UTERINE LEIOMYOMATA


I. Pathophyiology and epidermiology
  1. Benign tumors of smooth muscle
  2. Growth is promoted by estrogen and progesterone
  3. Diagnosed in about 30% of reproductive-aged women; Asymptomatic prevalence likely higher
  4. Peak incidence is in the 5th decade of life
  5. Risk factors include African ancestry and family history
II. Clinical features-Usually asymptomatic
  1. Menorrhagia, sometimes leading to anemia
  2. Pelvic pain
  3. Recurrent pregnancy loss
  4. If very large can cause obstructive symptoms e.g. urinary obstruction
III. Diagnosis
  1. Often suspected on physical exam (enlarged and/or irregularly-shaped uterus)
  2. Ultrasound is often diagnosis; MRI can identify small fibroids; Sonohysterography and hysteroscopy can identify submucosal fibroids
  3. Differential diagnosis includes non-uterine neoplasm (e.g. colon, ovary) or leiomyosarcoma (may be differentiated ins ome cases by MRI features and elevation of LDH, which suggests leiomyosarcoma).
IV. Classification based on locatin
  1. Intramural
  2. Subserosal (if pedunculated may undergo torsion)
  3. Submucosal (may impair fertility)
  4. Intracavitary
  5. Cervical
V. Management
  1. Keep in mind that symptoms usually resolve with menopause
  2. GnRH analogues (e.g. leuprolide) can be useful to shrink fibroids prior to surgery, but menopause-like side effects preclude long-term use
  3. Myomectomy
    1. Often done laparoscopically
    2. Requires general anesthesia and longer length of hospital stay than uterine artery embolization, but better preservation of fertility
    3. 5y recurrence rate 15-30%
    4. May be associated with increased risk of uterine rupture during subsequent labor
  4. Uterine artery embolization
    1. Polyvinyl particles are inserted through a catheter into the branch of the uterine artery that is supporting the fibroid, causing infarction of the fibroid
    2. Decrases size significantly
    3. About 25% of women need a 2nd procedure within 6mos
    4. In a study in 140 pts with symptomatic uterine fibroids randomized to uterine artery embolization vs. (abdominal hysterectomy or, if pt preferred, myomectomy); at 12mos, there was no sig. diff. in quality of life or sx in the two groups; 20% of the embolization group required an additional invasive procedure for continued or recurrent symptoms. ("REST" Trial; NEJM 356:360, 2007--JW)
  1. Hysteroscopic resection (option for submucosal fibroids only)
  2. Myolysis (using heat, laser, or cryotherapy)
  3. MR-guided high-intensity focused ultrasound
    1. High-intensity sound delivered via an array of transducers on the skin
    2. In an uncontrolled study in women with fibroids > 10cm in diameter treated with 3mos of a GnRH-agonist tx'd with focused ultrasound ablation.  Pts had mean 45% reduction in median symptom severity score at 6mos, and 48% at 12mos.  No serious complications noted (Obs. Gyn. 108:49, 2006--JW)
  4. Progestin-containing IUDs may reduce bleeding from submucosal fibroids
  5. Progestin receptor blockers
    1. Ulipristal (Ella)-Decreases bleeding and fibroid size
    2. Asoprisnil-Shown to shrink firboids and reduce sx in uncontrolled trials (FP news 7/1/06 p. 38)
  6. Hysterectomy (definitive therapy but obviously, invasive and eliminates fertility)
  7. Comparisons among treatments for uterine leiomyomata
    1. In a study in 157 women (nonrandomized?) who underwent bilateral uterine artery embolization vs. surgery (hysterectomy or myomectomy), embolization pts had sig. shorter hospital stays and faster resumption of normal activities but at 1y there were no sig. diffs in quality of life (though surgical group had better symptom scores).  10% of embolization pts underwent repeat embolization or hysterectomy during first year of follow-up ("REST" Trial; NEJM 356:360, 2007--JW)
    2. In a study in 28 women undergoing bilateral laparoscopic occlusion of the uterine aa. vs. 28 who underwent bilateral uterine artery embolization, there was no sig. diff. in reduction in bleeding; additional treatment in 6mos following initial therapy was necessary in > 20% of pts (Obs. Gyn. 109:20, 2007--JW)
    3. In a 5y study in 157 women with symptomatic uterine fibroids randomized to uterine artery embolization vs. surgery (about 80% of surgery pts had hysterectomy; 20% had myomectomy), there was no sig. diff in SF-36 quality-of-life measures or in the % of women who indicated they would recommend their treatment to a friend.  However, the embolization group had sig. higher likelihood of reintervention for treatment failure or complications (32% vs. 4%) (BJOG 4/12/11-e-publication ahead of print; http://dx.doi.org/10.1111/j.1471-0528.2011.02952.x-JW)
(Sources includes Core Content Review in Family Medicine, 2012)