Management of Conflicts Women with Fibroids- I have been on - PDF document

9/26/2018 Management of Conflicts Women with Fibroids-  I have been on advisory board for Pfizer, Searchlight, Why we Need New Merck and Acerus  I have spoken for Pfizer, Searchlight Options NAMS 2018 Wendy Wolfman MD FRCS(C) FACOG Professor Department of Ob/Gyn University of Toronto Director Menopause and POI Units Mt. Sinai Hospital Objectives Ms X Hausted  41 yr old G3P0 menses q 23 days for 10 days  To discuss impact of fibroids on a woman’s life  Uses 7 super tampons with pads- sometimes bleeds through her  To discuss current options for treatments clothes and misses work  Bloated with lower abdominal discomfort and constipation  To discuss reasons for women’s preference for non- surgical options  Hgb 98  known uterine fibroids for many years  wants to retain her uterus as she still hopes to conceive  doesn’t know how much longer she can continue  doesn’t want OCP’s or an IUD and finds tranexamic acid minimally helpful 1

9/26/2018 Why do we need new Fibroids options?-  Benign monoclonal hormonally sensitive to estrogen and Lifetime prevalence of progesterone  smooth muscle tumors hysterectomy in US is  Somatic mutations of MED12 or HMGA2 45%!!!!  Very common- 80%of black women and 70% of white women  Symptoms related to location, location, location and size  Responsible for reduction in quality of life , health burden and lost 3/4 of fibroid procedures are hysterectomy work days ($700 annually) accounting for $6-34 billion health costs 200,000 of 600,000 hysterectomies are due to fibroids  Effective medical therapies would improve lives of women Baird D Am J Obstet Gynecol 2003 Moravek Curr Opin Obstet Gynecol 2015 Stewart NEJM 2015 Cardoza ER A J Ostet Gynecol 2012 Donnez Best Practice & Research Clinical Ob & Gyn 2018 Stewart EA Minn Med 2012 Hartmann KE Obstet Gynecol 2006 Symptoms Associated with Fibroid Risk Factors Fibroids  50% have no symptoms- no treatments necessary Non controllable factors Lifestyle factors  Triad of symptoms-up to 50% need therapy  Age  High body mass-21% with each 10kg  BLEEDING  Ethnicity  Physical activity  BULK  Vit D deficiency  COMT polymorphism  Use of OCP’s under 16  REPRODUCTIVE EFFECTS  Early menarche  Progestin injectable reduces risk  ER polymorphism  Dietary –fruit, vegies, low fat dairy reduces risk  Higher TGF- β 3 serum  Tobacco, caffeine, and alcohol  Parity reduces risk Mohamed Biol Reprod 2017 Wise LA Am J Epidemiol 2004 Baird D Epidemiology 2003 Tropeano G, et al. Hum Reprod Update 2008 Pavone Best Pract Res Clin Obstet Gynaecol 2018 Downes E, et al. Eur J Obstet Gynecol Reprod Biol 2010 Wise LA Am J Clin Nutr 2011 Wise LA Epidemiology 2005 2

