ISSUES IN OFFICE GYNECOLOGY
| FIBROIDS: HOW TO TREAT— Wesley C. Fowler, Jr, MD, Professor and Vice Chair, and Director, Division of Gynecologic
Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill. School of Medicine
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| Introduction: numerous terms, eg, myomas, fibroids, fibromyomas, and leiomyofibromas; most common pelvic tumor
in women; highest prevalence in fifth decade; incidence higher in black women (50%) than white women (25%); 20% to
40% of women in reproductive years; most common indication for hysterectomy; unknown why fibroids develop in some
women and not in others (possible genetic predisposition); vary greatly in size and location
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| Etiology: unclear; each tumor arises from single cell, ie, each myoma of monoclonal origin; ≈60% have normal karyotypes;
≈40% have abnormal karyotypes with lower DNA; believed to be somatic mutation of normal myometrium under
influence of estrogen, progesterone, and local growth factors; malignant transformation to leiomyosarcoma rare; targeted
therapy at forefront of treatment; sarcomas probably arise de novo; pressure from enlarging myomas, pain, and abnormal
uterine bleeding most common symptoms; abnormal bleeding—present in ≈30% of patients; bleeding patterns vary;
may be due to disturbance in microcirculation of endometrium
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| Diagnosis: routinely made with bimanual examination of pelvis and vaginal ultrasonography (US); magnetic resonance
imaging (MRI) and computed tomography (CT) used only with high index of suspicion for sarcoma; hysteroscopy indicated
if hysteroscopic resection planned; indications for management—abnormal uterine bleeding that cannot be controlled,
high level of suspicion for malignancy, infertility associated with distortion of endometrial cavity, pain or
pressure symptoms, urinary tract symptoms, and anemia secondary to blood loss; size alone not indication for surgery
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| Medical therapy: antiprostaglandins, low-dose oral contraceptive pills (OCPs; reestablish microcirculation of endometrium)
and progesterone (evidence suggests increases fibroid size); gonadotropin-releasing hormone (GnRH) agonist
(leuprolide)—produces hypogonadotropic, hypogonadal state; most patients develop amenorrhea; reduces size of
myoma 35% to 50%; side effects restrict long-term use; rapid regrowth of fibroid after discontinuation; useful for preoperative
shrinkage; side effects include hot flushes (add-back estrogen therapy may help), acne, accelerated bone loss (recovered
on discontinuation), and atrophic vagina; mifepristone (RU486)—antiprogesterone and antiglucucorticoid; preliminary
studies promising; data show decrease in size of fibroids (30%-70%), uterine bleeding, and dysmenorrhea; some patients have
transient increase in transaminases, endometrial hyperplasia, and hot flushes (with higher doses); long-term effects unknown;
preoperative shrinkage, fertility preservation, and older age (buys time until menopause) major indications for use; data show
≈50% reduction in size of fibroids in patients taking 5 mg or 10 mg daily over 12-mo period; 65% of patients became amenorrheic
at 6 mo; simple hyperplasia occurred in patients taking 10 mg; asoprinsil (J867)—experimental in treating fibroids;
selective progesterone receptor modulator; agonist and antagonist; tissue-selective progesterone activity; induces amenorrhea
by targeting endometrial vasculature; selective inhibition of endometrial proliferation; does not terminate pregnancy; used in
treatment of endometriosis; does not inhibit estrogen levels; effective in shrinking fibroid volume
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 | Hysterectomy: mainstay of therapy for fibroids; definitive procedure; most common indication for hysterectomy (30%
white and 50% of black women); eliminates symptoms and chance for recurrence
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| Myomectomy: option for patients desiring future pregnancy and patient wishing to retain uterus; use in infertility patients or
those experiencing repeated pregnancy loss; patient should have no other likely explanation for failure to conceive or recurrent
pregnancy loss; laparoscopic myomectomy—≈50% of patients develop new myomas 5 yr after myomectomy,
≈25% require second surgical procedure; complications increase with number of myomas removed; open
myomectomy—recurrence rate ≈5% to 30% (depends on skill of surgeon); recurrence rate may be higher in patients
treated preoperatively with GnRH agonist; most myomas encapsulated (can be “shelled” out); consider sarcoma if fibroma
difficult to shell out; layered closure of uterus recommended; subcuticular closure recommended to prevent adhesions;
laparoscopic myomectomy—requires careful patient selection; procedure not suitable for fibroids >5 to 7 cm or
if fibroid adjacent to uterine artery or tubal cornua; robotic myomectomy—same indications as laparoscopic myomectomy;
allows for easier dissection and suturing than laparoscopy; hysteroscopic myomectomy—limited to submucous
myomas <4 cm diameter; ≈50% of fibroids should be intracavitary; data show effectiveness decreases with duration of
follow-up; effectiveness of procedure enhanced by concurrent endometrial ablation; small study showed 60% pregnancy
rate after procedure in previously infertile women
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| Myolysis: laparoscopic thermal coagulation or cryoablation; easier to perform than resection; increased chance of adhesion
formation; should be limited to women with ≤4 myomas <10 cm; option only for women who have completed childbearing
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| Uterine artery embolization (UAE): nonsurgical, minimally invasive procedure; shorter recovery period; effective with
