Outline Clinical Manifestation of Fibroids Updates in the Primary - - PowerPoint PPT Presentation

12/15/2014 1

Updates in the Primary Care Management of Fibroids

Eve Zaritsky MD, FACOG Minimally Invasive Gynecologic Specialist Kaiser Permanente Northern California Oakland

No Disclosures

Outline

• Clinical Manifestation of Fibroids
• Treatment Options

– Medical – Minimally Invasive – Surgical

• When to Refer to a Gynecologist
• Case Scenarios

Learning Objectives

At the end of this presentation you will be able to:

• Evaluate a patient with fibroids
• Provide counseling on medical treatments
• Explain minimally invasive therapies
• Review surgical options
• Communicate fertility sparing modalities
• Know when to refer to a gynecologist
• Create an individualized patient care plan

Clinical Manifestation of Fibroids

• Uterine leiomyomas are very common
• Fibroids in up to 70% of white women and

>80% of black women by age 50 years

Day et al 2003

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Clinical Manifestation of Fibroids

• Two most common symptoms for which

women with leiomyoma seek treatment are

– Bleeding – Pelvic pressure

• Great variation in size, number and location

Clinical Manifestation of Fibroids

Risk Factors

• Race
• Family History
• Early Menarche
• Late or No Pregnancies
• Diet and Alcohol
• ?Obesity

Surgical Options: Hysteroscopy

Munro MG 2010

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ACOG

• Symptoms and treatment options are

affected by the size, number, and location of the leiomyomas. The lack of a simple, inexpensive, and safe long-term medical treatment means that most symptomatic leiomyomas are still managed surgically.

ACOG Practice Bulletin 2012

Treatment Options

• Expectant Management
• Medical Therapy
• Minimally Invasive Modalities
• Surgical Options

Watchful Waiting :

• Long term Progression Hard to Predict
• Evaluate 1-2 years pelvic exam
• Consider Baseline Ultrasound
• Management may be different for women

desiring fertility

• Expectant management if slow growing,

asymptomatic or perimenopausal

Watchful Waiting

Fibroid growth in premenopausal women

• High variability median growth rate 9% at 6 months

(range – 89% to +138%)

• 1.2 cm per 2.5 years, but great variation in growth

rates were noted

• ACOG: Expectant management in an asymptomatic

patient should be the norm

– some instances an asymptomatic fibroids might require treatment

Peddada et al 2008 DeWaay et al 2002

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Medical Therapy: Hormonal

No Size Reduction but Decreases Menorrhagia

• Estrogen-progestin contraceptives
• Progestin implants, injections, and pills
• Levonorgestrel- releasing IUD

Medical Therapy: Hormonal

Size Reduction and Decreases Menorrhagia

• Gonadotropin agonists (Lupron)

– 35-60% reduction in size within 3 months – Bridge to Menopause – Surgical preparation – Significant side effects (add back progesterone)

Medical Therapy:

No Size Reduction but Decreases Menorrhagia

• Antifibrinolytic agents
• Nonsteroidal antinflammatory drugs
• Danazol and gestrinone

Medical Therapy: Hormonal

Less Frequently Used or Not Used in U.S.

• Gonadotropin antagonists -daily and $$
• Antiprogestins and progesterone receptor

modulators – hyperplasia risk

• Mifepristone (RU-486) *
• Ulipristal *
• Aromatase inhibitors

*Available dose in U.S. is an impediment to off-label treatment

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Minimally Invasive Options

Non Fertility-Sparing Options

• Uterine Artery Embolization
• Endometrial Ablation
• Myolysis
• MRI resonance guided focused ultrasound

Minimally Invasive Options

Uterine Artery Embolization

• Uterine arteries embolized -> devascularization and involution
• Volume reduction (42%) (Pron 2003)
• UAE versus TAH (Emmy trial 2005)

– Less pain, return to work , major complications similar

• 5-year follow-up of 200 patients treated with UAE:

