Indications for Surgical Therapy for Fibroids Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 32
A 44-year-old African American, G3P2012, woman complains of increasing abdominal girth and urinary frequency for the past 6 months. She has noted that she has had difficulty buttoning her pants and has had to buy clothes several sizes larger. She denies dysuria, hematuria, or nocturia. She denies any change in bowel habits. She reports menstrual cycles every 30 days with a flow lasting for 7 days. She has no chronic medical conditions and no family history of gynecologic malignancies. Past surgical history includes a tubal ligation.
The pelvic examination reveals normal external female genitalia. The vaginal and cervix are without lesions. The uterus is 16-week size on palpation, irregular and mobile. Six months ago, the uterus measured 10-week size on examination. The patient’s adnexa are not well palpated due to the midline mass. The rectal examination reveals a 3-cm firm mass that is continuous with the uterus. A pelvic ultrasound reveals multiple hypoechoic densities suggestive of fibroids, the largest measuring 8 cm in the fundal region.
➤ What is the most likely diagnosis?
➤ What are the indications for surgery in the presence of myomas?
➤ What is the best treatment for this patient?
ANSWERS TO CASE 32:
Indications for Surgical Therapy for Fibroids
Summary: This is a 44-year-old multiparous woman has a rapidly enlarging pelvic mass which is most likely due to uterine fibroids. She has symptoms of increasing abdominal girth and urinary frequency. She does not desire more children.
➤ Most likely diagnosis: Uterine leiomyoma.
➤ Indications for surgery: The list of indications is lengthy, here are the common indications:
- Abnormal uterine bleeding not responsive to conservative therapy
- High level of suspicion for pelvic malignancy
- Myoma growth after menopause
- Infertility with distortion of endometrial cavity or tubal obstruction
- Recurrent pregnancy loss due to distortion of endometrial cavity
- Pain or pressure symptoms interfering with quality of life
- Urinary tract symptoms like frequency and/or obstruction
- Iron deficiency anemia secondary to chronic blood loss
- Adnexa cannot be palpated due to uterine enlargement
➤ Best treatment: Hysterectomy, possibly also bilateral salpingoophrorectomy. The route of hysterectomy should be tailored to the situation.
ANALYSIS
Objectives
- Develop a differential diagnosis of a pelvic mass.
- List symptoms caused by leiomyoma.
- List indications for fibroid surgery.
- List surgical treatment options for symptomatic uterine fibroids.
Considerations
This 44-year-old woman has worsening symptoms from her uterine fibroids, specifically the increasing pelvic pressure and menorrhagia. She does not desire more children. Medical therapy does not seem to be effective. Thus, surgical therapy should be considered. Myomas are the most common solid pelvic tumors in women. The benign monoclonal tumors develop from a chromosomal mutation in a single smooth muscle cell of the uterus. Leiomyomas contain fibrous tissue as well as smooth muscle cells and are bounded by a fibrous capsule. Approximately 20% to 40% of women will be diagnosed with a leiomyoma during their reproductive years, and it is the most common indication for hysterectomy.
APPROACH TO
Uterine Fibroids
DEFINITIONS
MEIGS SYNDROME: Benign fibromas of the ovary associated with ascites and pleural effusion.
CARNEOUS DEGENERATION (aka Red degeneration): Necrosis of the leiomyoma that occurs because the myoma has outgrown its blood supply, especially in pregnancy. Clinically, it causes severe pain and local peritoneal inflammation. Carneous degeneration is associated with marked softening and red color of the fibroid. This type of degeneration occurs in 5% to 10% of pregnant women with leiomyomas.
TENESMUS: Ineffectual and painful straining with bowel movement or upon urination.
MONOCLONAL: Originating from a single cell. Monoclonal smooth muscle cells in the uterus that form leiomyoma often have aberrant chromosomes.
CLINICAL APPROACH
Symptoms
Most women with leiomyoma are asymptomatic. However, the size, number, location, and degeneration status of the myomas can determine the symptoms that the patient will experience. Myomas can range in size from subcentimeter to occupying the whole pelvic cavity. They can be subserosal, submucosal, or intramural in location. They can be pedunculated or prolapsed through the cervix. The myoma may become parasitic and derive its blood supply from an organ other than the uterus.
Aside from leiomyoma, other etiology for pelvic masses should be considered in order to plan for surgery. Differential diagnoses for pelvic and lower abdominal masses include follicular cyst, hemorrhagic corpora lutea, serous cystadenoma, benign cystic teratoma, mucinous cystadenoma, malignant ovarian tumors, Meigs syndrome, endometrioma, malignant uterine tumors, metastatic disease, benign or malignant masses of the fallopian tubes, diverticulitis, pregnancy, gestational trophoblastic disease, and adenomyosis.
