Gynecology Book

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Uterine Fibroid

Aka: Uterine Fibroid, Uterine Leiomyoma, Uterine Leiomyomata, Uterine Myoma
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  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

Uterine Fibroids (C0042133)

Definition (MEDLINEPLUS)

Uterine fibroids are the most common non-cancerous tumors in women of childbearing age. Fibroids are made of muscle cells and other tissues that grow in and around the wall of the uterus, or womb. The cause of fibroids is unknown. Risk factors include being African-American or being overweight.

Many women with uterine fibroids have no symptoms. If you have symptoms, they may include

  • Heavy or painful periods or bleeding between periods
  • Feeling "full" in the lower abdomen
  • Urinating often
  • Pain during sex
  • Lower back pain
  • Reproductive problems, such as infertility, multiple miscarriages or early labor

Most women with fibroids can get pregnant naturally. For those who cannot, infertility treatments may help. Treatment for uterine fibroids includes medicines that can slow or stop their growth, or surgery. If you have no symptoms, you may not even need treatment.

NIH: National Institute of Child Health and Human Development

Definition (NCI) A benign smooth muscle neoplasm arising from the body of the uterus. It is characterized by the presence of spindle cells with cigar-shaped nuclei, interlacing fascicles, and a whorled pattern.
Concepts Neoplastic Process (T191)
MSH D007889
ICD9 218.9, 218
ICD10 D25, D25.9
SnomedCT 154616000, 44598004, 189106003, 95315005
English Myofibroma, UTERINE FIBROMA, UTERUS FIBROMA, Fibroid, Uterine, Fibroids, Uterine, Uterine Fibroids, UTERUS, LEIOMYOMA, FIBROIDS, UTERINE FIBROID, Fibroma, Uterine, Fibromas, Uterine, Uterine Fibromas, Uterus, Fibroid, UTERINE FIBROMYOMA, UTERUS, FIBROIDS, UTERUS, FIBROMYOMA, UTERUS, MYOMA, Uterine Fibroma, Uterine Leiomyoma, Uterine Myoma, Leiomyoma of uterus, unspecified, Uterine leiomyoma NOS, LEIOMYOMA, UTERINE, UL, Uterine leiomyomata, benign leiomyoma of uterus, benign leiomyoma of uterus (diagnosis), Uterine leiomyoma, NOS, fibroid uterus, Uterine fibroid (disorder), Leiomyoma, no ICD-O subtype, Uterine Corpus Leiomyomata, Uterine fibromyoma, Uterine myoma, UTERINE LEIOMYOMA, Uterine leiomyoma NOS (disorder), Leiomyoma of uterus, uterine fibromyoma, fibroleiomyoma, leiomyofibroma, myofibroma, uterine fibroma, fibromyoma, leiomyoma, uterus leiomyoma, Fibroid;uterus, Fibromyoma;uterus, leiomyomas, uterine leiomyoma nos, uterus myoma, Myoma;uterus, uterine fibroids, leiomyoma of uterus, tumor of uterine muscle, uterus fibroid, fibroids, uterine fibromas, uterus fibroids, uterus fibroma, Uterine Leiomyomata, Benign uterine leiomyomas, Fibromyoma, Leiomyofibroma, Leiomyoma, Uterine leiomyoma, Fibroid uterus, Uterine fibroid, Fibroids, Fibroleiomyoma, Leiomyoma of body of uterus, Uterine leiomyoma - fibroids, Uterine fibroids, Leiomyoma, no ICD-O subtype (morphologic abnormality), Uterine leiomyoma (disorder), uterine leiomyoma, uterine leiomyomata, Fibromyoma