IsabelGuerridoMartinezObstetricsandGynecologyClerkship

NuriaLunaRamrezEvidenceBasedMedicineWrittenPresentation
NicoleP.RebolloRodriguezOctober23,2015
RaymondRiveraVergara

UterineMyomas

HISTORY

ChiefComplaint:
Llevo14mesessangrando
History ofPresent Illness:Patient is a59year oldG6 P1051womanwhoisaninmatethatwas
brought to the OBER at Hospital Universitario deAdultos(UDH) aftershewasfound to have
profusebleedingandanemiasecondarytobloodloss.Patientrefersthat1yearago,shewason
medicalevaluation at CentroCorreccional deMujeres in Bayamn duetoa 2 monthhistoryof
vaginal bleeding and was diagnosed with abortive uterine myomas, with treatment
recommendations of undergoing total abdominal hysterectomy. On April 2015, patient was
admittedto UDH for surgicalevaluation butrefersthatmedical clearancewasnot granteddue
toabsentevidence ofpulmonary function tests.PatientrefersthatsinceAprilshecontinuedto
experience profuse vaginal bleeding and a vaginal discharge described as acid pink water of
foul odor. She complained that medical evaluation at prison has been neglectfulforthe past
months until 5 days ago, when she was brought 5 days ago toOBERfor evaluationand was
found to have prolapsed myomas into vaginal canal. Patient was admitted to UDH and is
currentlyawaitinghysterectomythathasbeenscheduledtotakeplacein3days.

PastMedicalHistory:
HypertensiontreatedwithVasotec,LasixandTrental(unknowndosages).
COPD wasdiagnosed 14years agoand currently receivingtreatmentwithSpiriva,Ventolinand
Proventil (unknown dosages). Patient diagnosed 20 years ago with Diabetes Mellitus Type 2,
currently insulindependent. Diabetic neuropathy was diagnosed 10 years ago, receiving
treatment with Neurontinwhichpatientrefershasnotbeeneffective.Osteoarthritisdiagnosed
6yearsago,notcurrentlybeingtreated.

ReviewofSystems:

General:
persistentfatigue,norecentweightloss

HEENT:
noheadaches,noblurryvision

Lungs:
shortnessofbreath,persistentcoughandphlegm

Breasts:
norecentchangesinbreastconsistency,nogalactorrhea.

Cardiovascular:
nopalpitations,nochestpain

Gastrointestinal:
refers

constipationatprison,currentlywithnormalbowelmovements

Urinary:
highurinevolumes,

needstostraininordertovoid,nobloodinurine


Musculoskeletal:
jointpain,unabletoambulatewithoutassistance

Neurological:
abnormalsensationsinrightleg,lossofsensationinplantarsurfacesbilaterally

PHYSICALEXAMINATION

VitalSigns:

BP:130/82HR:82bpmRR:22Temp:36.6C
General: awake, alert and oriented to person, place and time; patient appears older
thanchronologicalagebuthasadequatehygiene.Handcuffedtobed.

Chest:
dyspnea,tachypnea,diffusebilateralcrackles

Breasts:
pendulous,nopalpablemasses

Abdomen:
enlarged,mobile

uterusapproximately21weeksinsize,positivebowel
sounds

Pelvic:
cervixisanteriorlydisplaced,withuterinemyomasprolapsedintovaginalcanal

DIAGNOSIS,DIFFERENTIALDIAGNOSES,ANDDIAGNOSTICMODALITIES

Diagnosisinthis patientisabnormaluterinebleedingduetouterineleiomyomas.Inthis
patient, risk factors for development of uterine myomas (early menarche, multiparity,
AfricanAmerican race, use of hormonal contraception, obesity) are inconsistent with her
medical history but physical examination sonographic findings suggest this diagnosis.
Nonetheless,adefinitivediagnosisisobtainableonlyafterpathologicexaminationoftheuterus
removedontotalabdominalhysterectomy.
Differential diagnoses in a postmenopausal patient with abnormal uterine bleeding
include adenomyosis, leiomyosarcoma, endometrial carcinoma, and ovarian or tuboovarian
masses. Inthe caseof adenomyosis,physicalexaminationwould haveshown a diffuseuterine
enlargement, generallynotexceedingthesizeofa12weekuterus.Formationofadenomyomas
would have been differentiated from leiomyomas solely on the basis of pathological
examination.Ontheother hand, presenceofleiomyosarcomaswouldhavebeendistinguished
from myomas by pathological examination aswell,asclinicalpresentation is indistinguishable
from that of myomas. Endometrial carcinoma is another diagnostic possibility due to
postmenopausal bleeding, but less likely given the clinical presence of prolapsed uterine
masses.Lastly,ovarianortuboovarianmassesarealsoconsideredinthedifferentialdiagnoses,
but sonographic evaluation and midline location of palpable masses in the patient favor a
uterineetiology.
Main diagnostictestsemployedinthispatientwereultrasoundexamination,bothpelvic
and transvaginal sonograms. And, as stated above, definitive diagnosis was determined
histologically.