minimal complications; ideal candidate premenopausal woman with fibroids causing symptoms who wishes to preserve
uterus and does not want hysterectomy or myomectomy; destroys myometrial blood supply; performed under
conscious sedation; both uterine arteries accessed via single femoral arterial puncture; bilateral embolization performed
to destroy collateral circulation; embolic material injected under gravity flow; uterine arteries may not need to
be blocked entirely (need to block only vessels supplying fibroid); embolic materials— polyvinyl alcohol (PVA) particles
ground from blocks of foam and separated into different sizes; capable of penetrating myoma blood supply and
blocking it (may block uterine artery completely); gelatin sponge particles (Gelfoam) usually result in complete blockage
of uterine artery (not sure of recanalization); Embosphere microspheres (tris-acryl gelatin) have little tendency to
clump after injection; less tissue reaction than PVA particles; initial data suggest Embosphere microspheres likely to
block fibroid vessels without closing all uterine arteries; almost 95% improvement in menstrual bleeding; ≈95% improvement
in pelvic pressure and bulk-related symptoms; 35% to 50% uterine and fibroid volume reduction; fibroid
registry data—show no improvement in ≈5% of patients, follow-up hysterectomy in ≈3% of patients, and ≈7.5% of
patients becoming amenorrheic (80% >45 yr of age); majority of patients reported being satisfied with procedure;
complications—groin hematomas, postprocedure pain, transvaginal expulsion of fibroids (usually 2-3 wk after procedure),
uterine rupture requiring hysterectomy, sepsis requiring surgery, and death (2 per 10,000 procedures); buttock
necrosis reported; permanent amenorrhea and/or ovarian failure (2%-3%, 15% in women ≥45 yr of age); persistent
vaginal discharge probably due to infarcted myoma communicating with endometrial cavity; ovarian failure <1% if patient
<40 yr of age and ≈50% if >50 yr of age; most failures occur within first year; postembolization syndrome—
pain, nausea, vomiting, fever, and leukocytosis (caused by tissue ischemia and infarction of fibroid); manage with antipyretics,
fluids, and pain medication; pregnancy outcomes—not recommended for patient desiring pregnancy; little
data, but successful pregnancies reported; data suggest increased risk for preterm delivery and malpresentations; no reports
of uterine rupture during pregnancy; abnormal placentations reported; procedure costs significantly more than
other surgical options because of imaging studies performed before and after procedure
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| Focused ultrasound ablation (ExAblate): uses focused US under MRI guidance; 3-hr procedure; known side effects include
leg pain, skin burn, nerve damage, and bowel symptoms
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| Future options: inhibitors of angiogenesis (targeted therapy), ultrasound-guided high-intensity focused US, regulation
of growth factors, targeted selective estrogen receptor modulators (SERMs), and prevention; transient uterine artery
occlusion—Doppler-guided transvaginal clamp to occlude uterine artery for 6 hr; outpatient procedure; single case report
decreased fibroid by ≈50%
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| DECISION-MAKING IN HYSTERECTOMY —Rosanne M. Kho, MD, Senior Associate Consultant, Department of Gynecology,
Mayo Clinic, Scottsdale, AZ
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| Introduction: most common surgical procedure performed in women; >600,000 hysterectomies performed annually; by
60 yr of age, 1 of 3 women in United States have undergone hysterectomy; 85% of hysterectomies elective
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| Indications for elective hysterectomy
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| Fibroids: affect 30% of women by 30 yr of age; risk for sarcoma <1 in 1000 women; possibility of developing symptoms
small; observation only may be appropriate; repeat pelvic examination and transvaginal US 4 to 6 mo; increased size
raises suspicion for possibility of sarcoma; high index of suspicion if MRI with gadolinium shows markedly increased uptake;
increased lactate dehydrogenase (LDH) isoenzymes; medical options include OCPs and GnRH agonists; surgical
options include myomectomy, UAE, and hysterectomy
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| Adnexal mass: premenopausal patient with single simple cyst (3-4 cm)—repeat US in 6 to 9 wk; if cyst still present
and patient has no symptoms, repeat US in 4 to 6 mo; possibility of torsion higher with cyst >5 cm; risk for malignancy
rare; surgery option for patient experiencing pain and discomfort (laparoscopy recommended); postmenopausal
patient—data showed simple cyst in 18% of postmenopausal women, risk for malignancy <0.1%, with 70% chance of
cyst resolving spontaneously; management options include observation and obtaining CA-125; high index of suspicion
with findings on US and elevated CA-125; laparoscopy recommended if patient desires surgery; studies show 10% to
15% risk for future surgery with removal of single ovary; discuss option of hysterectomy with patient
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| Recurrent abnormal Papanicolaou (Pap) tests with cervical stenosis: hysterectomy may be indicated for woman who has
had loop electrosurgical excision procedure (LEEP) conization; options include repeat Pap test and colposcopy; counsel
patient colposcopic examination limited (risk of missing high-grade lesion further up in canal; another option is to
perform LEEP or hysterectomy)
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| Complications associated with hysterectomy: data show mortality rate low (1.6 per 1000 women), with few major
complications; hemorrhage—average blood loss ≈400 mL; risk for excessive bleeding 3%; risk of requiring blood transfusion