Women with uterine fibroids may complain of abnormal uterine bleeding, pelvic pressure, and increasing abdominal girth. Although other bleeding patterns can be present, menorrhagia is the most common type of bleeding associated with myomas. Explanation for the cause of menorrhagia includes the obstructive effect of myomas, leading to ectasia of the endometrial venules, which causes congestion in the endometrium and myometrium, contributing to an increase in bleeding during menstrual cycle. The increased surface area from the enlarged uterine cavity can cause menorrhagia. Endometritis is often histologically seen in the endometrial tissue overlying the submucous myoma and can contribute to excessive menstrual flow. Aberrant angiogenesis and dysregulation of local growth factors have been linked to abnormal uterine bleeding in patients with leiomyoma. Persistent abnormal uterine bleeding can lead to iron deficiency anemia due to chronic blood loss.
Pelvic pain is rarely caused by leiomyoma. Myomas can cause acute pain if there is torsion of a pediculated myoma, cervical dilation from a prolapsing pediculated submucosal myoma, or carneous degeneration with pregnancy. More frequently, the pelvic discomfort is described as pelvic pressure. Pelvic pressure and increasing abdominal girth are a result of the enlarging leiomyoma. Urinary symptoms include urinary frequency, outflow obstruction, and compression of the ureters which can result from the myoma pressing on the bladder and pelvic side wall. Gastrointestinal symptoms include constipation and tenesmus which are due to pressure on the rectosigmoid by a myoma on the posterior wall of the uterus. An incarcerated uterus in the posterior culde- sac or a single large posterior wall myoma may cause rectal pressure, but this symptom is rare.
Rarely, myomas have been associated with infertility. When all the other causes of infertility are excluded, 2% to 3% of the infertility cases can be attributed to the presence of myomas. Mechanisms by which myomas can cause infertility include the following:
- Alteration of the endometrial cavity may inhibit implantation.
- Enlarged and deformed endometrial cavity can inhibit sperm transport.
- Displacement of the cervix can block access by ejaculated sperm.
- Alteration in uterine contractility may alter sperm movement.
- Persistent blood or clots in endometrial cavity may inhibit implantation.
- Tubal ostia may be obstructed or distorted.
In patients undergoing in vitro fertilization, decreased rates of implantation and pregnancy were noted in patients who had a endometrial cavity distortedby leiomyomas up to 50% of the time. Recurrent pregnancy losses have also been linked to myomas. Although no prospective studies comparing expectant management to myomectomy in asymptomatic women have been done, most clinicians conclude that surgery does improve pregnancy rates.
Malignancy associated with uterine fibroids is rare. A study done by Parker evaluated 1332 women who underwent hysterectomy or myomectomy for symptomatic leiomyoma; uterine sarcoma (leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor) was found in 0.23%. The incidence of leiomyosarcoma usually increases with age. Women in the reproductive years have a 0.1% risk and women undergoing uterine surgery for myomas have a risk of approximately 1.7%. The possibility of sarcoma in a uterine myoma is 10 times greater in a woman in her 60s than a woman in her 40s. Although malignancy is usually suspected if the leiomyoma displays rapid growth, the incidence of leiomyosarcoma is not related to the rate of growth or the uterine size. Considering the high prevalence of uterine fibroids, most researchers agree that sarcomas arise spontaneously in fibroid uterus. Of note, myomas tend to exhibit an accelerated rate of growth in the fifth decade of life, likely due to unopposed estrogen stimulation from anovulatory cycles in the perimenopausal period.
Some clinicians advocate treatment for asymptomatic uterine myomas if the uterine size is larger than 12 weeks’ size due to inability to palpate the adnexa which may interfere with the detection of an ovarian tumor or cancer.
Summary of clinical settings that may require surgical therapy for myomas includes
- Abnormal uterine bleeding not responsive to conservative therapy.
- High level of suspicion for pelvic malignancy.
- Myoma growth after menopause.
- Infertility with distortion of endometrial cavity or tubal obstruction.
- Recurrent pregnancy loss due to distortion of endometrial cavity.
- Pain or pressure symptoms interfering with quality of life.
- Urinary tract symptoms like frequency and/or obstruction.
- Iron deficiency anemia secondary to chronic blood loss.
- Adnexa cannot be palpated due to uterine enlargement.
Treatment
The choice and approach for therapy should take into account medical and social factors.
Considerations for treatment:
1. Age
2. Parity
3. Desire for childbearing
4. Extent and severity of symptoms
5. Size and number of myomas
6. Locations of myoma
7. Medical conditions
8. Possibility of malignancy
9. Proximity to menopause
10. Desire for uterine preservation
There are various options for management of leiomyomas. These include expectant management, medical management, surgical management, uterine artery embolization, high-frequency ultrasonography, laser treatment, cryotherapy, and thermablation. Surgical management includes hysterectomy and myomectomy. Hysterectomy is the most common treatment for leiomyomas because it is the only therapeutic option that provides a cure and eliminates the chance of recurrence. It is second to cesarean delivery as the most common major surgical procedure performed in women in the United States. Of note, all surgical alternatives to hysterectomy allow for the chance that new myomas may form or leiomyomas that were already present and were too small to be seen or intentionally not removed may grow significantly and may require another procedure. Also, complications from surgical procedures other than a hysterectomy may lead to a hysterectomy. Before proceeding with treatment, it is important to rule out adnexal or endometrial pathology. Pathology in either of these locations will determine which therapeutic option is chosen.
