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