam she had a 16 week sized uterus, nontender She strongly desires a minimally invasive procedure. Radiologic findings Radiologic treatment options Uterine artery embolization is a minimally invasive therapy for symptomatic uterine fibroids Using a small catheter, the arteries supplying blood to the fibroids are blocked by small beads Once the arteries are blocked, the fibroid will die and shrink in approximately 3 months Procedural success is 85-95%
UAE UAE MRI guided focused ultrasound MRIfUS MR guided focused ultrasound is a novel procedure where high energy ultrasound waves are focused onto a focal point in the fibroid and cause burning an death of the fibroid. MR technology allows us to determine the exact temperature of the focus burned in order to optimize therapy. Completely noninvasive and outpatient.
UAE vs. MRgFUS Laparoscopic radiofrequency ablation There is no randomized data to tell us which of these procedures is better. Case based, patient preference. Insurance coverage is to be considered. FDA approved in November 2012 Components: 3mm RF handpiece Laparoscopic ultrasound Generator with foot pedal Recurrence of symptoms is another concern. L/S RFA Case 4 Renee is a 32 year old who presents because she felt a lump while she was lying in bed. She has noted more urinary frequency. She recently got married and desires children in the next year. Important history Imaging
Prominent fibroid Multiple fibroids Myomectomy techniques Laparoscopic myomectomy Technique Hospital Stay Notes Hysteroscopic Same day discharge Only submucosal fibroids Laparoscopic or robotic assisted laparoscopic 0-1 nights Dependent on location and number Abdominal or open 1-3 nights Multiple or large fibroids
Abdominal myomectomy Case 5 Tanya is a 45 year old who presents with known history of fibroids for several years. Over the last 5 months, she had increasing dysmenorrhea and heavy menstrual bleeding. She feels pressure in her lower abdomen and has a dull pain. She does not desire future childbearing and doesn t want to worry about this issue in the future. Hysterectomy is still an option Conclusions Overview of uterine fibroids Types and classification of fibroids Submucosal, intramural and subserosal FIGO classification Common presentation Discussion of medical options, radiological options (UAE, MRIfUS), LSC RFA and surgical options (hysteroscopic, laparoscopic, robotic-assisted laparoscopic, open myomectomy) Hysterectomy is an option for those patients that desire definitive surgery but is not the only option.
Conclusion UCSF Comprehensive Fibroid Center I do most earnestly estl commend this beneficial efic ial operation, [the myomectomy] my] in the hopes that in the near future, ur removal of a relatively ly young woman s womb on account coun of fibroids ids will, excepting in exceptional circumstances, ces, cease to be perpetrated. petr ed. http://coe.ucsf.edu/coe/fibroid/index.html Victor Bonney.