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Dx Leiomyomata/ Fibroid Uterus Treatments: Read more...


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Observation:
Leiomyomata/ Fibroid Uterus

The Merck Manual Home Edition states:
"A fibroid is a noncancerous tumor composed of muscle and fibrous tissue.
*Fibroids can cause pain, abnormal vaginal bleeding, constipation, repeated miscarriages, and an urge to urinate frequently or urgently.
*Doctors do a pelvic examination and usually ultrasonography to confirm the diagnosis.
*Treatment is necessary only if fibroids cause problems.
*Doctors may prescribe drugs to control the symptoms, but surgery or a procedure to destroy the fibroids is often needed to relieve symptoms or to make childbirth possible.

*Fibroids in the uterus are the most common noncancerous tumor of the female reproductive tract. By age 45, about 70% of women develop at least one fibroid. Many fibroids are small and cause no symptoms. But about one fourth of white women and one half of black women have fibroids that cause symptoms. Fibroids are more common among women who are overweight.

*By age 45, about 7 out of 10 women develop fibroids of the uterus.
*What causes fibroids to grow in the uterus is unknown. High levels of estrogen and possibly progesterone(female hormones) seem to stimulate their growth. Fibroids may become larger during pregnancy—when levels of these hormones increase—and fibroids tend to shrink after menopause—when levels decrease drastically. If fibroids grow too large, they may not be able to get enough blood. As a result, they begin to degenerate and cause pain.

Fibroids may be microscopic or as large as a basketball. They may grow in different parts of the uterus, usually in the wall (which has three layers):
*In the wall of the uterus (intramural fibroids)
*Under the inside layer (lining or endometrium) of the uterus (submucosal fibroids)
*On the outside of the uterus (subserosal fibroids)
*Some fibroids grow from a stalk (called pedunculated fibroids). Some submucosal fibroids extend into the interior of the uterus (called intracavitary fibroids). Fibroids that grow in the wall or just under the endometrium can distort the shape of the interior of the uterus. Often, women have more than one fibroid.

Diagnosis
Doctors may suspect fibroids based on results of a pelvic examination. However, imaging tests are often needed to confirm the diagnosis.
Imaging tests include:
*Transvaginal ultrasonography: An ultrasound device is inserted into the vagina.
*Saline infusion sonography (sonohysterography): Ultrasonography is done after a small amount of fluid is infused into the uterus to outline its interior.

If women have had any bleeding other than that during their menstrual periods, doctors may want to exclude cancer of the uterus. So they may do a Papanicolaou (Pap) test, a biopsy of the uterine lining (endometrial biopsy), ultrasonography, sonohysterography, or hysteroscopy. For hysteroscopy, a viewing tube is inserted through the vagina and cervix into the uterus. A local, regional, or general anesthetic is often used. During hysteroscopy, a sample of tissue may be removed and examined (biopsy).

Treatment
For most women who have fibroids but no bothersome symptoms or other problems, treatment is not required. They are reexamined every 6 to 12 months so that doctors can determine whether symptoms are worsening or lessening and whether fibroids are growing.
Several treatment options, including drugs and surgery, are available if bleeding or other symptoms worsen or if fibroids enlarge substantially.
Drugs:
A few drugs may be used to relieve symptoms or to shrink fibroids, but their effects are only temporary. No drug can permanently shrink a fibroid.
Gonadotropin-releasing hormone (GnRH) analogs are most commonly used. These drugs are synthetic forms of a hormone produced by the body (GnRH). Leuprolide and goserelin are most commonly used. They can shrink fibroids and reduce bleeding by causing the body to produce less estrogen (and progesterone). Because they shrink the fibroids and reduce bleeding, doctors may give GnRH analogs before surgery to make removal of fibroids easier, reduce blood loss, and thus reduce the risks of surgery. The drugs may be injected once a month or implanted as a pellet under the skin. Nafarelin, another GnRH analog, can be used as a nasal spray. GnRH analogs are usually taken for less than 6 months. If taken for a long time, they may reduce bone density and increase the risk of osteoporosis. Low doses of estrogen, usually combined with a progestin (a drug that is similar to the hormone progesterone), may be given with GnRH analogs to help prevent loss of bone density. Within 6 months after GnRH analogs are stopped, fibroids may become as large as they were before treatment.

