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

12/15/2014 Outline • Clinical Manifestation of Fibroids Updates in the Primary Care • Treatment Options Management of Fibroids – Medical – Minimally Invasive Eve Zaritsky MD, FACOG – Surgical Minimally Invasive Gynecologic Specialist • When to Refer to a Gynecologist Kaiser Permanente Northern California Oakland • Case Scenarios No Disclosures Learning Objectives Clinical Manifestation of Fibroids At the end of this presentation you will be able to: • Evaluate a patient with fibroids • Uterine leiomyomas are very common • Provide counseling on medical treatments • Fibroids in up to 70% of white women and • Explain minimally invasive therapies • Review surgical options >80% of black women by age 50 years • Communicate fertility sparing modalities • Know when to refer to a gynecologist • Create an individualized patient care plan Day et al 2003 1

12/15/2014 Clinical Manifestation of Fibroids Clinical Manifestation of Fibroids Risk Factors • Two most common symptoms for which • Race women with leiomyoma seek treatment are • Family History – Bleeding • Early Menarche • Late or No Pregnancies – Pelvic pressure • Diet and Alcohol • Great variation in size, number and location • ?Obesity Surgical Options: Hysteroscopy Munro MG 2010 2

12/15/2014 ACOG Treatment Options • Symptoms and treatment options are affected by the size, number, and location of • Expectant Management the leiomyomas. The lack of a simple, • Medical Therapy inexpensive, and safe long-term medical • Minimally Invasive Modalities treatment means that most symptomatic • Surgical Options leiomyomas are still managed surgically. ACOG Practice Bulletin 2012 Watchful Waiting : Watchful Waiting Fibroid growth in premenopausal women • Long term Progression Hard to Predict • High variability median growth rate 9% at 6 months • Evaluate 1-2 years pelvic exam (range – 89% to +138%) • Consider Baseline Ultrasound • 1.2 cm per 2.5 years, but great variation in growth rates were noted • Management may be different for women • ACOG: Expectant management in an asymptomatic desiring fertility patient should be the norm • Expectant management if slow growing, – some instances an asymptomatic fibroids might require treatment asymptomatic or perimenopausal Peddada et al 2008 DeWaay et al 2002 3

12/15/2014 Medical Therapy: Hormonal Medical Therapy: Hormonal Size Reduction and Decreases Menorrhagia No Size Reduction but Decreases Menorrhagia • Gonadotropin agonists (Lupron) • Estrogen-progestin contraceptives – 35-60% reduction in size within 3 months • Progestin implants, injections, and pills – Bridge to Menopause • Levonorgestrel- releasing IUD – Surgical preparation – Significant side effects (add back progesterone) Medical Therapy: Medical Therapy: Hormonal Less Frequently Used or Not Used in U.S. • Gonadotropin antagonists - daily and $$ No Size Reduction but Decreases Menorrhagia • Antiprogestins and progesterone receptor • Antifibrinolytic agents modulators – hyperplasia risk • Mifepristone (RU-486) * • Nonsteroidal antinflammatory drugs • Ulipristal * • Aromatase inhibitors • Danazol and gestrinone *Available dose in U.S. is an impediment to off-label treatment 4

12/15/2014 Minimally Invasive Options Minimally Invasive Options Uterine Artery Embolization Non Fertility-Sparing Options • Uterine arteries embolized -> devascularization and involution • Volume reduction (42%) (Pron 2003) • Uterine Artery Embolization • UAE versus TAH (Emmy trial 2005) • Endometrial Ablation – Less pain, return to work , major complications similar • 5-year follow-up of 200 patients treated with UAE: • Myolysis – 20% reoperation rate (hysterectomy 14%, myomectomy 4%, repeat UAE 2%) • MRI resonance guided focused ultrasound – failure to control symptoms in 25% were documented (Spies 2005) Minimally Invasive Options Minimally Invasive Options • Myolysis • Endometrial Ablation • Laparoscopic thermal coagulation • Done alone or with hysteroscopic myomectomy • Infrequently used in current practice • Risk of a second surgery 10-40% • ~ 50% reduction size • Outpatient • < 4 leiomyomas no larger than 10 cm in diameter • Dense adhesions 5

12/15/2014 Surgical Options: Fertility Sparing Minimally Invasive Options • MRI resonance guided focused Myomectomy Treatment Options: ultrasound • Hysteroscopy • High-intensity ultrasound waves • Protein denaturation, cell damage, coagulative • Laparoscopic/Robotic necrosis • Maximum size ~ 10 cm • Laparotomy • Symptom reduction 71% at 6 months 51% at 12 months Venkatachalam 2004 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 Baggish 2007 6

12/15/2014 Surgical Options: Myomectomy Surgical Options: Definitive • Laparotomy or Laparoscopic /Robotic Hysterectomy • Fibroid size and Surgeon skill determine Route • Vaginal I N V A S I V E • Recovery • Fertility 3-6 months* • Laparoscopic/Robotic • Recurrence 59% , 26% required repeat surgery • Laparotomy (Malone 1969) Procedure What is it? Benefits Risks Procedure Recovery Time Time When to Refer When to Refer Hysterectomy Removal of uterus Definitive treatment • Fertility Lost 1-3 hours 2-6 weeks • Surgical Risks • Recovery Myomectomy Removal of fibroids Preserves Fertility and • Surgical Risks 1-4 hours 2-6 weeks • uterus Recovery • Recurrence I N V A S I V E UAE Uterine artery • Preserves uterus • Radiation 1-2 hours 7-10 days blocked with small • Less invasive • Not suitable if particles, starving • Recovery desires future • Preconception & Fertility the fibroid pregnancy • Recurrence MRgFUS Focused US waves • No incision • Size and location 3-5 hours 1-2 days to heat and destroy • No radiation • Burns (rare) • Obstetrical Risk/ Benefits fibroid with MR • Recovery • Recurrence • guidance Can consider pregnancy • • Hormone Therapy Meds that cause Non surgical Effective for 6-12 Not Applicable Not Applicable • Considering Surgical Options Non Fertility fibroid shrinkage months • Symptoms return • Menopause symptoms • • Watchful Waiting No treatment, Symptoms can Increase in growth Not Applicable Not Applicable monitoring only diminish with and symptoms • menopause May need surgery 7

12/15/2014 Case Scenario Case Scenario • 36 year old gravida 2 para 0 with 16 week • 43 year old gravida 2 para 2 with 10 cm fibroid preterm premature rupture of membranes and abnormal uterine bleeding. Wants to and known 8 cm fibroid. Comes to you for preserve her uterus, not interested in future consultation: fertility. • What do you recommend? • What do you recommend? Case Scenario Patient Handouts • ACOG • 25 year old found to have a 5 cm fibroid and comes in to discuss birth control options • UptoDate.com • What would you recommend? • Medline Plus- U.S. National Library of Medicine/ NIH • AAFP • Personalized After Visit Summaries 8

12/15/2014 Learning Objectives Questions 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 9