Uterus myomatosus A.J. Henriquez March 14, 2015 Uterus myomatosus Definition, incidence, clinical presentation and diagnosis. New FIGO classification for uterine leiomyomas Brief description on treatment modalities and what do we have available in Curacao. Should we treat asymptomatic leiomyomas and what are the recommendations for follow up. GnRH agonist use preoperatively. Is it necessary? Ulipristal: a promising new preoperative treatment modality When to suspect a uterine sarcoma Saludos, Igor Introduction Causes? Introduction Genetic changes Hormones Race Family history Higher education Incidence Clinical presentation 3 out of 4 women Most common solid pelvic tumor in women Solitary vs multiple Growth rate vary Range in size 1
Symptoms: Clinical presentation Symptoms: Clinical presentation Heavy menstrual bleeding Prolonged menstrual periods, > 7 days Pelvic pressure or pain Frequent urination / difficult to empty bladder Constipation Backache or leg pain Acute pain: rarely Heavy menstrual bleeding Prolonged menstrual periods, > 7 days Pelvic pressure or pain Frequent urination / difficult to empty bladder Constipation Backache or leg pain Acute pain: rarely Terminology & location Terminology & location Traditional classification Traditional classification Submucosal Submucosal Intramural Intramural Subserosal Subserosal Terminology & location FIGO classification Pelvic exam Speculum exam 2
Imaging Ultrasound (transabdominal / transvaginal) Imaging Saline infusion sonography 3
Imaging Diagnostic hysteroscopy Imaging MRI 4
When to treat? Medical: Myomectomy: Birth control pills Depo-provera GnRH-agonist LNG-IUD Progesterone-modulator Laparotomy Preservation of the uterus Recurrence of fibroids 5
Myomectomy: Laparoscopic < 6 cm, not too much, not too deep Increased risk of uterine rupture during subsequent pregnancy Myomectomy: Hysteroscopic Submucosal fibroid 1 or more tempi Uterine artery embolization: 40% reduction of the largest fibroid Quicker return to routine activities Beneficial effect on menstrual duration, dysmenorrhea Reoperation rate 30% vs 3% in myomectomy group first 5 years Pregnancy after UAE? 6
MRI-guided focused ultrasound surgery: Non invasive approach Ultrasound energy produces regions of cell damage / necrosis Use in research setting Hysterectomy: Last option? Fibroids leading cause of hysterectomy for larger uteri Definitive treatment 7
2013 2014 Abdominal hysterectomy 235 243 Vaginal hysterectomy 22 31 Laparoscopic hysterectomy 22 35 Abdominal myomectomy 24 30 Laparoscopic myomectomy 1 1 Hysteroscopic myomectomy 47 54 Asymptomatic leiomyomas Uterine sarcoma Expectative management Small fibroids Nearing menopause Growing fibroids Desire for pregnancy in the future 2 3 cases / 1000 Rapidly growing fibroids? Endometrial biopsy MRI Uterine sarcoma Uterine sarcoma leiomyoma leiosarcoma Risk factors: Fibroid growth during postmenopausal period Age History of prior pelvic radiation Use of Tamoxifen Renal cell carcinoma syndrome Int J Womens Health, 2014 Jan 29;6:95-114, Khan AT et all 8
Uterine sarcoma Necessity to treat leiomyomas pre-operatively Do leiomyomas progress to sarcoma? No, sarcomas arise independently GnRH-agonists, given 3-4 months preoperatively -30 to 40% volume reduction Is it necessary to treat all patients planned for hysterectomy / myomectomy? Necessity to treat leiomyomas pre-operatively Necessity to treat leiomyomas pre-operatively Cochrane Database: Personal opinion: GnRH before surgery for leiomyomas, if Pre-and postoperative hemoglobin and hematocrit were significantly improved by GnRH agonist therapy prior to surgery Uterine volume, uterine size and fibroid volume were all reduced Hysterectomy appeared to be easier after pre-treatment with GnRH-agonist therapy Operating time was reduced Duration of hospital stay was reduced Blood loss and rate of vertical incision were reduced both for myomectomy and hysterectomy multiple or large fibroids If the uterus is huge If the Hb is low Jehovah witness To gain some time Cochrane Database Syst Rev. 2001;(2):CD000547, Lethabt et all Ulipristal (UPA): promising treatment modality? Advantages of UPA Pearl I Randomized, double blind, placebo-controlled Inclusion criteria: heavy menstrual bleeding, anemic, Iron During 12 weeks Hysterectomy myomectomy uterine artery embolization It s faster than the GnRH-agonists in reducing bleedings Significantly improves Hb and Ht in anemic patients Significant reduction in fibroid size, lasting > 6 months after treatment Better tolerated compared to GnRH analogues Estradiol levels in midfollicular range UPA 5mg UPA 10mg placebo Uterine bleeding controlled 91% 92% 19% Amenorrhea 73% 82% 6% Changes in fibroid volume -21% -12% +3% Pain reduction + + - Headache / breast tenderness: not significantly more frequent than with placebo Drug Des Develop Ther, 2014 Feb 20; 8:285-292, Biglia et all 9
Pearl II Randomized, double blind Inclusion criteria: heavy menstrual bleeding, anemic, Iron During 12 weeks Symptomatic patients 4 sequential courses of UPA 10mg Pearl III UPA 5mg UPA 10mg Lupron Uterine bleeding controlled 90% 98% 89% Median time to amenorrhea 7 days 5 days 21 days Volume reduction -36% -42% -53% Hot flashes 11% 10% 40% UPA longer sustained effect on the reduction of fibroids during 6 months, compared to Lupron Control of bleeding achieved sooner after each course Amenorrhea rate increased after every additional course With each additional course significantly more patients with fibroid reduction > 50% QoL Pain Treatment with UPA Treatment with UPA Take home message(s) Fibroids are very common among our female population Non-cyclical abdominal pain is very seldom caused by fibroids When suspecting an uterine fibroid and diagnosis is needed, ask for the size and localization of fibroids 10
Update in Obstetrics and Gynecology 2015 Hilton Curacao March 13-15, 2015 11