Comprehension Questions
32.1 A 43-year-old G3P3 woman has a 10-week irregular uterus on palpation. No adnexal masses are palpated. She reports normal menstrual cycles and no other symptoms. What is the best treatment for this patient?
A. Expectant management
B. Medical management
C. Myomectomy
D. Hysterectomy
32.2 A 43-year-old G1P1 woman complains of heavy menstrual bleeding lasting for 10 days for 3 months. She feels chronic fatigue. She has been on iron supplements. She has had a BTL and no other medical or surgical conditions. She does not smoke. Her pelvic examination reveals a 16-week size irregularly shaped uterus. Adnexa are not well palpated due to the midline mass. What is the next step in the management of this patient?
A. Expectant management
B. Oral contraceptives
C. Pelvic ultrasound
D. Hysterectomy
32.3 A 35-year-old woman is noted to have an irregular uterus with menorrhagia. The excessive bleeding with fibroids is caused by dysregulation of growth factors, the obstructive effect of leiomyoma, and which of the following?
A. Associated endometritis
B. Coagulopathy
C. Endometrial hyperplasia
D. Carneous degeneration
ANSWERS
32.1 A. Since this patient is asymptomatic, the small uterine myomas do not require treatment. Initially she should be examined every 6 months for uterine growth and the development of symptoms. Annual visits can resume when the clinician is confident that the leiomyomas are not enlarging.
33.2 C. Although this patient’s history and physical are highly suggestive of uterine leiomyoma, other gynecologic conditions should be considered in the differential diagnosis prior to instituting therapy. Since the adnexa were not well evaluated with the pelvic examination, ovarian or adnexal pathology should be ruled out. Pelvic ultrasound is a reliable tool that will evaluate not only the adnexa, but it will
better characterize the location and size of the myomas. The presence or absence of concurrent adnexal pathology may guide the final treatment that the patient receives. Furthermore, the endometrium
in this patient older than 35 years with abnormal uterine bleeding should be evaluated prior to surgery.
32.3 A. Associated endometritis is noted in patient with fibroids and menorrhagia.
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ Most women with leiomyoma will be asymptomatic and will not require treatment (Level A).
➤ Menorrhagia is the most common type of abnormal uterine bleeding associated with leiomyoma (Level B).
➤ If all other causes of infertility are ruled out, in the presence of leiomyoma, a myomectomy can improve fertility outcome (Level B).
➤ Hysterectomy is the only surgical procedure that will not allow myomas to form or allow the previously remaining ones to increase in size (Level B).
➤ Malignancy originating from leiomyoma is very rare (Level A).
➤ Most common differential diagnosis for pelvic mass is leiomyoma, adenomyosis, pregnancy, and adnexal pathology (Level B).
REFERENCES
1. Parker W, Berek J, Fu YS. Uterine sarcoma in patients operated on for presumed leiomyomas and rapidly growing leiomyomas. Obstet and Gynecol. 1994; 83:414-8.
2. Benson CB, Chow JS, Chang-Lee W, Hill JA 3rd, Doubilet PM. Outcome of pregnancies in women with uterine leiomyomas identified by sonography in the first trimester. J Clin Ultrasound. 2001;29:261-264.
3. Buttran VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril. 1981;36:433-435.
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5. Farrer-Brown G, Beilby JO, Tarbit MH. Venous changes in the endometrium of myomatous uteri. Obstet Gynecol. 1971;38:743-751.
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8. Propst AM, Hill JA 3rd. Anatomic factors associated with recurrent pregnancy loss. Semin Reprod Med. 2000;18:341-350.
9. Sehgal N, Haskins AL. The mechanism of uterine bleeding in the presence of fibromyomas. Am Surg. 1960;26:21-23.
10. Seoud MA, Patterson R, Muasher SJ, Coddington CC 3rd. Effects of myomas or prior myomectomy on in vitro fertilization (IVF) performance. J Assist Reprod Genet. 1992;9:217-221.
11. Stewart EA, Nowak RA. Leiomyoma-related bleeding: a classic hypothesis updated for the molecular era. Hum Reprod Update. 1996;2:295-306.
12. American College of Ostetricians and Gynecologists. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas. ACOG Practice Bulletin No. 16. Washington, DC; May 2000.
13. The Practice Committee of the American Society for Reproductive Medicine. Myomas and reproductive function. Fertil Steril. 2006;86(suppl 5):194-199.
14. Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol. 2004;104:393-406.
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