Guidelines 2016 – Uterine Leiomyomata
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Often referred to as uterine fibroids, fibromyomas, myomas, or fibromas, leiomyomas are benign uterine tumors arising from the smooth muscle and having some connective tissue elements as well. They are nonmalignant growths that do not pose any increased risk for uterine cancer.
II. ETIOLOGY
A. Physiology
1. Appear to arise from single (monoclonal) neoplastic smooth muscle cells (fourth and fifth decades) within the myometrium
2. May be single or multiple
3. May range in size from microscopic to more than 20 cm (filling the abdomen)
4. May occur within the uterine wall (intramural) or extend externally from the serosal surface (subserosal) internally into endometrial cavity (submucous); have both estrogen and progesterone receptors
5. Can also be in broad ligament, ovary, or cervix
6. Occur most commonly during a woman’s fertile years (35–50); usually asymptomatic
7. Usually undergo regression with menopause; rare before menarche
8. Sometimes increase in size with hormonal contraceptives or pregnancy
UTERINE LEIOMYOMATA 231
III. HISTORY
A. What the patient may present with
1. May be asymptomatic
2. Pelvic pain (acute or chronic) in one out of three women
3. Abnormal vaginal bleeding (30%), menorrhagia
4. Urinary frequency, retention, incontinence, urgency
5. Constipation
6. Pelvic pressure
7. Dyspareunia
8. Backache or leg aches
9. Occasionally acute pain
B. Additional information to be considered
1. Menstrual history, menorrhagia, dysmenorrhea
2. History of infertility
3. Habitual spontaneous abortions—may need surgical removal of fibroids
4. Menopausal symptoms
5. LMP, methods of birth control, IUD in place or history of IUD use
6. Any pelvic surgery
7. Pregnancy history; parity—may have a protective effect
8. Use of hormones: oral contraceptives, hormone therapy, infertility drugs
9. Family history; ethnic background; genetic alterations, may run in families—Black women more likely to have fibroids
10. Obesity (elevated body mass index [BMI])
11. OCP use—usually lowers risk for fibroids to develop
IV. PHYSICAL EXAMINATION
A. Vital signs as indicated
B. Abdominal examination
1. Any abdominal guarding or tenderness
2. Location of any pain
3. Bladder (palpable or distended)
C. Vaginal examination
1. Examine cervix for any extraneous tissue, distortion of configuration
2. Palpate vagina for any masses
3. Examine any bleeding or discharge
D. Bimanual examination
1. Examine uterus for tenderness, masses
2. Examine adnexa for masses, tenderness
3. Locate any pain if possible
E. Rectovaginal examination for tenderness, masses
V. LABORATORY EXAMINATION
A. Ultrasound—more detail with transvaginal
B. Pregnancy test if premenopausal or perimenopausal
C. CBC
D. MRI
E. Endoscopic visualization
F. Hysterosalpingography
G. Sonohysterography
VI. DIFFERENTIAL DIAGNOSIS
A. Uterine pregnancy
B. Malignant uterine tumor
C. Ovarian cyst or tumor
D. Extrauterine pelvic mass
E. Bowel tumor
F. Bladder tumor
G. Tumor of ureter, kidney
H. Pelvic abscess
I. Extrauterine pregnancy
J. Bicornuate uterus
VII. TREATMENT
A. As indicated by ultrasound
1. Note the size of leiomyomata with bimanual examination and repeat ultrasound and monitor with exams and/or ultrasounds
2. Consultation for medical management: Progestins, GnRH agonists cause estrogen and progesterone levels to decrease, thus fibroids shrink
3. Consultation for surgical management: hysterectomy, myomectomy, hysteroscope, resectoscope, laser ablation; myolysis or myoma coagulation; cryomyolysis; fibroid embolization
4. Progesterone IUD may provide relief from symptoms of fibroids
5. Androgens such as Danazol can relieve symptoms; no menstruation, thus decrease in fibroid size and uterine size
VIII. COMPLICATIONS
A. Torsion of pedunculated leiomyomata resulting in necrosis
B. Uterine abscess
C. Infarction
D. Hemorrhage
E. Degeneration: hyalinization, cystic, calcification, fatty
F. May affect fertility, increase risk of miscarriage; may also create malposition of fetus, premature labor and delivery
IX. CONSULTATION/REFERRAL
A. Rapid change in size
B. Signs of complications
C. Menorrhagia
D. Compromise of adjacent organs
E. Intractable pelvic pressure or pain
X. FOLLOW-UP
A. Reevaluate every 6 to 12 months or as indicated
B. As indicated under medical management with medication
1. Long-term GnRH agonists for more than 6 months add estrogen for osteoporosis, menopausal symptom relief
See Bibliographies.
Website: www.mayoclinic.com/health/uterine-fibroids/DS00078/DSECTION= symptoms