fibroleiomyoma (fibroid, uterine leiomyoma)
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Introduction
Fibrous leiomyoma, especially occurring in the uterus.
Epidemiology
- 11 of 64 women > 30 years of age (57 premenopausal) with fibroids*
- particularly prevalent among black women[11]
- symptoms often more severe in black women than white women[11]
* small study
Pathology
- on average fibroids increase 1.2 cm in 2.5 years*
- variation in growth
- 1/3 of fibroids may regress*
- smaller fibroids in older women more likely to regress
Genetics
- t(12;14)(q15;q23-24) involving HMGA2 with RAD51L1; (not principle mechanism)
- other implicated genes: PDGFC
Clinical manifestations
- pelvic heaviness
- abnormal uterine bleeding
- infertility
- enlarged uterus on bimanual exam[6]
Radiology
- pelvic ultrasound shows enlarged uterus
Complications
- 1 in 350 women undergoing hysterectomy for fibroids found to have uterine sarcoma, especially leiomyosarcoma[10]
Management
- observation
- hormonal contaceptives
- levonorgestrel-releasing intrauterine device[11]
- gonadotropin-releasing hormone agonist - leuprolide may be used in combination with
- medroxyprogesterone acetate
- conjugated equine estrogens
- norethindrome
- estriopipate
- mifepristone reduces uterine volume 25-75% comparable to leuprolide
- tranexamic acid[11]
- raloxifene & danazole have been used
- ulipristal acetate may control bleeding[8]
- surgery
- hysterectomy is the most effective treatment
- endoscopic myomectomy may be effective for women with submucosal fibroids as the cause of bleeding[11]
- laparoscopic power morcellation in hysterectomy & myomectomy is discouraged due to risk of dissmeninating unsuspected uterine sarcoma[10]
- focused ultrasound surgery[11]
- radiofrequency ablation[11]
- bilateral uterine artery embolization[3][4][5][7]
- alternative to hysterectomy
- higher rate (vs surgery) of subsequent retreatment within 5 years (32% vs 4%)[7]
- failure rate 18% during 7 years of follow-up[9]
- adverse events similar to surgery ~20%[7]
More general terms
References
- ↑ Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
- ↑ Journal Watch 22(16):129, 2002 DeWaay DJ et al Natural history of uterine polyps and leiomyomata. Obstet Gynecol 100:3, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12100797
- ↑ 3.0 3.1 Journal Watch 23(4):33, 2003 Pron G, Bennett J, Common A, Wall J, Asch M, Sniderman K; Ontario Uterine Fibroid Embolization Collaboration Group. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003 Jan;79(1):120-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12524074
- ↑ 4.0 4.1 Journal Watch 25(4):34, 2005 Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L; Ontario UFE Collaborative Group. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol. 2005 Jan;105(1):67-76. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15625144
- ↑ 5.0 5.1 Worthington-Kirsch R, Spies JB, Myers ER, Mulgund J, Mauro M, Pron G, Peterson ED, Goodwin S; FIBROID Investigators. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol. 2005 Jul;106(1):52-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15994617
- ↑ 6.0 6.1 Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
- ↑ 7.0 7.1 7.2 7.3 Moss JG et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG 2011 Apr 12 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21481151 <Internet> http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.02952.x/abstract
- ↑ 8.0 8.1 Donnez J et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012 Feb 2; 366:409. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22296075
Donnez J et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012 Feb 2; 366:421. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22296076
Stewart EA. Uterine fibroids and evidence-based medicine-Not an oxymoron. N Engl J Med 2012 Feb 2; 366:471. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22296082 - ↑ 9.0 9.1 Tropeano G et al. Incidence and risk factors for clinical failure of uterine leiomyoma embolization. Obstet Gynecol 2012 Aug; 120:269. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22825084
- ↑ 10.0 10.1 10.2 FDA MedWatch. April 17, 2014 Laparoscopic Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication - Use Discouraged Due to Increased Risk in Women With Uterine Fibroids. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm393809.htm
FDA News Release. Nov 24, 2014 FDA warns against using laparoscopic power morcellators to treat uterine fibroids. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm424435.htm - ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 Stewart EA Uterine Fibroids. N Engl J Med 2015; 372:1646-1655. April 23, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25901428 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcp1411029