– 20% reoperation rate (hysterectomy 14%, myomectomy 4%, repeat UAE 2%) – failure to control symptoms in 25% were documented (Spies 2005)

Minimally Invasive Options

• Endometrial Ablation
• Done alone or with hysteroscopic myomectomy
• Risk of a second surgery 10-40%
• Outpatient

Minimally Invasive Options

• Myolysis
• Laparoscopic thermal coagulation
• Infrequently used in current practice
• ~ 50% reduction size
• < 4 leiomyomas no larger than 10 cm in

diameter

• Dense adhesions

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Minimally Invasive Options

• MRI resonance guided focused

ultrasound

• High-intensity ultrasound waves
• Protein denaturation, cell damage, coagulative

necrosis

• Maximum size ~ 10 cm
• Symptom reduction 71% at 6 months 51% at 12

months

Venkatachalam 2004

Surgical Options: Fertility Sparing

Myomectomy Treatment Options:

• Hysteroscopy
• Laparoscopic/Robotic
• Laparotomy

Baggish 2007

Surgical Options: Hysteroscopy

• Endoscope inserted through the cervix to resect

fibroid

– Successful removal 85-95% – Subsequent surgery in 5-15% of cases (Jenkins 2006) – Success: 95% at 1 year and 76% at 5 years (Polena 2007)

• Outpatient

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Surgical Options: Myomectomy

• Laparotomy or Laparoscopic /Robotic
• Fibroid size and Surgeon skill determine Route
• Recovery
• Fertility 3-6 months*
• Recurrence 59% , 26% required repeat surgery

(Malone 1969)

Surgical Options: Definitive

Hysterectomy

• Vaginal
• Laparoscopic/Robotic
• Laparotomy

I N V A S I V E

When to Refer

• Preconception & Fertility
• Obstetrical Risk/ Benefits
• Considering Surgical Options Non Fertility

When to Refer

Procedure What is it? Benefits Risks Procedure Time Recovery Time

Hysterectomy Removal of uterus Definitive treatment

• Fertility Lost
• Surgical Risks
• Recovery

1-3 hours 2-6 weeks Myomectomy Removal of fibroids Preserves Fertility and uterus

• Surgical Risks
• Recovery
• Recurrence

1-4 hours 2-6 weeks UAE Uterine artery blocked with small particles, starving the fibroid

• Preserves uterus
• Less invasive
• Recovery
• Radiation
• Not suitable if

desires future pregnancy

• Recurrence

1-2 hours 7-10 days MRgFUS Focused US waves to heat and destroy fibroid with MR guidance

• No incision
• No radiation
• Recovery
• Can consider

pregnancy

• Size and location
• Burns (rare)
• Recurrence

3-5 hours 1-2 days Hormone Therapy Meds that cause fibroid shrinkage

• Non surgical
• Effective for 6-12

months

• Symptoms return
• Menopause

symptoms Not Applicable Not Applicable Watchful Waiting No treatment, monitoring only

• Symptoms can

diminish with menopause

• Increase in growth

and symptoms

• May need surgery

Not Applicable Not Applicable

I N V A S I V E

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Case Scenario

• 36 year old gravida 2 para 0 with 16 week

preterm premature rupture of membranes and known 8 cm fibroid. Comes to you for consultation:

• What do you recommend?

Case Scenario

• 43 year old gravida 2 para 2 with 10 cm fibroid

and abnormal uterine bleeding. Wants to preserve her uterus, not interested in future fertility.

• What do you recommend?

Case Scenario

• 25 year old found to have a 5 cm fibroid and

comes in to discuss birth control options

• What would you recommend?

Patient Handouts

• ACOG
• UptoDate.com
• Medline Plus- U.S. National Library of Medicine/ NIH
• AAFP
• Personalized After Visit Summaries

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At the end of the presentation you can:

• Evaluate a patient with fibroids
• Provide counseling on medical treatments
• Explain minimally invasive therapies
• Review surgical options
• Communicate fertility sparing modalities
• Know when to refer to a gynecologist
• Create an individualized patient care plan

Questions