Post by SydT on Jan 17, 2009 22:33:18 GMT -5
This is taken from a medical textbook, "Clinical Protocols in Obstetrics and Gynecology" John Turrentine MD, 3rd edition, 2008.
FIBROIDS
Symptoms of bleeding vs pain/pressure 33% vs 33%
Symptoms depend on #, size and location. (Frequency, urgency, rectalpressure, infertility, enlarging midline mass?)
What % of fibroids are symptomatic? 20 - 40%
Uterine sarcoma noted in only 0.1%
Treatment Options
Expectant
(1) Expectant especially if uterus is 12 cm or less, with slow growth (< 6 cm in size in 1 year) or no growth
Hormonal
(2) Hormone therapy - Lupron, DMPA, danazol, RU486
(A) Advantages
(a) Perimenopausal - often avoids hysterectomy
(b) Shrink to allow better surgery mode
(c) Decreases blood loss (100-150 cc)
(d) Correct anemia decreasing need for transfusion
(e) Atrophy endometrium for hysteroscopic ablation
(B) Disadvantages
(a) Can cause degeneration - piece meal myoma
(b) Hypoestrogenic side-effects
(c) Expense
(d) Need for injections
Myomectomy
(3) Myomectomy - used especially for retaining fertility. Recurrence rate with myomectomy is 20%
Destructive techniques
(4) Laparoscopic myolysis -electrothermy, laser coagulation or cryo (holes drilled)
(5) Laparoscopic cryomyolysis - one hole is drilled into center of fibroid to form ice ball ('her/option¡' cryoblation system by
CryoGen, San Diego, CA)
Both myolysis and cryomyolysis respond better if treated
preoperatively with GnRH agonist
UAE (6) Uterine arterial embolization
Hysterectomy (7) Hysterectomy
Comparison of hysterectomy
Advantage of hysterectomy over myomectomy
to myomectomy (1) Less blood loss
(2) Decrease chance of recurrence (within 20 years of a
myomectomy, 25% subsequently have hysterectomy for recurrences)
(3) Postop complications much less wound infection 2%
bleeding 2%
Advantages of myomectomy over hysterectomy
(1) Preservation of reproductive capacity
(2) Lack of possible negative psychological effects from uterine loss
Myomectomy for infertility
Fibroid in association with recurrent second-trimester pregnancy loss.
Location (submucous) is more signifi cant than size of fi broid.
Theories
(1) Thinning of endometrium so implantation is in poor site
(2) Rapid growth (increased hormones of pregnancy) leads to compromises blood
supply, leads to necrosis (red degeneration) leads to uterus contracts
(3) Encroachment of fibroids upon fetal space to develop
Surgery
Reserved for repetitive second-trimester spontaneous abortions with
female whose abortuses were normal (pheno + karyotype) and
viability is > 9-10 weeks gestation
Recurrence rate of myomectomy for infertility is 20-25%
Red degeneration
Myomas during pregnancy or puerperium occasionally undergo 'red' or
'carneous' degeneration that is caused by a hemorrhagic infarction
Signs and symptoms
(1) Focal pain
(2) Tenderness to palpation
(3) Occasional low grade fever
(4) Moderate leukocytosis common
(5) Peritoneal 'rub' - develops secondary to inflammation of parietalperitoneum overlies infarcted myoma
Differential
(1) Appendicitis
(2) Placental abruption
(3) Ureteral stone
(4) Pyelonephritis
Treatment
(1) Analgesia (i.e. codeine)
(2) Usually spontaneously abates within a few days
__END OF ARTICLE___
FIBROIDS
Symptoms of bleeding vs pain/pressure 33% vs 33%
Symptoms depend on #, size and location. (Frequency, urgency, rectalpressure, infertility, enlarging midline mass?)
What % of fibroids are symptomatic? 20 - 40%
Uterine sarcoma noted in only 0.1%
Treatment Options
Expectant
(1) Expectant especially if uterus is 12 cm or less, with slow growth (< 6 cm in size in 1 year) or no growth
Hormonal
(2) Hormone therapy - Lupron, DMPA, danazol, RU486
(A) Advantages
(a) Perimenopausal - often avoids hysterectomy
(b) Shrink to allow better surgery mode
(c) Decreases blood loss (100-150 cc)
(d) Correct anemia decreasing need for transfusion
(e) Atrophy endometrium for hysteroscopic ablation
(B) Disadvantages
(a) Can cause degeneration - piece meal myoma
(b) Hypoestrogenic side-effects
(c) Expense
(d) Need for injections
Myomectomy
(3) Myomectomy - used especially for retaining fertility. Recurrence rate with myomectomy is 20%
Destructive techniques
(4) Laparoscopic myolysis -electrothermy, laser coagulation or cryo (holes drilled)
(5) Laparoscopic cryomyolysis - one hole is drilled into center of fibroid to form ice ball ('her/option¡' cryoblation system by
CryoGen, San Diego, CA)
Both myolysis and cryomyolysis respond better if treated
preoperatively with GnRH agonist
UAE (6) Uterine arterial embolization
Hysterectomy (7) Hysterectomy
Comparison of hysterectomy
Advantage of hysterectomy over myomectomy
to myomectomy (1) Less blood loss
(2) Decrease chance of recurrence (within 20 years of a
myomectomy, 25% subsequently have hysterectomy for recurrences)
(3) Postop complications much less wound infection 2%
bleeding 2%
Advantages of myomectomy over hysterectomy
(1) Preservation of reproductive capacity
(2) Lack of possible negative psychological effects from uterine loss
Myomectomy for infertility
Fibroid in association with recurrent second-trimester pregnancy loss.
Location (submucous) is more signifi cant than size of fi broid.
Theories
(1) Thinning of endometrium so implantation is in poor site
(2) Rapid growth (increased hormones of pregnancy) leads to compromises blood
supply, leads to necrosis (red degeneration) leads to uterus contracts
(3) Encroachment of fibroids upon fetal space to develop
Surgery
Reserved for repetitive second-trimester spontaneous abortions with
female whose abortuses were normal (pheno + karyotype) and
viability is > 9-10 weeks gestation
Recurrence rate of myomectomy for infertility is 20-25%
Red degeneration
Myomas during pregnancy or puerperium occasionally undergo 'red' or
'carneous' degeneration that is caused by a hemorrhagic infarction
Signs and symptoms
(1) Focal pain
(2) Tenderness to palpation
(3) Occasional low grade fever
(4) Moderate leukocytosis common
(5) Peritoneal 'rub' - develops secondary to inflammation of parietalperitoneum overlies infarcted myoma
Differential
(1) Appendicitis
(2) Placental abruption
(3) Ureteral stone
(4) Pyelonephritis
Treatment
(1) Analgesia (i.e. codeine)
(2) Usually spontaneously abates within a few days
__END OF ARTICLE___