Updated: 11/18/2019

Leiomyoma (Fibroids)

Topic
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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.
Overview
 
Introduction
  • Otherwise known as fibroids
  • Leiomyomas are smooth muscle growths of the uterine myometrium can be
    • intramural
    • submucosal
    • subserosal
  • Epidemiology (most common)
    • benign uterine tumor
    • tumor in females
    • seen in African Americans (5x more common)
    • occurs in women 20-40 years of age
  • Often present with multiple discrete tumors
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
Evaluation
  • Diagnosed with clinical history and exam
  • Diagnosis confirmed with sonogram 
    • transvaginal ultrasound has high sensitivity (95-100%)
    • hyperechoic, well-circumscribed round masses
  • Labs
    • β-hCG to rule out pregnancy
  • Histology
    • whorled pattern of smooth muscle bundles
Differential Diagnosis
  • Leiomyosarcoma
  • Adenomyosis
  • Endometrial polyp
  • Pregnancy
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
Prognosis, Prevention, and Complications
  • Prognosis
    • having symptomatic fibroids decreases quality of life
  • Complications
    • very rarely (if at all) transforms into leiomyosarcoma
    • infertility
    • iron deficiency anemia 
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.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?
Review Topic | Tested Concept

QID: 106210
1

Folate

1%

(1/90)

2

Hysterectomy

9%

(8/90)

3

Iron

76%

(68/90)

4

Myomectomy

6%

(5/90)

5

Oral contraceptive pills

6%

(5/90)

M2 C

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(M2.GN.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?
Review Topic | Tested Concept

QID: 108706
1

Molar pregnancy

34%

(11/32)

2

Dating error due to unreliable LMP

41%

(13/32)

3

Leiomyomata

19%

(6/32)

4

Multiple gestation pregnancy

6%

(2/32)

5

Anteverted uterus

0%

(0/32)

M2 D

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