2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study Fibroids Ch 20 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Case Study 41 yo G3P3 AAF presents to clinic with c/o abdominal bloating, pelvic pain, and pressure. C/o feeling her uterus through her abdomen as if she was pregnant, but she had a BTL 8 yrs ago. Menses are q28days with heavy bleeding and large clots, lasting 9 days. Exam reveals a 14-week irregular shape, mobile uterus and normal adnexa bilaterally. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Questions to Consider 1. What is your differential diagnosis? Uterine  Fibroids, adenomyosis, Endometrial cancer Adnexal  Ovarian cancer, ovarian cyst Abdominal  Colon tumor, intestine etiology 2. What are treatment options for women with fibroids? Hormonal therapy (OCPs, Progesterone, GnRH Agonists) Myomectomy (hysteroscopic, laparoscopic, abdominal) Hysterectomy Uterine Artery (Fibroid) Embolization (UAE/UFE) 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies 3. If she was a 22 yo G0P0 how would your recommendations change? Uterine conservation therapy (fertility desires) 4. What makes fibroids get bigger? Smaller? Estrogen, progesterone, Pregnancy Menopause 5. What are risk factors for fibroids? Increasing age, African Am, nulliparity, FMHx 6. How often can fibroids become malignant? Less than 1 per 1000 uteri 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

APGO Educational Topic 53 A. Describe the prevalence of uterine leiomyomas. B. Describe the symptoms and physical findings in patients with uterine leiomyomas. C. Apply diagnostic methods to confirm uterine leiomyomas. D. List the indications for medical and surgical treatment of uterine leiomyomas. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Prevalence 45% of women have fibroids by age 50 Many are asymptomatic Primary indication for hysterectomy 200,000 – 300,000 surgeries per year in USA 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Symptoms Menorrhagia, metrorrhagia, menometrorrhagia  anemia Pelvic mass Pelvic pressure Bloating (clothes fit tighter) Feeling of heaviness Low Back Pain 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Signs (Physical Exam) Abdominal palpation – uterus palpable if larger than 14 week size (correlate size of uterus to gestational sizing) Irregularly shaped uterus on BME, masses move with cervix Nodular uterus (firm, cystic, soft) Recto-vaginal exam – can palpate posterior fibroids 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Diagnosis History and Physical Exam !!!!!!!!!!! Endometrial biopsy Rule out endometrial cancer Ultrasound Can usually identify fibroids on US – will NOT r/o leiomyosarcoma (malignant fibroids) 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies US Images of fibroids www.lakeridgehealth.on.ca 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Treatment When to Operate and When to Wait? Conservative Treatment Desired fertility Declines operative Tx Correct anemia prior to surgery Poor surgical candidate Postmenopausal (depending on sx’s) Hysterectomy Premenopausal No future fertility desires Large uterus (>12-14 week size) Could consider myomectomy if fertility Concern for cancer Renal obstruction Medical Tx is sometimes first line, followed by surgical Tx for medical Tx failures. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Clerkship Self Directed Studies Treatment Options Cannot achieve pregnancy during this Tx 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies