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

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fibroids ch 20

FibroidsCh 20

2009-2010 Academic Year

MSIII Ob/Gyn Clerkship

Self-Directed Study

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

case study
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

questions to consider
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)

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

slide4
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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

apgo educational topic 53
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

prevalence
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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

symptoms
Symptoms
  • Menorrhagia, metrorrhagia, menometrorrhagia  anemia
  • Pelvic mass
  • Pelvic pressure
  • Bloating (clothes fit tighter)
  • Feeling of heaviness
  • Low Back Pain

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

signs physical exam
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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

slide9
USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

diagnosis
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)

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

us images of fibroids
US Images of fibroids

www.lakeridgehealth.on.ca

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

TreatmentWhen to Operate and When to Wait?

Medical Tx is sometimes first line, followed

by surgical Tx for medical Tx failures.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

treatment options
Treatment Options

Cannot achieve pregnancy during this Tx

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies