A 32-year-old G5P4 presents with an 8 week history of amenorrhea and suggestive symptoms of pregnancy. Physical examination reveals an irregular, enlarged uterus of 16 weeks size. Ultrasound confirms the presence of an 8 week viable pregnancy and a multiple fibroid uterus.
The correct management for this patient is:
Correct Answer D:
Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal vaginal bleeding (eg, menorrhagia, menometrorrhagia), pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy complications. Diagnosis is by pelvic examination and imaging. Treatment of symptomatic patients depends on the patient's desire for fertility and desire to keep her uterus and may include oral contraceptives, brief presurgical gonadotropin-releasing hormone therapy to shrink fibroids, and more definitive surgical procedures (eg, myomectomy, hysterectomy, endometrial ablation).
Some pregnant women will have fibroids, some of which occasionally interfere with the normal progress of a pregnancy. Though fibroids tend to grow in size during pregnancy, it is unlikely that they will cause any symptoms. Some pregnant women do experience minor symptoms, particularly pelvic pain and light spotting.
The majority of fibroids are of no significance and have no effect upon a woman's fertility, her pregnancy or delivery. Some, however, impinge upon or distort the actual cavity of the uterus and may cause complications in pregnancy, as may a very large fibroid which by virtue of its size distorts the uterus and the other pelvic organs.
What is the commonest type of bleeding encountered with uterine leiomyomas?
Correct Answer C:
Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal vaginal bleeding (eg, menorrhagia, menometrorrhagia), pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy complications. Diagnosis is by pelvic examination and imaging.
Fibroids can cause hypermenorrhea, menorrhagia or menometrorrhagia. If fibroids grow, degenerate, or hemorrhage, or if pedunculated fibroids twist, severe acute or chronic pressure or pain can result. Urinary symptoms (eg, urinary frequency or urgency) can result from bladder compression, and intestinal symptoms (eg, constipation) can result from intestinal compression.
A 36-year-old Asian gravida 1 para 1 presents with pain and bleeding due to a large uterine fibroid confirmed by examination and pelvic ultrasonography. The patient requests treatment but wants to preserve her fertility.
Which one of the following is the best treatment?
In the younger patient who wishes to retain fertility, myomectomy is the surgical treatment of choice in significantly symptomatic uterine fibroids. Uterine artery embolization, while effective, may induce menopause or reduce fertility by decreasing ovarian reserve. It has also been associated with adverse pregnancy outcomes including malpresentation, preterm birth, and postpartum hemorrhage. Although oral contraceptives are useful in dysmenorrhea and dysfunctional uterine bleeding, they are ineffective in symptoms secondary to uterine myomas. GnRH agonists, danazol, and mifepristone are effective medications for symptomatic uterine fibroids. Metformin is useful in the treatment of polycystic ovary syndrome, but not for fibroids.
The following statements are true about uterine leiomyomas, except:
Leiomyomas are generally found only in the reproductive age group. Since they tend to regress after menopause and often grow during pregnancy, estrogen is felt to be stimulatory to their growth. GnRH analogs (choice D) can be used to create a pseudo-menopausal state and suppress their growth.
→ Leiomyomas are much more common in women of African-American descent. (choice A is incorrect)
→ Ultrasound is the most common diagnostic test done. The classic whorl-shaped lesions can be easily seen by this modality along with their location in the uterus. (choice B is incorrect)
→ Most women with fibroids are not infertile, but there is an association with fibroids and infertility. (choice C is incorrect)
→ Most women with fibroids do not have any problems with menorrhagia, pain, infertility, or other conditions. (choice E is incorrect)
A 40-year-old multiparous patient presents with a 10-day history of heavy vaginal bleeding and lower abdominal cramping that began at the expected time of her menses. Pelvic examination reveals a 6-cm mass judged to be a prolapsed submucosal myoma protruding from the cervix on a 1.5 cm stalk. The uterus is enlarged to twice normal size and is mobile. Active bleeding is present, and the patient’s hematocrit is 26%.
Which of the following is optimal management at this time?
The most likely diagnosis is a prolapsed submucous fibroid. If this patient were 80 years old, presenting in the same fashion, one would be suspicious of a stromal sarcoma. Although this could be a carcinoma, the simplest and safest way to stop the bleeding is to remove the mass vaginally (ligate the stalk and then excise) (choice D). The mass can be sent for pathologic evaluation with further therapy is indicated.
→ Although Transfusion and vaginal/abdominal hysterectomy (choice A and choice B) would stop her bleeding, it carries a much higher risk to the patient (blood loss, ureteral injury, bladder injury). Should the mass turn out to be a malignancy, then the wrong procedure may have been done.
→ Biopsy of the mass (choice C) alone will not solve the bleeding. Since the stalk is visible and only 1.5 cm in diameter, then excision of the mass would be the best therapy.
→ High dose birth control pills (choice E) can be used for dysfunctional uterine bleeding. Here, the bleeding is due to a prolapsed fibroid. OCPs will not affect her bleeding and pain.
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