Progestins (such as medroxyprogesterone acetate or megestrol) can control bleeding in some women. They reduce bleeding by preventing the lining of the uterus from growing too much. When the uterine lining grows too much, there is more of it to break down and be shed. As a result, menstrual bleeding may be heavier than usual. Progestins are taken by mouth. They may be taken every day or only for 10 to 14 consecutive days each menstrual cycle. Or doctors may give women injections of medroxy-progesterone acetate every 3 months or insert an intrauterine device (IUD) that releases this drug. If taken by mouth every day or injected, progestins also provide contraception. However, these drugs may have bothersome side effects, such as weight gain, depression, and irregular bleeding.

Rarely, other drugs can be prescribed. They can be used if a GnRH analog or progestin has been ineffective or has bothersome side effects. These drugs include:
*Mifepristone and related drugs (called antiprogestins): These drugs inhibit the activity of the hormone progesterone.
*Raloxifene and related drugs (called selective estrogen receptor modulators, or SERMs): These drugs reverse some of estrogen's effects. They may not be as effective as other drugs.
*Danazol (a synthetic hormone related to testosterone): Danazol inhibits the activity of estrogen and progesterone. It has many side effects, such as weight gain, acne, increased body hair (hirsutism), swollen ankles, loss of scalp hair, and lowering of the voice.
*Tranexamic acid: This drug works by preventing blood clots (which are made by the body to help stop bleeding) from breaking down as quickly. As a result, bleeding decreases.
*Nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain but may not reduce bleeding.

Surgery:
Surgery is usually considered for women who have any of the following:
*Fibroids that are rapidly enlarging
*Bleeding that continues or recurs despite treatment with drugs
*Severe or persistent pain
*Large fibroids that cause problems, such as the need to urinate frequently, constipation, pain during sexual intercourse, or blockage of the urinary tract
*For women who want to conceive, fibroids that have caused infertility or repeated miscarriages.

If women do not want to have any more children or want a definitive cure, surgery may be a good option. Several types of surgery can be done. Which one is recommended depends on the size, number, and location of fibroids. However, before making a decision about treatment, women should talk to their doctor about the problems that can result from each type of surgery so that they can make an informed decision.

Surgery to treat fibroids traditionally involves one of the following:
*Hysterectomy: The uterus is removed, but the ovaries are not. Hysterectomy is the only permanent solution to fibroids. However, after hysterectomy, women cannot have children. Thus, hysterectomy is done only when women do not wish to become pregnant.
*Myomectomy: Only the fibroid or fibroids are removed. In contrast to a hysterectomy, most women who have a myomectomy can have children. Also, some women feel psychologically better when they keep their uterus. However, after myomectomy, new fibroids may grow, and about 25% of women need a hysterectomy about 4 to 8 years later.
*[Editor] Uterine artery ablation cuts the blood supply to the uterus and may cause it to shrink in size and uterine bleeding stop. It is less invasive and safer than hysterectomy.

