Uterine Fibroid

Aka: Uterine Fibroid, Uterine Leiomyoma, Uterine Myoma

1. Epidemiology
   1. Most common solid pelvic tumor in women
   2. More common in non-white women
2. Risk factors: Positive (increased risk of fibroids)
   1. Overweight women (increased Body Mass Index)
   2. Advancing age
      1. Age 20-30 years: 4% fibroid Incidence
      2. Age 30-40 years: Up to 18% fibroid Incidence
      3. Age 40-60 years: 33% fibroid Incidence
   3. Hyperestrogenic states or Estrogen agonist use
      1. Enlarge in pregnancy (and regress after Menopause)
   4. Black women with higher Incidence
      1. Larger fibroids
      2. More symptomatic fibroids
   5. Comorbid Hypertension
   6. Family History of Uterine Fibroids
   7. Nulliparity
3. Risk Factors: Negative (lower risk of fibroids)
   1. Five pregnancies or more
   2. Menopause (fibroids typically regress)
   3. Oral Contraceptive or Depo Provera use
   4. Tobacco Abuse
4. Pathophysiology
   1. Benign tumors arising from myometrial smooth muscle
      1. Malignant leiomyosarcoma is uncommon (0.23%)
   2. Hormonally mediated
      1. Enlarge with Estrogen and Growth Hormone
      2. Regress with Progesterone
   3. Types of leiomyoma
      1. Subserosal leiomyoma
      2. Intramural leiomyoma
      3. Submucous leiomyoma
5. Symptoms (20-50% of fibroid disease is symptomatic)
   1. Symptoms with fibroids: Well supported by literature
      1. Menorrhagia (prolonged or heavy menstrual flow)
         1. Fibroids are most common cause of Menorrhagia
      2. Pelvic pressure or Pain Sensation (large fibroids)
         1. Pelvic discomfort
         2. Urine symptoms
         3. Constipation
         4. Exacerbated by pregnancy (see below)
   2. Symptoms with fibroids: Controversial
      1. Infertility
      2. Pregnancy complications
         1. Recurrent Miscarriage
         2. Premature labor
         3. Fetal Malpresentation
         4. Labor complications
         5. Placental Abruption
6. Signs
   1. Abdominal exam
      1. Uterus palpable above symphysis pubis
   2. Bimanual examination
      1. Enlarged, mobile and irregular uterine contour
7. Differential Diagnosis
   1. Adenomyoma
   2. Malignant Leiomyosarcoma (0.23% of fibroids)
8. Diagnostics
   1. Transvaginal Ultrasound
      1. Best initial test due to cost efficacy
      2. Least Test Sensitivity and Specificity
   2. Pelvic MRI
      1. Best for fibroid mapping preoperatively
      2. Expensive
   3. Sonohysterography or hysteroscopy
      1. Good Test Sensitivity and Specificity, but invasive
9. Management: Surgery
   1. Hysterectomy
      1. Fibroids account for up to 33% of hysterectomies
      2. Indications
         1. Postmenopausal women with enlarging fibroids
         2. Peristent Abnormal Uterine Bleeding
         3. Symptomatic fibroids refractory to other measures
   2. Myomectomy
      1. Performed with hysteroscopy, laparoscopy, robotic-assisted or laparotomy
      2. Excision of fibroids with preservation of Uterus
      3. High risk of recurrence (15-30% in 5 years)
      4. Indications
         1. Submucosal Fibroids in women who want to preserve fertility (hysteroscopic)
   3. Uterine Fibroid Embolization
      1. Uterine arteries occluded with polyvinyl Alcohol foam (or other embolic agents)
         1. Incomplete embolization used now to reduce pain
         2. Intervention radiology procedure under IV Sedation
         3. Well tolerated (less painful than surgery)
      2. Second procedure required in 28% of cases
      3. References
         1. McLucas (2001) J Am Coll Surg 192:100
         2. Edwards (2007) N Engl J Med 356: 360-70
         3. Van der Kooij (2010) ACOG 203(105): e1-13
   4. Myolysis
      1. Fibroid destruction by Nd-YAG laser or bipolar needle
      2. Often combined with endometrial ablation
      3. Recurrence rate not yet established
      4. Indications
         1. Fibroids in women who want to preserve fertility
10. Management: Medical
    1. Observation (preferred for asymptomatic cases)
    2. GnRH agonists (induce hypoestrogenism)
       1. Results in Amenorrhea and fibroid mass reduction
       2. Fibroids recur when medication stopped
       3. Hypoestrogenic side effects (Hot Flushes, BMD risk)
       4. Used in combination with Progesterone
          1. Reduces Hot Flushes (vasomotor symptoms)
    3. Progesterone receptor-binder (Mifepristone)
       1. Mifepristone 5 mg daily
          1. Eisinger (2003) Obstet Gynecol 101:243-50
          2. Fiscella (2006) Obstet Gynecol 108:1381-7
    4. Other investigational measures
       1. Raloxifene (Evista)
       2. ExAblate 2000
          1. Uses combination of Ultrasound and MRI
          2. Focused coagulation necrosis of fibroids
    5. Agents effective in Menorrhagia but are not typically effective at reducing fibroid size
       1. Androgenic agents (e.g. Danazol)
       2. Levonorgestrel IUD
       3. Progestins (e.g. Depo Provera)
       4. Oral Contraceptive cycling (not effective)
       5. Tranexamic Acid (Lysteda)
11. References
    1. Stewart (2012) Mayo POIM Conference, Rochester
    2. Evans (2007) Am Fam Physician 75:1503-8
    3. Myers (2002) Obstet Gynecol 100:8-17
    4. Rackow (2006) Gynecol Clin North Am 33:97-113