9/26/2018 Bleeding Symptoms Bulk Symptoms  Postulated causes-increased surface area, increased  Pelvic pressure and cramps ,Back pain and leg pain vascularity, impaired contractility, endometrial ulceration, venous engorgement and uterine congestion  Bloating and abdominal distention  60% Increased amount, length, intermenstrual and if severe  Urinary - frequency ,urgency and incontinence,-anterior emergency visits fibroids and increased size – rarely hydronephrosis  Heavy bleeding occurs in 33%  Bowel -constipation  Produces anemia and may require transfusions  Gynae -Dyspareunia and dysmenorrhoea,  Crampy pain in 75% - also occurs with bulk issues  Rate of growth is unpredictable 89% shrinkage to 138%  Other causes of AUB should be ruled out growth, median 9% growth  Bleeding stops at menopause  Rapid growth not necessarily=malignancy Borah B Am J Obstet Gynecol 2013 Day Baird D Fertil Steril 2011 Wegienka Gobstet Gynecol 2003 Parker W Obstet Gynecol 1994 Wu JM Obstet Gynecol 2007 Stewart NEJM 2015 Talaulikar Best Pract Res Clin Ostet Gynaecol 2018 Effect of Uterine Fibroids Reproductive Dysfunction on Quality of Life  Uterine fibroids may significantly decrease health-related  Infertility-diagnosis of exclusion and controversial QOL  Recurrent pregnancy loss  includes sexuality, self-image, relationships, social, emotional and physical well-being  Pregnancy complications  Societal burden: absenteeism, productivity impairment, and  Abnormal placentation economic loss.  Premature Delivery  Heavy menstrual bleeding is a major cause of physician  Malpresentation visits and lost work days.  Postpartum hemorrhage  QOL related to number of symptoms –most common back  SGA (65%),fatigue 63%, bloating 61%, bleeding 51%, cramping with menses (63%) and heavy bleeding during menses  Caesarian delivery (54%) Hartmann K Am J Epidem 2017 Soliman AM Curr Med Res Opin 2017 Chen Y Him Reprod 2009 Fortin C Best Pract Res Clin Obstet Gynaecol 2018 Pritts E Fertil Steril 2009 Borah B Am J Obstet Gynecol 2013 Klatsky P Am J Obstet Gynecol 2008 3

9/26/2018 Diagnosis of Uterine Fibroids Diagnostic Work ‐ up  Clinical history-  Investigate based on presentation and symptoms  Bleeding  Abnormal uterine bleeding 1  Bulk  History, Physical  Reproductive problems  Pap test  Cultures  History of bleeding problems, Thyroid disease  Endometrial biopsy as per guidelines to rule out pathology  Family history  Blood work-up (hemoglobin, ferritin)  TSH, prolactin  Rarely Inherited renal CA and Fibroids  Ultrasound  Hysterosonogram, or hysteroscopy to rule out intracavity myoma  Physical exam-abdominal, pelvic and speculum examinations  MRI •  Atypical presentation Uterine sarcomas are rare (3-7 / 10,000) 2  Incidence may be higher in patients undergoing surgery 3  Hydronephrosis  No diagnostic test determines sarcoma diagnosis  Pain (degeneration  Risk-radiation, tamoxifen 1. Lefebvre G, et al. J Obstet Gynaecol Can 2003;25:396 ‐ 418; 2. Brooks SE, et al. Gynecol Oncol 2004;93:204 ‐ 8; Khan AT, et al. Int J Womens Health 2014;6:95 ‐ 114 3. Seidman MA, et al. PLoS One 2012;7:e50058 Classification of Fibroids Treatments for Uterine Fibroids European Society of Hysteroscopy Classification: 1 Leiomyoma Subclassification System 2 TYPE 0 – Intracavitary S M ‐ Submucosal  Conservative: TYPE I – > 50% in cavity 0: Pedunculated Intracavitary 3 3 TYPE II – < 50% in cavity 4 4 4  Medical 1: <50% Intramural 2-5 2-5 2-5 TYPE III – Serosal/intramural 1 1 1 2: ≥ 50% Intramural 0 0  0 0 Surgical O – Other 6 6 2 2  laparascopic, vaginal, abdominal, robotic 5 5 3: Contacts endometrium; 100% Intramural  Endometrial Ablation-for AUB-first and second 7 7 7 4: Intramural generation (failure rate associated with length and distortion of cavity)-heat, cold, mechanical 5: Subserosal ≥ 50% Intramural  Myomectomy 6: Subserosal < 50% Intramural  Hysteroscopic-best treatment for type 0 7: Subserosal Pedunculated 8: Other (specify eg. cervical, parasitic)  Interventional Hybrid Leiomyomas  Uterine Artery Embolization (impact both endometrium and serosa)  MRI guided focused ultrasound Example:  Radiofrequency ablation during laparoscopic 2 ‐ 5: Submucosal and subserosal, each with less than  half the diameter in the endometrial and peritoneal Hysterectomy-definitive and no recurrence Myoma to cavities respectively. serosa distance Stewart NEJM 2015 1. Wamsteker K, et al. Obstet Gynecol 1993;82:736 ‐ 40 Song Cochrane Database 2013 2. Munro MG, et al. Int J Gynaecol Obstet 2011;113:3 ‐ 13 Deng Cochrane 2012 4