Patient Cases

1

35 year old woman

16 week size fibroid uterus desiring fertility. History of a prior myomectomy.

Symptoms

  • Infertility
  • Increased urinary frequency
  • Pelvic pressure

Ultrasound

17 cm uterus with multiple fibroids, large lower uterine segment fibroid

Examination

14 week size fibroid uterus

Recommendations

Expectant management (no treatment) or myomectomy. Pre-op Lupron recommended to shrink the large lower uterine segment fibroid

Treatment

Patient underwent uncomplicated myomectomy through mini-laparotomy incision 3 months following Lupron injection. 6 fibroids removed. Adhesions of uterus to abdominal wall encountered and lysed. Minimal blood loss. Patient discharged on post-op day #1.

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2

30-year-old woman

Endometrial cavity distortion due to fibroid uterus desiring fertility.

Symptoms

  • Infertility
  • Heavy menses
  • Increased urinary frequency
  • Pelvic pressure

Ultrasound

Uterus with multiple fibroids, large fibroid compressing endometrial cavity

Examination

14 week size fibroid uterus

Recommendations

Expectant management (no treatment) or myomectomy. Discussion of decreased pregnancy rate and increased miscarriage rate due to compression of endometrial cavity where embryo implants

Treatment

Patient underwent uncomplicated myomectomy through mini-laparotomy incision. Large central fibroid plus other smaller ones removed. Minimal blood loss. Patient advised that she will require cesarean deliveries in future due to incisions > 50% of myometrial wall thickness. Patient discharged on post-op day #1.

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3

42-year-old woman

16 week size fibroid uterus not desiring fertility.

Symptoms

  • Heavy, irregular vaginal bleeding
  • Increased urinary frequency
  • Pelvic pain

Prior treatments

Failed treatment with Mirena IUD and oral contraceptive pills (OCPs)

Ultrasound

10 cm central fibroid

Examination

16 week size fibroid uterus

Recommendations

Expectant management (no treatment), Uterine Fibroid Embolization (UFE), myomectomy, supracervical hysterectomy (SCH).

Treatment

Patient underwent uncomplicated supracervical hysterectomy (SCH) through mini-laparotomy incision. Large central fibroid removed to debulk uterus prior to removing uterus. Minimal blood loss. Patient discharged on post-op day #1.

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4

46-year-old woman

30 week size fibroid uterus not desiring fertility.

Symptoms

  • Heavy, irregular vaginal bleeding
  • Increased urinary frequency
  • Abdominal distension
  • Pelvic pain

Ultrasound

30+ cm uterus with multiple fibroids

Examination

30+ week size fibroid uterus

Recommendations

expectant management (no treatment), myomectomy, supracervical hysterectomy (SCH).

Treatment

She received Lupron pre-op to shrink uterus and increase hemoglobin. Patient underwent uncomplicated supracervical hysterectomy (SCH) through mini-laparotomy incision. Multiple fibroids removed to debulk uterus prior to removing uterus. Minimal blood loss. Patient discharged on post-op day #1.

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5

22-year-old woman

Irregular vaginal bleeding and mass prolapsing through cervix initially believed to be a benign fibroid.

Symptoms

  • Spotting throughout the month
  • Ultrasound

  • Suspected fibroid in the endometrial cavity
  • Examination

  • Necrotic fibroid at top of the vagina passing through a partially dilated cervix. The uterus was 14-week size.
  • Recommendations

  • Patient initially recommended to undergo vaginal myomectomy
  • Treatment

    D&C with removal of necrotic mass. Pathology reported a Leiomyosarcoma (cancerous fibroid). The patient then underwent TAH/BSO (total abdominal hysterectomy, bilateral salpingo-oophorectomy), lymph node dissection, and omentectomy.

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    6

    33-year-old woman

    15 week size fibroid uterus not desiring fertility. Prior vaginal deliveries. One prior pelvic surgery.

    Symptoms

    • Heavy menses
    • Increased urinary frequency
    • Dyspareunia (painful intercourse)

    Ultrasound

    Uterus with multiple fibroids

    Examination

    15 week size fibroid uterus

    Recommendations

    Expectant management (no treatment), UFE, myomectomy, vaginal hysterectomy

    Treatment

    Patient underwent uncomplicated vaginal hysterectomy. Multiple fibroids removed vaginally to debulk uterus. Minimal blood loss. Patient discharged on post-op day #1.

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    7

    32-year-old woman

    14 week size fibroid uterus desiring fertility.

    Symptoms

    • Heavy menses
    • Increased urinary frequency
    • Dyspareunia (painful intercourse)
    • Infertility

    Ultrasound

    Uterus with multiple fibroids distorting endometrial cavity

    Examination

    14 week size fibroid uterus

    Recommendations

    Expectant management (no treatment) or myomectomy

    Treatment

    Patient underwent uncomplicated myomectomy via mini-lap incision. Multiple fibroids removed to debulk uterus. Minimal blood loss. Patient discharged on post-op day #1.

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    8

    40-year-old woman

    18 week size fibroid uterus not desiring fertility, but desiring uterine preservation.

    Symptoms

    • Increased urinary frequency
    • Pelvic pain

    Ultrasound

    Uterus with multiple fibroids

    Examination

    18 week size fibroid uterus

    Recommendations

    Expectant management (no treatment), UFE, myomectomy, hysterectomy.

    Treatment

    Patient underwent uncomplicated myomectomy via mini-lap incision. Multiple fibroids removed to debulk uterus. Minimal blood loss. Patient discharged on post-op day #1.

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    9

    40-year-old woman

    18 week fibroid uterus treated with UFE

    Symptoms

    • Bulk symptoms of back pain, urinary frequency, and pelvic pressure moderately affecting her quality of life (QOL).

    Ultrasound

    Multiple fibroids

    Examination

    18 week bulky fibroid uterus

    Recommendations

    No treatement, UFE, Myomectomy, and Hysterectomy recommended to this pateint not desiring fertility.

    Treatment

    Patient underwent UFE as an outpatient. She returned to work in one week. Three months post-UFE, her uterus had shrunk to 14 week size. Her bulk symptoms had significantly improved.

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    10

    49-year-old woman

    Presented for a 2nd opinion after hysterectomy was recommended due to the risk of malignancy.

    Symptoms

    • She reported minimal symptoms, not affecting her quality of life.

    Ultrasound

    Multiple large fibroids

    Examination

    20 week size uterus filling the pelvis up to her umbilicus

    Recommendations

    The patient was educated of the rarity of leiomyosarcoma. Given minimal effect on her QOL and proximity to menopause, no treatment (expectant management) was recommended. Other options discussed were UFE, myomectomy, and hysterectomy.

    Treatment

    She elected no treatment with no increase in her symptoms. Following menopause, her uterus decreased in size by 50%.

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