CLINICALMANAGEMENT

Treatmentneedstobeindividualizeddependingonpresentationage,parityandothers.
In this case, the patient had already reached the end of her reproductive age, and had had
multiplepregnanciesofwhichonly one was successfullycarriedtoterm. Thepatienthadbeen
initially treated with Provera, which proved to be of little efficacy. However, withherclinical
presentation ofuterine bleeding compromisingherhemodynamic stability,and thesymptoms
of pelvic bulkiness and pressure sensation along with the prolapsed myoma into the vaginal
canal, hysterectomy is the only definitive treatment. Other pharmacologic treatments that
could have been attemptedinthispatientwere combined oralcontraceptives, GnRHagonists
and levonorgestrel intrauterine devices. GnRH agonists are the most effective for decreasing
uterine fibroid volume, but can only be used as a short term treatment after which normal
fibroidgrowthresumes.

When scientific literature was researched, the following alternative treatments for
uterineleiomyomaswerefound:
1.Noninvasiveprocedure:Magneticresonanceimagingguidedfocusedultrasound
surgery(MRgFUS)
2.Uterinearteryembolization
3.Myomectomyopenabdominal,laparoscopic,hysteroscopicorroboticassisted.

In this patient, management wasdrasticandfocused oneliminatingwithcertaintythe

source ofmyomas.Medicalconsequencesofatotal abdominal hysterectomyina patientwho
has already entered menopause arenotassignificantastheywouldhavebeentoapatientstill
in the midst of her reproductive years and who desired to maintain fertility. This is why we
wanted tofurther investigate whichcouldbethemosteffective managementoptionshadour
patient been premenopausal. Five research articles were reviewed in order to identify other
treatment options, the clinical significance of myomasintermsofeffectsonfertility andhow
treatmentcorrelateswithpregnancyoutcomes.

CLINICALQUESTION
Given that hysterectomy istheonlytreatmentforcompleteeradicationofsymptomaticuterine
myomas, what other alternative treatments would be effective for women diagnosed with
uterinemyomaswhowishtomaintainfertility?

DISCUSSIONOFEVIDENCE

The objective of the scientific article Do submucous myoma characteristics affect

fertility andmenstrualoutcomesinpatientswhounderwenthysteroscopicmyomectomy?was

todeterminethelongterm effects ofuterinemyomas onfertility andmenorraghia.According

to this article, submucous myomas are associated to heavy menstrual bleeding along with
infertility in premenopausal patients. This studywas pertinentto clinicalquestioninorderto
learn of the management of uterine myomasand how it could improve fertilityinpatients.A
total of98womenwhowerereferredtohysteroscopyforsymptomaticsubmucosalfibroids,51
of these with symptoms of menorrhagia and 47 of these with infertilitywereenrolledinthis
retrospective cohort study. Limitations in this study include a small sample size, 47 of these
beingpertinenttoour clinicalquestion.Also, beingaretrospectivecohortstudyisalimitations
considering little control over data recollected. Exclusion criteria included patients with
multiplemyomas,infertilitywith other causes, persistentanovulationorpatientsthatreceived
invitro fertilization. This article concludes that 60% of patients (28/47) experienced thirty
pregnanciesandfoundnosignificanteffectofmyomasize,typeorlocationonpregnancyrates.
This studyisconsidereda levelII2which is an observational studywithoutcontrols.Thislevel
of study is difficult to generalize to the population and could have possible confounding
variablesthataffectthefinaldata.

