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Not all roads point to hysterectomy: treatment options for ... · PDF file Surgical treatments Terminology: fibroids=myomas=leiomyomas Uterine Leiomyomas/Fibroids Hysterectomy is the

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  • MAUREEN KOHI, MD D E P A R T M E N T O F R A D I O L O G Y

    JEANNETTE LAGER, MD D E P A R T M E N T O F O B S T E T R I C S ,

    G Y N E C O L O G Y A N D R E P R O D U C T I V E S C I E N C E S

    Not all roads point to hysterectomy: treatment options

    for fibroids

    “…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

      Overview of uterine fibroids   Types and classification of fibroids   Common presentation   Discussion of treatment options

      Medication   Radiology procedures   Surgical treatments

      Terminology: fibroids=myomas=leiomyomas

    Uterine Leiomyomas/Fibroids

      Hysterectomy is the 2nd most common surgical procedure in the US   77-80% had fibroids on pathology   Causes symptoms in 25% of women of reproductive age

  • Risk factors

      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

    Appearance

    Classification of myomas Types of leiomyomas

      Submucosal   Intramural   Subserosal

  • Types of Fibroids

      Submucosal   Intramural   Subserosal

    Types of leiomyomas

      Submucosal   Intramural   Subserosal

    Types of Fibroids Symptoms

  • Symptoms

      Bulk symptoms   Dysmenorrhea   Dyspareunia   Pain   Heavy menstrual bleeding

    Infertility Pregnancy

      Pregnancy loss   Malpresentation   Placental abnormalities   Fetal growth   Postpartum hemorrhage

    Reproduction and Pregnancy

    Evaluation

      History   Physical exam   Imaging

      U/S   MRI   CT

    Ultrasound image

      Ultrasound image demonstrating 2 uterine fibroids

  • MRI image

      Large fibroid on this MR image

    CT

      Large fibroid depicted on the CT image

    CT

      Fibroids can sometime calcify as shown on this CT image

    Treatment options

      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%

    M A N A G E M E N T

    Case discussion

  • Case 1

      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

    Ultrasound/ SIS

    MRI

      Submucosal fibroid with >50% of its mass located in the uterine cavity

    Hysteroscopic myomectomy

      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

      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

    UAE

      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

      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.

    MRIfUS

  • UAE vs. MRgFUS

      There is no randomized data to tell us which of these procedures is better.

      Case based, patient preference.

      Insurance coverage is to be considered.

      Recurrence of symptoms is another concern.

    Laparoscopic radiofrequency ablation

      FDA approved in November 2012   Components:

      3mm RF handpiece   Laparoscopic ultrasound   Generator with foot pedal

    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

    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

    Laparoscopic myomectomy

  • 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

    I do most earnestly commend this beneficial operation, [the myomectomy] in the hopes that in the near future, removal of a relatively young woman’s womb on account of fibroids will, excepting in exceptional circumstances, cease to be perpetrated. Victor Bonney.

    CConcllusiioonn

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    UCSF Comprehensive Fibroid Center

      http://coe.ucsf.edu/coe/fibroid/index.html