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fibroleiomyoma (fibroid, uterine leiomyoma)

Fibrous leiomyoma, especially occurring in the uterus. Epidemiology: - 11 of 64 women > 30 years of age (57 premenopausal) with fibroids* - particularly prevalent among black women [11] - symptoms often more severe in black women than white women [11] * small study Pathology: 1) on average fibroids increase 1.2 cm in 2.5 years* 2) variation in growth 3) 1/3 of fibroids may regress* - smaller fibroids in older women more likely to regress Genetics: - t(12;14)(q15;q23-24) involving HMGA2 with RAD51L1; (not principle mechanism) - other implicated genes: PDGFC Clinical manifestations: - pelvic heaviness - abnormal uterine bleeding - infertility - enlarged uterus on bimanual exam [6] Radiology: - pelvic ultrasound shows enlarged uterus Complications: - 1 in 350 women undergoing hysterectomy for fibroids found to have uterine sarcoma, especially leiomyosarcoma [10] Management: 1) observation 2) hormonal contaceptives - levonorgestrel-releasing intrauterine device [11] - gonadotropin-releasing hormone agonist - leuprolide may be used in combination with - medroxyprogesterone acetate - conjugated equine estrogens - norethindrome - estriopipate 3) mifepristone reduces uterine volume 25-75% comparable to leuprolide 4) tranexamic acid [11] 5) raloxifene & danazole have been used 6) ulipristal acetate may control bleeding [8] 7) surgery a) hysterectomy is the most effective treatment b) endoscopic myomectomy may be effective for women with submucosal fibroids as the cause of bleeding [11] c) laparoscopic power morcellation in hysterectomy & myomectomy is discouraged due to risk of dissmeninating unsuspected uterine sarcoma [10] d) focused ultrasound surgery [11] e) radiofrequency ablation [11] 8) bilateral uterine artery embolization [3,4,5,7] a) alternative to hysterectomy b) higher rate (vs surgery) of subsequent retreatment within 5 years (32% vs 4%) [7] c) failure rate 18% during 7 years of follow-up [9] d) adverse events similar to surgery ~20% [7]

General

leiomyoma

Database Correlations

OMIM 150699

References

  1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
  2. Journal Watch 22(16):129, 2002 DeWaay DJ et al Natural history of uterine polyps and leiomyomata. Obstet Gynecol 100:3, 2002 PMID: 12100797
  3. Journal Watch 23(4):33, 2003 Pron G, Bennett J, Common A, Wall J, Asch M, Sniderman K; Ontario Uterine Fibroid Embolization Collaboration Group. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003 Jan;79(1):120-7. PMID: 12524074
  4. Journal Watch 25(4):34, 2005 Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L; Ontario UFE Collaborative Group. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol. 2005 Jan;105(1):67-76. PMID: 15625144
  5. Worthington-Kirsch R, Spies JB, Myers ER, Mulgund J, Mauro M, Pron G, Peterson ED, Goodwin S; FIBROID Investigators. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol. 2005 Jul;106(1):52-9. PMID: 15994617
  6. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
  7. Moss JG et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG 2011 Apr 12 PMID: 21481151 http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.02952.x/abstract
  8. Donnez J et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012 Feb 2; 366:409. PMID: 22296075 - Donnez J et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012 Feb 2; 366:421. PMID: 22296076 - Stewart EA. Uterine fibroids and evidence-based medicine-Not an oxymoron. N Engl J Med 2012 Feb 2; 366:471. PMID: 22296082
  9. Tropeano G et al. Incidence and risk factors for clinical failure of uterine leiomyoma embolization. Obstet Gynecol 2012 Aug; 120:269. PMID: 22825084
  10. FDA MedWatch. April 17, 2014 Laparoscopic Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication - Use Discouraged Due to Increased Risk in Women With Uterine Fibroids. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm393809.htm - FDA News Release. Nov 24, 2014 FDA warns against using laparoscopic power morcellators to treat uterine fibroids. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm424435.htm
  11. Stewart EA Uterine Fibroids. N Engl J Med 2015; 372:1646-1655. April 23, 2015 PMID: 25901428 http://www.nejm.org/doi/full/10.1056/NEJMcp1411029