For uterine artery embolization, doctors use an anesthetic to numb a small area of the thigh and make a small puncture hole or incision there. Then, they insert a thin, flexible tube (catheter) through the incision into the main artery of the thigh (femoral artery). The catheter is threaded to the arteries that supply blood to the fibroid, and small synthetic particles are injected. The particles travel to the small arteries supplying the fibroid and block them. As a result, the fibroid dies, then shrinks. Most of the rest of the uterus appears to be unaffected. However, whether the fibroid will regrow (because blocked arteries reopen or new arteries form) is unknown. After this procedure, most women have pain and cramping in the pelvis, nausea, vomiting, fever, fatigue, and muscle aches. These symptoms develop within 48 hours after the procedure and gradually lessen over 7 days. An infection may develop in the uterus or surrounding tissues. Women recover more quickly after this procedure than after a hysterectomy or myomectomy. Some procedures (high-intensity focused sonography, radiofrequency ablation, and magnetic resonance-guided focused ultrasound surgery) use heat to destroy fibroids. For these procedures, doctors insert a needle that transmits an electrical current or heat into the fibroid and use it to destroy the core of the fibroid. In another procedure (cryoablation), a cold probe is used to destroy the fibroid. Ultrasonography or magnetic resonance imaging may be used with these procedures to locate the fibroids.

After these treatments, fibroids may grow back. In such cases, another treatment or a hysterectomy may be recommended."<>td>

Medications Used in Treatment:
1. Progestins: Provera, Prometrium
2. Oral Contraceptives: Yaz, LoEstrin
3. Danazol
4. Androgens
6. Estrogen Antagonists
7. Aromatase inhibitor: Tamoxifen, Arimidex


Suggested Links:
*N.H.S. United Kingdom
*Medscape


*[Editor]   In our experience, and those of others, the use of low dose danazol controls uterine bleeding, except for emergency bleeding. As a gynecologist, an office D&C (dilatation and curettage) is performed to stop the bleeding and rule out malignancy or any persistent mass. "Intrauterine fibroids can often be palpated. Many women whom have had persistent uterine bleeding elect to have an "endometrial ablation" and resection of intrauterine leionyomata invented by my colleague, Milton Goldrath, M.D. in Detroit, Michigan in 1979. The procedure worked well for 30 years; today, the Editor follows a course of mixed androgen therapy. Not only is the bleeding controlled, but the hormonal replacement is beneficial in that it can keep some fibroids from growing and shrink some; for maintaining bone and muscle, mental focus, and libido.

Over the last 15 years, the post-operative use of aromatase inhibitors has gained favor. The original medication, Tamoxifen, had the troubling side-effect of thickening the uterine lining and causing more uterine bleeding so it was added to Lupron®. The second generation medication was Arimidex®/anastrozole with Alesse® was better, then letrozole can be used with northisterone. The strongest of the aromatase inhibitors is Aromasin®/exemestan. Data is limited but when it has been added to Lupron® in creates a more atropic uterine lining.

*[Editor] Two of the F.D.A. approved anabolic steroids described in use as the mixed androgen injection have been used in menopausal women, even with breast cancer.
1) Stanozolol
has been used in patients with advanced metastatic carcinoma with almost half having a positive response.
2) Nandrolone
has been combined with the aromatase inhibitor (tamoxifen) for prophylaxis against breasts cancer recurrences. The use of these two anabolic steroids do not raise, rather they lower estradiol and progesterone levels. These anabolic steroids can improve the quality of life: the women have less symptoms of menopause: they offer treatments for the hot flushes, insomnia, osteoporosis, poor memory and loss of libido. The two anabolic steroids used together will produce usually an atrophic endometrium.

*[Editor] A recent article from the French note that:
*Letrozole seems as efficient as GnRH in reducing leiomyomata volume and provides less hot flushes.
*Mifepristone reduces the size of leiomyomata but can cause endometrial hyperplasia.
*Danazol could be useful to reduce leiomyomata related symptoms in short terms.

*[Editor] Experience with the mixed androgen therapy has been effective for more than 15 years in shrinking some medium sized leiomyomata and avoiding some hysterectomies.

*[Editor]: An August 2015 article in the American Journal of Obstetrics and Gynecology highlighted that the cost of leiomyomata (fibroids) was $2,400 to almost $16,000 in excess indirect costs per years; the direct costs were almost $10,000 per year. Now with evidence that a mixture of anabolic steroids may shrink moderately sized leiomyomata while stopping or minimizing bleeding complications.

Copyrighted 2014© Revised November 1, 2015