Alison F. Jacoby
History of present illness
A 45-year-old gravida 2, para 2 presents for a routine well- woman visit. She describes heavier and longer menstrual periods, but thought this was common for women her age.
She does not experience any urinary symptoms or pelvic discomfort. She is sexually active with one male partner and denies dyspareunia. She had a tubal ligation at the time of her second Cesarean section. Her mother had a hysterectomy at age 42 for heavy bleeding. On her last pelvic examination two years ago, no mention was made of an enlarged uterus. She has no other medical problems.
Physical examination
General appearance:Well-developed, well-nourished woman in no apparent distress
Vital signs:
Temperature: 37.0°C Pulse: 74 beats/min
Blood pressure: 128/72 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air BMI: 27 kg/m2
Abdomen:Soft, nontender with a palpable mass extending from the pelvis to midway to the umbilicus, no
hepatosplenomegaly
External genitalia:Unremarkable Vagina:Unremarkable
Cervix:Parous, displaced anteriorly
Uterus:Bulky, mobile, nontender, 14-week size uterus with a prominentfirm smooth massfilling the posterior cul-de-sac
Adnexa:Nontender, no masses Laboratory studies:
Hb: 12.1 g/dL Ht: 36.4%
Imaging:To evaluate the pelvic mass, a transabdominal and endovaginal pelvic sonogram is performed (Fig. 21.1).
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 21.1Transvaginal ultrasound image of myoma.
The uterus measures 14.3 cm in length, 8.9 cm in width, and 7.8 cm in anteroposterior (AP) dimension. A uterine myoma is identified along the posterior uterine body measuring 7.4 × 5.4 × 7.1 cm in diameter. There is displacement of the underlying endometrial cavity. The endometrium measures 8 mm. No freefluid is noted in the cul-de-sac. The left and right adnexa are unremarkable
How would you manage this patient?
The patient has a posterior intramural leiomyoma and increas- ingly heavy periods without anemia. Since her symptoms are manageable and her quality of life is not affected then expect- ant management is an acceptable approach. If her symptoms worsen over time then a number of treatment options are available to her including medical management of heavy bleed- ing, hysterectomy, myomectomy, uterine artery embolization, MR-guided focused ultrasound, and radio-frequency ablation.
Uterine leiomyomas
Uterine leiomyomas, commonly known as fibroids, affect 20–40% of premenopausal women. African-American women are at least three times more likely than white women to develop leiomyomas and to have more numerous and larger leiomyomas. Many leiomyomas are small and asymptomatic, but larger leiomyomas and those in specific locations can cause debilitating health problems. Common symptoms include heavy and prolonged menstrual bleeding, urinary frequency and urgency, dyspareunia, and pelvic pressure. The menstrual cycle typically remains regular and menstrual cramps are infrequent. Patients use terms like pelvic heaviness, pressure, and discomfort rather than pain. The only exception is during an episode of acute leiomyoma degeneration or infarction.
When this occurs, women experience sharp, localized pain lasting from two to four weeks.
Leiomyomas are composed of a benign proliferation of smooth muscle cells and an abundant extracellular matrix of collagens, proteoglycans, andfibronectin. Estrogen, progester- one, and local growth factors stimulate the proliferation of the smooth muscle cells. There is no evidence that leiomyomas can transform into malignant sarcomas. Leiomyosarcomas are extremely rare with an incidence of 2–6 per 1000 cases of presumed leiomyoma. Therefore, when a premenopausal woman presents with typical symptoms and has characteristic ultrasoundfindings, the chance that the leiomyoma is benign is 99.4–99.8%.
Thefirst tenet of leiomyoma management is that treatment is reserved for women with symptomatic leiomyomas that adversely affect their quality of life. Leiomyoma size and rate of growth are irrelevant if a woman is without symptoms.
There is no evidence to support the long-held belief that rapidly growing leiomyomas in premenopausal women are at increased risk for leiomyosarcoma [1].
For women with symptomatic leiomyomas, the number of treatment options has expanded considerably in the last
20 years beyond that of hysterectomy and myomectomy.
New procedures such as uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound (MRgFUS) and radio-frequency thermal ablation (RFA) are examples of less invasive procedures.
Hysterectomy remains the most common treatment for leiomyomas because it provides guaranteed resolution of bleeding and eliminates the possibility of new leiomyoma growth. A number of factors, including uterine size, prior pelvic surgery, and a surgeon’s expertise, dictate whether a hysterectomy can be performed via a laparotomy, laparoscopy, or transvaginally. Data have shown that the majority of women who undergo hysterectomy report improvement in health- related quality-of-life scores and rarely report adverse effects on their sexual function. However, hysterectomy has been associated with a greater likelihood for urinary incontinence and an earlier onset of menopause.
Myomectomy, a procedure in which leiomyomas are sur- gically removed, can be performed by laparotomy, laparos- copy, or hysteroscopy depending on the location, number, and size of the leiomyomas. Although rates of symptom improvement exceed 80%, the risk of persistent or recurrent ultrasound-documented leiomyomas is as high as 62%, and the risk for subsequent major surgery is 9% within 5 years after an abdominal myomectomy. The presence of multiple leiomyo- mas increases the risk for new leiomyoma growth [2]. Trad- itionally, myomectomy was reserved for women who desire future childbearing; however, recently women of all ages are choosing to conserve their uteri despite the chance for persist- ent symptoms and future leiomyoma development.
