In this activity, Dr. Linda Bradley reviews risk factors for uterine fibroids, the use of TVS,
SIS, and MRI for diagnosis, and nonsurgical options that can help relieve symptoms associated with these bothersome growths.
Welcome to CME on ReachMD. This activity, entitled Uterine Fibroids: Focus on Medical Management is provided by Omnia.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
Thank you for joining us. This is CME for ReachMD. I’m Dr. Linda Bradley. During this program, we will look at the presentation of uterine fibroids, techniques for diagnosis and counseling, and medical treatments that can help reduce symptoms and increase the quality of life for patients.
Leiomyoma, or uterine fibroids are the most common uterine growths found in women. They are influenced by hormones. While our understanding of uterine fibroids is incomplete, we do know that they are an equal opportunity disease affecting all women across ethnic and racial categories.
Using ultrasound imaging, we know that by the age of 50 years, that 70 to 80% of women demonstrate imaging findings consistent with uterine fibroids. Fortunately, most women have no symptoms. Among the women with fibroids who present with symptoms, the following chief complaints may encourage a woman to see us in our office. These include abnormal uterine bleeding, including heavy, prolonged or aberrant bleeding, passage of blood clots, as fibroids enlarge, pelvic pain, dysmenorrhea, and lower back pain may ensue, bulk symptoms from enlargement of uterine fibroids, including pressure on the bladder with urinary frequency, urgency and urinary retention, and bowel complaints, including constipation, tenesmus, and straining to affect a bowel movement with the development of hemorrhoids. Due to uterine volume increase, patients may note an increase in abdominal girth with the complaints of looking pregnant or feeling an abdominal mass. Infertility may be associated with uterine fibroids. Patients may experience painful sex. Risk factors associated with the development of uterine fibroids include women of the African diaspora, family history, obesity and overweight, low vitamin D levels, nulliparity, increased age and early menarche.
As healthcare providers who see women with fibroids, it is critical to assess the impact on the quality of life that a symptomatic patient experiences. Query and determine if your patient has any of these concerns. Is she socially embarrassed by flooding blood, gushing blood, clotting, having accidents? Does she experience disruption, decrease or curtail activities including her work, hobbies, and sexual function? Does she experience mood changes due to impairment of activities due to body image or overall health?
So how do we diagnose fibroids? Once the diagnosis of fibroids is suspected by history and/or physical examination, confirmation of the etiology of her symptoms requires imaging. Hysteroscopy, transvaginal ultrasound and saline infusion sonohysterography, or SIS are most commonly used.
Transvaginal ultrasound and saline infusion sonogram are helpful to exclude the possibility of other uterine or adnexal masses. Transvaginal ultrasound has high sensitivity, about 95 to 100% for detecting myomas and uteri that are less than 10 week size. However, localization of unique fibroids is not as accurate and is limited when a patient has a uterine size of greater than 10 weeks gestational size or when there are innumerable fibroids. Transvaginal ultrasound technology is the most widely used modality due to its availability and cost-effectiveness. Saline infusion sonography or sonohysterography improves characterization of the extent of protrusion into the endometrial cavity by submucous myomas and allows identification of intracavitary lesions, not seen on routine ultrasonography. By using SIS, a gynecologist can adopt the FIGO classification which elucidates individual fibroid size, but more importantly, location of uterine fibroids and the relationship to the endometrial cavity. CT scan imaging has little clinical utility in delineating the position of fibroids relative to the endometrium or myometrium.
So, let’s look at these ultrasound figures. On the left, the sagittal transvaginal view shows a hypoechoic endometrial thickening, as marked by the arrowheads. On the right, the sagittal SIS shows a submucosal or intracavitary fibroid. It’s either a FIGO type 0 or type 1 with a thin overlying endometrium, as you can see with the cursors.
On this slide, the MRI image and ultrasonography are often used for presurgical planning of complex gynecologic cases. This MRI image of a patient with a symptomatic uterine fibroid depicts a uterine size that extends near the umbilicus. These images are helpful to the gynecologic surgeon to determine the surgical approach for uterine conserving options, including myomectomy. This fibroid is multi-lobulated and measures 10 cm x 10 cm x 16 cm with multiple intramural fibroids. And there is one submucosal FIGO type 2 fibroid displacing the fundal region of the endometrium inferiorly.
The philosophic goals of patient-centric care include the following caveats: shared decision making with the patient, clarify the patient’s goal, clarify the patient’s priorities, offer alternatives that would likely improve her symptoms and improve the quality of her life, relieve symptoms such as heavy bleeding, pain and pressure, improve anemia, avoid surgical intervention for patients who request non-surgical interventions, prevent regret for patients who desire a uterine-conserving procedures, prevent regret for those still contemplating pregnancy. So, the philosophical goals of therapy also would allow the patient to experience improvement in clinical symptoms and decide if continued therapy is acceptable, permit time to consider other alternatives, use therapy to bridge from one treatment modality to others, correction of anemia, bridge from perimenopause to menopause, improve comorbidities with medical therapy, the patient will need fewer office visits and may be followed-up with virtual visits, thereby alleviating concerns about hospitalizations, multiple office visits during the COVID-19 pandemic.
So, what are medical options for uterine fibroids? They include non-steroidal anti-inflammatories, or NSAIDs, combined estrogen progesterone contraception, progesterone only intrauterine device, progesterone only contraception, aromatase inhibitors, anti-fibrinolytics GNRH agonist versus antagonist, mechanism of action and clinical landscape. The agonist, how do they work? By down-regulating estrogen and progesterone production, they produce short term flare in LH and FSH levels, decrease stimulation of hormone receptors, improve bleeding and anemia. The antagonist down-regulate hypothalamic pituitary gonadal access, lack immediate flare effects, can be given with add-back therapy to attenuate menopausal symptoms and impact on bone mineral density, improve bleeding and anemia.
The GNRH antagonist add to our armamentarium of safe, rapidly effective, oral medical therapy for women with uterine fibroids.
Thank you for watching.
You have been listening to CME on ReachMD. This activity is provided by Omnia.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Omnia. Thank you for listening.