UTERINE FIBROIDS Hazem Al-Mandeel, M.D Course 481 Obstetrics and Gynecology Rotation

Introduction  Uterine fibroids (leiomyomas) are benign tumors derived from the smooth cells of the myometrium  It’s the most common neoplasm of the uterus (40-50%)  Most fibroids are asymptomatic  It’s one of the most common indication for hysterectomy (with or without abnormal bleeding)  It’s malignant potential is minimal (< 1/1000)

Pathogenesis  Initiation factors are unknown  ? Uterine fibroids grow under the effect of ovarian hormones (E & P)  rarely develop before menarche and seldom enlarge after menopause  Leiomyomas has increased levels of estrogen, progesterone, and growth factors  Fibroids can enlarge during pregnancy

Risk Factors  Increasing age during reproductive years  Ethnic (Black > Caucasian)  Nulliparity  Family History  Higher BMI  Oral contraceptive pills reduced  Depot medroxyprogesterone acetate risk

Clinical Findings  The majority of uterine fibroids cause no symptoms  Symptoms may include: o Pressure symptoms: pelvic pressure, feeling a heaviness in the lower abdomen, lower backache, bladder/bowel sx o Abnormal uterine bleeding: menorrhagia, metrorrhagia, and/or intermenstrual bleeding o Severe pain: secondary to degenerative changes in the fibroids (mostly during pregnancy), Types: ………………. o Pregnancy-related: ?difficulty in conception, or recurrent abortions

Clinical Findings  Uterine leiomyomas may be palpated as a hard, non- tender mass (abdominally or by bimanual exam)  Differential Diagnosis:  Endometrial poly  Ovarian tumors (benign or malignant)  Uterine malignant tumors (e.g. sarcoma)  Pelvic kidney  Tubo-ovarian mass  Diverticular or inflammatory bowel mass  Colon cancer

Diagnosis  Ultrasonography  CT scan of the pelvis  MRI of the pelvis  Endometrial Biopsy (by aspiration or by dilatation and curettage)

Management  If uterine fibroid is asymptomatic and small(found by USS)  repeat ultrasound in 6 months  Medical management: mainly to treat abnormal uterine bleeding o Combined hormonal contraceptive pills o Progestin-only therapy (pills, injection, or IUCD) o GnRH agonists therapy (can reduce the size of fibroid) o Mifepristone (RU 486) (can reduce the size of fibroid)

Surgical Management Desired infertility: embolization or myomectomy Desired uterine preservation or poor surgical candidate: endometrial ablation or embolization No desired fertility or uterine preservation: endometrial ablation or hysterectomy Rapidly growing uterus: hysterectomy