Clinical Review

Fibroids: Patient considerations in medical and surgical management

OBG Management Expert Panel

Joseph S. Sanfilippo, MD, MBA
Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences
University of Pittsburgh
Academic Division Director, Reproductive Endocrinology and Infertility
Magee Womens Hospital
Pittsburgh, Pennsylvania

Linda D. Bradley, MD
Professor of Surgery and Vice Chairman
Obstetrics, Gynecology, and
Women's Health Institute
Director, Center for Menstrual Disorders,
Fibroids, and Hysteroscopic Services
Cleveland Clinic
Cleveland, Ohio

Ted L. Anderson, MD, PhD
Vice Chair of Clinical Operations and Quality
Betty and Lonnie S. Burnett Professor
Obstetrics and Gynecology
Director, Division of Gynecology
Vanderbilt University Medical Center
Nashville, Tennessee

Dr. Anderson reports no financial relationships relevant to this article. Dr. Bradley reports receiving grant support from Bayer and Capture-US; serving on the Scientific Advisory Panel of AbbVie, Bayer, Boston Scientific, Medtronics, and PCORI; and receiving royalties from Elsevier, UpToDate, and Wolters Kluwer. Dr. Sanfilippo reports no financial relationships relevant to this article.

Uterine fibroids can cause abnormal bleeding, pain, and infertility. ObGyns should be prepared to develop a treatment plan based on patient symptoms and goals. A panel offers guidance based on experience and expertise.


 

References

Uterine fibroids (myomas or leiomyomas) are common and can cause considerable morbidity, including infertility, in reproductive-aged women. In this roundtable discussion, moderated by OBG Management Editorial Board member Joseph S. Sanfilippo, MD, MBA, 2 experts discuss imaging technologies and classification systems for assessing fibroids, various medical and surgical treatment options, and patient reproductive goals to consider when counseling women with fibroids.

Perspectives on a pervasive problem

Joseph S. Sanfilippo, MD, MBA: First let’s discuss the scope of the problem. How prevalent are uterine fibroids, and what are their effects on quality of life?

Linda D. Bradley, MD: Fibroids are extremely prevalent. Depending on age and race, between 60% and 80% of women have them.1 About 50% of women with fibroids have no symptoms2; in symptomatic women, the symptoms may vary based on age. Fibroids are more common in women from the African diaspora, who have earlier onset of symptoms, very large or more numerous fibroids, and more symptomatic fibroids, according to some clinical studies.3 While it is a very common disease state, about half of women with fibroids may not have significant symptoms that warrant anything more than watchful waiting or some minimally invasive options.

Ted L. Anderson, MD, PhD: We probably underestimate the scope because we see people coming in with fibroids only when they have a specific problem. There probably are a lot of asymptomatic women out there that we do not know about.

Case 1: Abnormal uterine bleeding in a young woman desiring pregnancy in the near future

Dr. Sanfilippo: Abnormal uterine bleeding is a common dilemma in my practice. Consider the following case example.

A 24-year-old woman (G1P1) presents with heavy, irregular menses over 6 months’ duration. She is interested in pregnancy, not immediately but in several months. She passes clots, soaks a pad in an hour, and has dysmenorrhea and fatigue. She uses no birth control. She is very distraught, as this bleeding truly has changed her lifestyle.

What is your approach to counseling this patient?

Dr. Bradley: You described a woman whose quality of life is very poor—frequent pad changes, clotting, pain. And she wants to have a child. A patient coming to me with those symptoms does not need to wait 4 to 6 months. I would immediately do some early evaluation.

Dr. Anderson: Sometimes a patient comes to us and already has had an ultrasonography exam. That is helpful, but I am driven by the fact that this patient is interested in pregnancy. I want to look at the uterine cavity and will probably do an office hysteroscopy to see if she has fibroids that distort the uterine cavity. Are there fibroids inside the cavity? To what degree does that possibly play a role? The presence of fibroids does not necessarily mean there is distortion of the cavity, and some evidence suggests that you do not need to do anything about those fibroids.4 Fibroids actually may not be the source of bleeding. We need to keep an open mind when we do the evaluation.

Continue to: Imaging technologies and classification aids...

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