UAE, first described for the treatment of leiomyomas in 1995, has gained popularity in the United States and Europe. It is performed using conscious sedation, by an interventional radiologist, who introduces a catheter into a patient’s femoral artery and uses real-time fluoroscopic imaging to guide it through the pelvic vasculature and into the uterine arteries.
Small particles of polyvinyl alcohol, injected into each artery, adhere to form an obstruction to bloodflow. With diminished perfusion, the leiomyomas become ischemic, leading to degen- eration and involution. Patient selection is based on uterine size, leiomyoma size, and desire for future childbearing. Cases of ovarian failure and endometrial atrophy following UAE have been described; therefore, UAE should be used with caution for women who are pursuing pregnancy [3].
Observational studies have described the outcomes of more than 3000 patients who have undergone UAE. Overall, the mean reduction in leiomyoma size reported by individ- ual studies ranged from 31 to 52%. Based on patient self- reports, 85–90% experience significant improvement in both bulk-related symptoms and menorrhagia following UAE.
A recent Cochrane review of trials found that women who had UAE and women who had surgery were equally likely to be satisfied with their treatment [4]. However, the UAE group had significantly shorter hospital stays and a quicker return to daily activities. There were no differences in major Case 21: A 45-year-old woman with an enlarging pelvic mass
complication rates. However, within five years of UAE there was a five times increased risk of needing a surgical intervention.
MRgFUS is a promising technology that was approved by the Food and Drug Administration (FDA) for the treatment of leiomyomas in 2004. MRgFUS uses converging sound waves passing through the skin and internal structures to create a focus of intense heat within the targeted tissue. The high temperature results in protein denaturation, coagulative necro- sis, and cell death. Dozens of“sonications”or pulses of sound energy are needed to ablate a leiomyoma.
For the duration of the 2–4-hour outpatient procedure, a woman lays prone with her abdomen positioned over the ultrasound apparatus and within the MR magnet. Pain control consists of narcotics, nonsteroidal anti-inflammatory drugs, and benzodiazepines. The recovery time is minimal with most women returning to full activities in one to two days. Outcome data is still limited to small observational studies with short follow-up. In a series of 130 women with symptomatic uterine leiomyomas treated with MRgFUS, at 3 and 12 months’ follow-up, 86% reported symptom improvement and 13%
reported no improvement [5].
The newest FDA-approved technique for treating symptomatic leiomyomas is RFA. In this procedure, patients undergo a diagnostic laparoscopy and an intra-abdominal sonogram to precisely map the size and location of the leio- myomas. A radio-frequency thermoablation needle is placed percutaneously into the center of the leiomyoma and several prongs are deployed to allow for ablation of the spherical mass.
The target tissue is heated to 95°C. Complete ablation of a 4 cm leiomyoma takes 5 minutes. A series of overlapping ablations can be performed for larger leiomyomas. In several small observational studies, laparoscopic RFA successfully reduced leiomyoma volumes and improved mean health-related quality
of life scores at 3, 6, and 12 months [6]. Recently, a prospective cohort study using transvaginal ultrasound-guided RFA was performed in 69 premenopausal women with symptomatic uterine leiomyomas. An improvement in menorrhagia occurred 1, 3, 6, and 12 months after the procedure.
A variety of minimally invasive procedures aimed at pre- serving the uterus and shortening recovery times have been introduced into the clinical arena. Although these techniques may prove to be effective, due to the small number of patients managed and the limited follow-up time, it is too soon to say whether they are comparable to the more established proced- ures such as hysterectomy and myomectomy.
Key teaching points
Asymptomatic leiomyomas rarely need to be treated.
Leiomyomas are benign in at least 99.4% of premenopausal women.
Rapid growth is not associated with leiomyosarcoma and should not be used as a justification for recommending hysterectomy.
Laparoscopic myomectomy, hysteroscopic myomectomy, and uterine artery embolization are the best-studied minimally invasive therapies for symptomatic leiomyomas, with significant improvement in menorrhagia and health- related quality of life, and infrequent complications.
Magnetic resonance-guided focused ultrasound and radio- frequency ablation are FDA-approved procedures for symptomatic leiomyomas; however, additional outcomes data is needed before they should be widely adopted.
Women who choose hysterectomy have high rates of satisfaction, sexual functioning, and health-related quality of life scores.
References
1. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma.Obstet Gynecol 1994;83:414–18.
2. HanafiM. Predictors of leiomyoma recurrence after myomectomy.Obstet Gynecol2005;105(4):877–81.
3. American College of Obstetricians and Gynecologists. Alternatives to
hysterectomy in the management of leiomyomas. Practice Bulletin No. 96.Obstet Gynecol2008;112:
387–400.
4. Gupta JK, Sinha A, Lumsden M, Hickey M. Uterine artery embolization for symptomatic uterinefibroids.Cochrane Database Syst Rev2012, Issue 5.
Art. No.: CD005073. DOI: 10.1002/
14651858.CD005073.pub3.
5. Gorny KR, Woodrum DA, Brown DL et al. Magnetic resonance-guided
focused ultrasound of uterinefibroids:
review of a 12-month outcome of 130 clinical patients.J Vasc Interv Radiol2011;22:857–64.
6. Garza Leal JG, Hernandez Leon I, Castillo Saenz L, Lee BB. Laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation of symptomatic uterine leiomyomas:
feasibility study using the Halt 2000 Ablation System.J Minim Invasive Gynecol2011;18:364–71.