<1%; infection—without prophylactic antibiotics, postoperative fever in 1 of 3 women and 9% with prophylactic
antibiotics; urinary tract infection (UTI) can occur in 5%; prompt removal of urinary catheter minimizes risk; injury to
other abdominal organs—12% of ureteral injuries and 35% of bladder injuries not identified intraoperatively before
cystoscopy; at speaker’s institution, cystoscopy performed routinely immediately after hysterectomy to identify genitourinary
injury; risk for bowel injury, particularly in patients with dense adhesions; thromboembolism—risk 0.2% in low-
risk patients and 2.4% in high-risk patients; preventive measures include sequential compression devices, low-dose heparin,
and early ambulation
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| Route of surgery: 65% of hysterectomies in United States performed abdominally; fewer complications and less operative
time with vaginal hysterectomy; subtotal supracervical hysterectomy—trial involving 279 women showed early
discharge from hospital and lower rate of infection among women undergoing abdominal subtotal supracervical hysterectomy;
7% of women had vaginal cyclic bleeding; trial also showed no difference in bladder, bowel, or sexual function;
another trial involving 135 women showed no difference in surgical complications, sexual function, or quality of life; Danish
trial showed cyclic bleeding in 20% of women who had subtotal hysterectomy (rate of urinary incontinence also
higher); studies have not shown advantages of subtotal hysterectomy medically, surgically, or in sexual function; risk for
vaginal bleeding 7% to 20%; future trachelectomy—data show 23% of women undergoing subtotal hysterectomy required
follow-up trachelectomy because of endometriosis, bleeding, and pain; Mayo Clinic study showed pelvic prolapse
most common indication for trachelectomy after subtotal hysterectomy
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| Oophorectomy: postmenopausal woman—risk for ovarian cancer ≈1 in 70 women; those >65 yr of age have increased
risk; recommended for postmenopausal woman; data show advantage of continued ovarian androgen production small
compared to greater risk for ovarian cancer; premenopausal woman—counsel about advantages of continued endogenous
ovarian production, compared to long-term effects of estrogen therapy; consider patient’s age, surgical difficulty,
and risk for ovarian cancer; risk for ovarian cancer 80% in BRCA1 or BRCA2 carriers; risk for extraovarian
primary peritoneal cancer 2%; family risk, personal medical history, and self-image additional factors to consider;
oophorectomy at time of hysterectomy may eliminate future surgeries and provide relief of symptoms, eg, cyclic menstrual
migraine, seizure activity, severe premenstrual dysphoric disorder (PMDD); disadvantages include need for hormone
replacement therapy (HRT), decreased libido, and risk for atherosclerosis (may be other factors that increase this
risk)
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| Psychosexual issues after hysterectomy and oophorectomy: data show improvement in mood and quality of
life, increased frequency of sexual activity, and decreased problems with sexual function; development of hot flushes,
weight gain, depression, anxiety, and lack of interest in sex reported
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| Pelvic organ prolapse and incontinence: at speaker’s institution, Mayo culdoplasty performed routinely at time of
hysterectomy to reduce risk; 2 studies show increased risk (can be as high as 60% for urge incontinence); 2 long-term
studies show no increased risk for stress or urge incontinence
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Educational Objectives
| The goal of this program is to educate the listener about the management of patients with fibroids and counseling issues pertaining
to elective hysterectomy. After hearing and assimilating this program, the clinician will be better able to:
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| 1. List the indications for the management of fibroids.
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| 2. Summarize the medical options available for the treatment of fibroids.
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| 3. Summarize surgical options for fibroids and their appropriateness for specific patient groups.
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| 4. List indications for elective hysterectomy.
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| 5. Counsel patients considering hysterectomy about oophorectomy at time of hysterectomy, and sexual functioning and
pelvic organ prolapse after hysterectomy.
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Discussed on This Program
Leuprolide acetate [Eligard, Lupron, Lupron Depot, Lupron Depot – 3 month, Lupron Depot – 4 month, Lupron Injection,
Lupron Depot-Ped, Lupron for Pediatric Use, Viadur]
Mifepristone (RU-486) [Mifeprex]
Suggested Reading
Eisinger SH et al: Twelve-month safety and efficacy of low-dose mifepristone for uterine myomas. J Minim Invasive
Gynecol 12(3):227, 2005; McPherson K et al: Severe complications of hysterectomy: the VALUE study. BJOG ;
Parker WH et al: Patient selection for laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2(1):23, 1994;
Sharp HT: Assessment of technology in the treatment of idiopathic menorrhagia and uterine leiomyomata. OB/Gyn
108(4):2006
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Dr. Fowler was recorded at the 37th Annual Ob/Gyn Spring Symposium, sponsored by the Medical University of South
Carolina and held March 27-29, 2006, in Charleston, SC. Dr. Kho was recorded at Women’s Health 2006, sponsored by
the Mayo Clinic College of Medicine and held March 9-11, 2006, in Phoenix, AZ. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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