Do submucous myoma characteristics affectfertilityand menstrual outcomesinpatientswho

underwenthysteroscopicmyomectomy
Ahmed Namazov M.D., Resul Karakus M.D., Ezgi Gencer M.D., Hamdullah SozenM.D., Levent
AcarM.D.

IranJReprodMedVol.13.No.6.pp:367372,June2015

The aim ofthis studywas to determine thelongtermeffectsofsubmucosal myomaresection

on menorrhagia and infertility; also to detect whether the type, size, andlocation ofmyoma
affectthesurgicalsuccessandoutcomes.

DatabaseofhysteroscopicmyomectomiesinZeynapKamilTrainingandResearchHospital.Data
recollected included: demographics, pregnancy rates before surgery, indications for surgery,
durationof infertility,menstrualbleedingpattern,causesofinfertility,complicationsrelatedto
procedures.

ResultsandConclusionsrelatedtothePICOquestion:

There was no statistical difference according to the myoma size. 28 of 47 infertile women
spontaneously experienced thirty pregnancies, with an overall 2310 months postoperatively
period (60%). The mean myoma size in patients who became pregnant was 30.38 mm, in

patientswho didnotconceive was29.95mmand nostatisticaldifferencewas found(p=0.961,

MannWhitneyUtest)

Pregnancyratesaccordingtomyomalocationandtypewere:lowersegment50%,fundus57%,
and corpus 80%; type 0) 75%,type1)62%, type 2) %50.Thosevariationswerenotstatistically
significant(ChiSquaretest).

These resultssuggest thatpregnancyrates,bleedingafter hysteroscopicmyomectomyarenot

significantly influencedby myoma location,typeand size. Thisdataisconsistent with mostof
the literature already present. Because there are many mechanisms by which myomas may
affect fertility, this paper also suggests thatregardlessof thesize, theireffects onfertility are
moreorlessthesame, evenwithmyomassmallerthan2cm.Thisimpliesthatthereisnoneed
tostratifystudy subjectsbased on locationorsizeofmyomainfertilityoutcomes.Weconsider
theinformationand researchprovidedreliable becausetheyexcludedpatientswithpreviously
diagnosed infertility causes such as patients with multiple myomas, persistentanovulationor
bilateral tubal occlusion and those patients who received intravaginal fertilization in order
eliminate otherpossiblebiasand strengthenconclusions. However,sample sizewassmall and
even though it was a retrospective cohort study, there is the need of a metaanalysis
examinationwithsimilarinvestigationsinordertoestablishasolidconclusion.

Menorrhagia and pregnancy rates after hysteroscopic myomectomy were not significantly
affected by variations in myoma size, type or location. According to our study the myoma
characteristics do not affect improvement rates after hysteroscopy myomectomy in patients
with unexplained infertility or excessive uterinebleeding.Large prospective randomizedtrials
could be designed, to assess the relationship betweensubmucousmyomacharacteristicsand
postoperative outcomes. But we think that in symptomatic patients (menorrhagia and
infertility) with submucous myoma, an expectant management will not be ethical. So
randomizedcontrolledtrialswillbedifficulttodesign.

Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under

MicrosurgicalConditionsinPronouncedUterusMyomatosus

This research article asses the fertility capability and pregnancy outcome after operative
removal of myomas by minilaparotomy in aspecial patient collective.Thisexploresapossible
management for myomas to see if it has beneficialeffectsinthe fertilityof thepatients.This
research was designed as a retrospective cohort study. They used SPSS 18 and calculated
results with the Wald test. The relationship between symptoms and complaints were
determined by thelogistic regressionmethod. Theresultsforthis paperwasthatanaverageof
5.0 myomas were removedinthe patients.Theaverage ofthe maximum sizewas6.6 cmand
the biggest size was 19 cm. 82.5% of the myomas that were selected were intramural.
Postoperative pregnancy rate was 60.3% forwhich28.4%were vaginal deliveriesand 71.6%
wereC/S.Also,the preoperativemiscarriagerate of75.6% wasreducedto22.5%.Someofthe
strengths of this paper was that throughout the discussion of the paper they compare
constantlytheirresultswithpreviouslypublished data andbothhavesimilarresults.Also,they
incorporated myomas that were intramural that are known to cause sterility, infertility or
serious complications of pregnancy. Some of the limitations of this research was that many
womenof thestudywereoverweight or with advancedmaternalagethatarefactorsthatare
knowntocauseinfertility.Sincethisisaretrospectivestudy,itcouldhavepossibleconfounding
factorsaffectingthefinaldata. Also,retrospective studiesarenotgeneralizableto thegeneral
population.Therefore,thisstudyisconsideredLevelII2asevidence.

