Fibroid uterus

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      • Leiomyomas
        • localized, benign, smooth muscle tumors of the uterus
        • hormonally responsive.
        • Clinically found in 25–33% of reproductive-age women
        • They are almost always multiple.
        • The most common indication for hysterectomy. (MCQ)
        • Leiomyomas are most commonly of the subserous type. (MCQ)
        • Rarely do leiomyomas (fibroids) progress
to malignancy (leiomyosarcoma).
        • Submucosal and intramural types of fibroids usually present as menorrhagia
        • Subserosal fibroids, which become pedunculated, may present with acute pain and torsion. (MCQ)
        • Sequelae
          • Hyaline degeneration.
          • Calcification.
          • Red degeneration (MCQ)
            • painful interstitial hemorrhage
            • often with pregnancy
          • Cystic degeneration—may rupture into adjacent cavities
        • Uterine locations of leiomyomas
          • Submucous: Just below endometrium; tend to bleed.
          • Intramural: Within the uterine wall.
          • Subserous: Just below the serosa/peritoneum.
          • Cervical: In the cervix.
          • Parasitic:
          • The fibroid obtains blood supply from another organ (ie, omentum).
            Interligamentous: The fibroid grows laterally into the broad ligament

            • Symptoms
                • Asymptomatic in > 50% of cases. (MCQ)
                • Bleeding +/− anemia:
                  • One-third of cases present with bleeding.
                • Bleeding is usually menorrhagia, caused by: (MCQ)
                  • Abnormal blood supply.
                  • Pressure ulceration.
                  • Abnormal endometrial covering.
                • Pain: Secondary dysmenorrhea. (MCQ)
                • Pelvic pressure: May be due to enlarging fibroids.
                • Infertility.
              • Diagnosis
                • Physical exam (bimanual pelvic and abdominal exams)
                • Fibroids are usually midline, enlarged, irregularly shaped, and mobile. (MCQ)
                • Sonography
                • may also be visualized by x-ray, MRI, CT, HSG, hysteroscopy.
                • Pap, ECC, endometrial biopsy, hysteroscopy, and D&C can be done to rule out malignancy. (MCQ)
              • Treatment
              • No treatment is indicated for asymptomatic women, as this hormonally sensitive tumor will likely shrink with menopause
              • Pregnancy is usually uncomplicated. (MCQ)
                • Some fibroids may grow in size during pregnancy.
                • Bed rest and narcotics are indicated for pain with red degeneration.
              • Treatment is usually initiated when: (MCQ)
                • Tumor is > 14 weeks’ gestation size. (MCQ)
                • Hematocrit falls.
                • Tumor compresses adjacent structures.
                • Symptoms limit lifestyle.
              • The treatment for asymptomatic fibroids at 11 weeks’ size is observation. (MCQ) (MCQ)
              • GnRH agonists can be given for up to 6 months to shrink tumors (ie, before surgery) and control bleeding: (MCQ)
              • Myomectomy:
                • Surgical removal of the fibroid in infertile patients with no other reason for infertility. (MCQ)
                • A myomectomy is for women who desire to retain their uterus for childbearing.
                • About one-third of fibroids recur following myomectomy
              • Hysterectomy:
                • Indicated for symptomatic women who have completed childbearing.
                • Definitive treatment for fibroids = hysterectomy
  • Pregnancy with fibroids carries ↑ relative risk: (MCQ)
    • Abruption:
    •  First-trimester bleeding
    •  Dysfunctional labor
    •  Breech
    • C-section


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