uterus, fibromyoma; uterus, leiomyoma; uterus, uterus; fibromyoma, uterus; leiomyoma, Leiomyoma, NOS, Uterine Fibroid, Corpus Uteri Fibroid, Corpus Uteri Leiomyoma, Fibroid of Body of Uterus, Fibroid of Corpus Uteri, Fibroid of Uterine Body, Fibroid of Uterine Corpus, Fibroid of the Body of Uterus, Fibroid of the Corpus Uteri, Fibroid of the Uterine Body, Fibroid of the Uterine Corpus, Leiomyoma of Body of Uterus, Leiomyoma of Corpus Uteri, Leiomyoma of Uterine Body, Leiomyoma of Uterine Corpus, Leiomyoma of the Body of Uterus, Leiomyoma of the Corpus Uteri, Leiomyoma of the Uterine Body, Leiomyoma of the Uterine Corpus, Uterine Body Fibroid, Uterine Body Leiomyoma, Uterine Corpus Fibroid, Uterine Corpus Leiomyoma, Body of Uterus Fibroid, Body of Uterus Leiomyoma, Fibroid Uterus, uterine fibroid, fibromyoma of the uterus, uterine myoma
Portuguese FIBROMA UTERINO, Fibromiomas uterinos, Fibromioma uterino, Liomioma do útero NE, Mioma uterino, Útero Fibróide, FIBROMIOMA UTERINO, Leiomioma uterino, Fibróides Uterinos, Fibroma Uterino
Spanish FIBROMA UTERINO, morfología: leiomioma, no clasificado como subtipo en CIE - O, Leiomioma de útero, no especificado, Fibroide uterino, Fibroides uterinos, Fibromioma uterino, Mioma uterino, fibroma uterino, Uterine fibroid, Útero Fibroide, Utero Fibroide, FIBROMIOMA UTERINO, fibroleiomioma, fibromioma, leiomiofibroma, leiomioma del útero (trastorno), leiomioma del útero, leiomioma uterino, SAI (trastorno), leiomioma uterino, SAI, leiomioma uterino, leiomioma, morfología: leiomioma, no clasificado como subtipo en CIE - O (anomalía morfológica), Leiomioma uterino, Fibroides del Útero, Fibroma Uterino, Fibroides del Utero
Italian Leiomioma uterino, Mioma dell'utero, Fibromi dell'utero, Fibromioma dell'utero, Fibroma dell'utero, Leiomioma dell'utero, non specificato
Dutch baarmoederfibroïden, uterus myoom, uterus fibroom, leiomyoom van de uterus, niet-gespecificeerd, uterus fibromyoom, Fibromyoom uterus, fibromyoom; uterus, leiomyoom; uterus, uterus; fibromyoom, uterus; leiomyoom, Leiomyoom van uterus, niet gespecificeerd, uterus leiomyoom, Leiomyoom van uterus, Uterusfibroom, Fibroïd, uterus-, Uterusfibroïd
French Fibromyome utérin, Myome utérin, Léiomyome de l'utérus, non précisé, Fibromes utérins, Fibrome utérin, FIBROMYOME UTERIN, Léiomyome utérin, Fibrome de l'utérus, Utérus fibromateux
German Uterusfibromyom, Uterusfibromyome, Uterusleiomyom, unspezifisch, Uterusmyom, Uterus fibroid, Fibroid, Uterus, FIBROMYOM UTERUS, Leiomyom des Uterus, nicht naeher bezeichnet, Leiomyom des Uterus, UTERUSMYOM, Uterusleiomyom, Fibroide, uterine, Fibrom, Uterus-
Japanese 子宮類線維症, 子宮平滑筋腫、詳細不明, 子宮線維筋腫, シキュウキンシュ, シキュウヘイカツキンシュ, シキュウセンイキンシュ, シキュウルイセンイショウ, シキュウヘイカツキンシュショウサイフメイ, 子宮類線維腫, 子宮平滑筋腫, 子宮筋腫, 平滑筋腫-子宮
Czech Děložní leiomyom, Leiomyom dělohy, blíže neurčený, Děložní fibroid, Děložní fibroidy, Děložní fibromyom, Děložní myom
Korean 상세불명의 자궁의 평활근종, 자궁의 평활근종
Hungarian Méh fibromyoma, Fibroid méh, Méh leiomyoma, Méh leiomyoma, nem meghatározott, Méhfibroidok, Méhmyoma
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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