PregnancyOutcomesFollowingRobotAssistedMyomectomy

This study assesses the pregnancy outcomes in women with symptomatic leiomyomata uteri
who underwent robotassisted laparoscopicmyomectomy(RALM).Thisaimisimportanttoour
study because it explores apossiblemanagementfor myomasto seeif thatmanagement has
beneficial effects in the fertility of the patients. Also, RALM treatment mayoffer aminimally
invasive alternative for uterine preservation for women with uterine fibroids. Some of the
strengths, isthatthroughout thediscussion ofthe paper they compareconstantlytheirresults
with previously published data and both have similar results. Also, it utilizeda largegroup of
peoplefromthreedifferentinstitutions. SomeofthelimitationsarethatDr. Pitter, one of the
authors, is on the speaker bureau for Intuitive Surgical. Also, since this was a retrospective
studyitdid not includeallwomenwhoattempted conceptionafter surgery.Also,themajority
of thewomen,around57.4%,wereoverweight or obesewhichareriskfactorsknowntoaffect
fertility. Since this is a retrospective study and used a population from three different
institutions it is considered a level II2 of evidence. Of note, this paper utilizes different
populations from different institutions. Therefore,this hasa higherlevel ofevidence thanthe
otherselectedpapers.

Pregnancy and Natural Delivery Following Magnetic Resonance ImagingGuided

FocusedUltrasoundSurgeryofUterineMyomas.


Thisscientificarticledescribesa31yearsoldKorean patientwhobecamepregnantand
gave birth following a series of two consecutive Magnetic Resonance ImagingGuided
Focused Ultrasound Surgery (MRgFUS) treatments, treating two distinct uterine
myomas. This study its consider a type III based on case report study design. The
researchers established that MRgFUS for uterus myomatosus could be a potential
beneficial treatment for women with myomas who are seeking to retain their
reproductive capabilities, with reduced complications compared to conventional
treatments. Most of the classical treatments for myomas involve invasive surgical
procedures that lead to scar and adhesion formation. MRgFUS is a procedure that is
noninvasive, thus avoiding scar formation in the uterus. The operator uses the
integrated system to deliver accurate energy pulses to a location identified on
anatomical MRI images. The heat generated during the course of these sonication is
monitored using images acquired in realtime. At the end of the treatment, the results
areevaluatedbythenonperfusedregionsonT1weightedcontrastenhancedimages.
Their study design was a case report study in CHA Bundang Medical Center, CHA
University,Seongnam,Korea.

Four months post treatment, the patient spontaneously conceived, and she continued
her pregnancy to term. After 39 weeks of normal pregnancy, a baby girl was born,
weighing 3,190 gram, through a vaginal delivery. No complications were recorded
during the labor or postpartum periods. This case report proposed that by
noninvasively ablating theinnerportionsof thetreatedmyomas,theywould bothshrink
in size and would become more flexible. The combination of these phenomena may
have contributed to reduction of the submucous component of these myomas and
reduced the possibility ofuterinecavitydistortioncontributingtosuchapositivefertility
outcomes. Some limitations of this case report are the lack of knowledge of prior
infertilityissues andthe limitation to evaluate its applicationsofthisfertilityoutcomesto
the general population. Therefore it isnecessaryto findsimilar casereportsto further
strengthentheirscientificsignificance.

Theeffectivenessofcombinedabdominalmyomectomyanduterinearteryembolization.

