Updated: 11/29/2021

Leiomyoma (Fibroids)

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  • Snapshot
    • A 45-year-old African American G2P2 woman presents with abnormal uterine bleeding. She reports irregular spotting between periods and pain with intercourse. Physical exam reveals a mobile, asymmetric, nontender uterus with multiple nodular abnormalities. A Transvaginal ultrasound shows hyperchoic masses within the uterine wall. She decides to undergo a hysterectomy because she does not want any more children.
  • summary
    • Otherwise known as fibroids
    • Leiomyomas are smooth muscle growths of the uterine myometrium can be
      • intramural
      • submucosal
      • subserosal
    • Often present with multiple discrete tumors
  • Epidemiology
    • benign uterine tumor
    • tumor in females
    • seen in African Americans (5x more common)
    • occurs in women 20-40 years of age
  • Presentation
    • Symptoms
      • sensitive to estrogen levels
        • tumor growth and increased symptoms during pregnancy
        • decreased symptoms during menopause
      • symptoms depend on location of leiomyoma
        • intramural
          • asymptomatic
        • submucosal
          • intermenstrual bleeding and menorrhagia
        • subserosal
          • compression of bladder, rectum, or ureter
            • pelvic pain
            • urinary or bowel issues
    • Physical exam
      • uterus is
        • enlarged
        • firm
        • mobile
        • asymmetric
        • nontender
        • multiple tumors
  • IMAGING
    • transvaginal ultrasound has high sensitivity (95-100%)
      • hyperechoic, well-circumscribed round masses
  • STUDIES
    • Labs
      • β-hCG to rule out pregnancy
    • Histology
      • whorled pattern of smooth muscle bundles
  • Differential Diagnosis
    • Leiomyosarcoma
    • Adenomyosis
    • Endometrial polyp
    • Pregnancy
  • Diagnosis
    • Confirmed with sonogram
  • Treatment
    • If asymptomatic
      • observation
        • fibroids can shrink substantially postpartum and after menopause
    • If symptomatic
      • NSAIDs for dysmenorrhea
      • OCPs for abnormal uterine bleeding
      • GnRH analogs to shrink fibroids pre-surgery
      • surgical management
        • myomectomy
          • preserves childbearing potential
        • uterine artery embolization
          • preserves childbearing potential if myomectomy is not an option
        • hysterectomy
          • definitive therapy
  • Complications
    • very rarely (if at all) transforms into leiomyosarcoma
    • infertility
    • iron deficiency anemia
  • Prognosis
    • having symptomatic fibroids decreases quality of life
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(M2.GN.17.4754) A 37-year-old G1P000 presents to her obstetrician for her first prenatal visit. She states that her last menstrual period (LMP) was 11 weeks ago, though she is unsure of the exact date as her periods are sometimes irregular. She and her husband had 5 months of timed, unprotected intercourse before she had a positive home pregnancy test 2 weeks ago. She has been feeling generally well but notes some morning nausea and vomiting. She also mentions that for the last 6 months or so, she has felt increasing pelvic pressure and worsening urinary frequency but has not sought medical care for these symptoms. The patient has a history of obesity and hypertension but is not on any medications. Her mother had a hysterectomy at age 64 for fibroids, and her sister had a twin pregnancy after assisted reproduction. At this visit, the patient’s temperature is 98.3° F (36.8° C), blood pressure is 142/85 mmHg, pulse is 82/min, and respirations are 14/min. She has gained 4 pounds since the last time she weighed herself 4 months ago. On exam, the patient’s fundus is palpated at the umbilicus, her cervix is closed and firm, and there are no adnexal masses. Her lab results are shown below:

ß-hCG: 81,324 mIU/mL
Thyroid stimulating hormone (TSH): 1.2 µIU/L

Which of the following is the most likely diagnosis?

QID: 108706
1

Molar pregnancy

36%

(15/42)

2

Dating error due to unreliable LMP

40%

(17/42)

3

Leiomyomata

17%

(7/42)

4

Multiple gestation pregnancy

5%

(2/42)

5

Anteverted uterus

0%

(0/42)

M 6 D

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(M2.GN.13.254) A 32-year-old woman presents to clinic complaining of pelvic pain and heavy menstrual bleeding for the past 2 years. The patient reports that her last menstrual period was 1 week ago and she soaked through 1 tampon every 1-2 hours during that time. She does not take any medications and denies alcohol and cigarette use. She is currently trying to have a child with her husband. She works as a school teacher and exercises regularly. Her temperature is 97.0°F (36.1°C), blood pressure is 122/80 mmHg, pulse is 93/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical examination reveals an enlarged, irregularly-shaped uterus palpable at the level of the umbilicus. Laboratory studies are ordered as seen below.

Hemoglobin: 9.0 g/dL
Hematocrit: 29%
MCV: 70 fL
Leukocyte count: 4,500/mm^3 with normal differential
Platelet count: 188,000/mm^3

Urine:
hCG: Negative
Blood: Negative
Leukocytes: Negative
Bacteria: Negative

Which of the following is the most effective treatment for this patient?

QID: 106210
1

Folate

2%

(2/102)

2

Hysterectomy

10%

(10/102)

3

Iron

68%

(69/102)

4

Myomectomy

13%

(13/102)

5

Oral contraceptive pills

5%

(5/102)

M 7 E

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