In this journal article,investigators establishcomparisons betweentheeffectiveness of

abdominal myomectomy (AM) versus acombinationof uterinearteryembolization(UAE)and
AM in the treatment of uterine myomas larger than 4 cm. Their study design was a
retrospective cohort that allowed the review of charts from patients who hadundergoneAM
within 1 week after UAE. Sample size was limited to 20 study subjects, which is known to
represent a limitation to the study. Outcomes were defined as a decrease in uterinevolume

and myoma diameter, days spent on hospital stay, blood loss volume, amount of myoma
removed as wellaspregnancyratesamongstthestudysubjects.Comparisonsweremadeusing
reports from previously published cohort studies that evaluated thesetreatmentsseparately.
This reports study design is subject to a decreased level of evidence given the inevitable
disparities between the collected data in the present study and the other retrospectivedata
with which the information is being compared to. Of consequence, confounding of results is
morelikely thanifcomparisonswereestablishedwithinthesamestudygroupandresearchers.
Nonetheless, the present study is considered to be a level II2 in quality of evidence, due to
inclusion of a cohort study frommorethanone researchgrouporcenter. Conclusions ofthe
present study include decreased rates of blood transfusion and shorter hospital stays in
patients undergoing UAEAM versus patients undergoing AM alone. Thirty percent of the
women in the study were able to conceive after being subjected to the procedures and
postoperative complications were significantly less than those reported in other studies
evaluatingUAEand AM alone.Ofnote,theresultspresentedhereprovidesupportingevidence
toourproposedstudyquestionthatisofacceptablequality.

CONCLUSIONSTATEMENTS

Toconclude,aninterventionmustbedoneinordertoimprovefertilityinpatientswithuterine
myomas.Watchfulwaitingisnotanoptionwhenfertilityisaffectedbyageofthewomen.
Thereisnoconsensusinspecificmanagementofuterinemyomas.Notreatmenthasbeen
provenmoreeffectivethanothers.Therefore,selectingtheprocedureofchoicemainly
dependsintheresourcesavailableineachhospitalsettingandpatientsdesire.Ideally,in
patientswhowishtomaintainfertility,aminimallyinvasiveprocedurecouldbedoneinorder
tomaintainuterinepreservation.Forexample,myomectomyincombinationwithuterine
arteryembolizationisafeasibleandcosteffectiveoptionforpatientswithamyomatousuterus
thatareofreproductiveageanddesireacosteffectivetreatment.

BONUS

Ideally, a randomized clinical trial would be the best way to assess the best treatment for
uterine myomas in patients who wish to maintain fertility. It would be able to assess the
relationship between uterine myomas and fertility postsurgery and provide information on
whether the study could be generalizable to the population. However, in contrast to
pharmaceutical clinical trials, a randomized clinical trial would be difficult toapply to surgical
interventionsdue to itsdependence onmultiplefactors.Forexample,blindingandinfluenceof
case providers can present difficulties for randomized trials. Surgical procedures involve

various components such as preoperative care, anesthetic procedures, the main surgical
intervention andpostoperativecarewhichinvolveseveralcareprovidersthat directlyaffectthe
outcomes of the patient. Therefore,thesuccessoftheintervention majorly depends onthe
skill, training and dedicationof thosethatintervene. Forthis reason, variations intechniques
andskillcouldbeconfoundingvariableswiththetreatmenteffects.

A prospective cohort study that follows patient fertility outcomes after undergoing
myomectomy, uterine artery embolization, MRgFUS, robot assisted myomectomy or
minilaparotomy myomectomy would be a better study design to assess the most effective
treatment in enhancingpregnancyrates inpreviously diagnosed infertile patients with uterine
myomas. This wouldrepresent an improvementfrom the retrospectivecohortstudiesthatwe
have reviewed becausewe wouldhavemorecontrol over the data collected, oversamplesize
and other possible long termoutcomes such as myomarecurrenceandtime torecoveryafter
surgery. Ideally, wewouldwantasample size from thePuertoRicanpopulationof morethan
500 patients fromdifferent gynecologicclinicsand hospitals. Information would beincludedin
adatabasethatcouldbeconstantlyupdatedonfollowupappointments.Assistedreproductive
technologies would not be usedinour studyasitcouldaffect ourfinalresults andpregnancy
rates. Inclusion criteria would be to have inability to conceivein1year without other known
causesofinfertility,patientsfrom2035yearsofagewithnoknownhistoryofsystemicillness.

REFERENCES

Theeffectivenessofcombinedabdominalmyomectomyanduterinearteryembolization.
McLucas,B.andVoorheesIII,W.D.
InternationalJournalofGynecologyandObstetrics
130
(2015)241243.

(SangWook Yoon, 2010) Pregnancy and Natural Delivery Following Magnetic

Resonance ImagingGuided Focused Ultrasound Surgery of Uterine Myomas.
Yonsei
Med
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