Case study: As you review your patient list this afternoon, you note that your next patient has returned for a follow-up visit. You last saw her in clinic two weeks ago for chief complaints of pelvic pressure and abnormal menstrual bleeding. When you enter the exam room, you see a 35-year-old woman in no apparent distress, scrolling through her cell phone. The patient, Amanda, looks up and cheerfully greets you. You remember her from her last visit, when she told you about her worsening pelvic pressure, low back pain, and excessive menstrual bleeding. At the time, you ordered a CBC and a transvaginal ultrasound. Not surprisingly, she was slightly anemic and her ultrasound showed one moderately-sized uterine fibroid. After you tell Amanda that the most likely cause of her symptoms was a uterine fibroid, the patient asks you, “How did I get fibroids?”
You tell the patient that fibroids are very common, and their frequency increases with age until menopause, at which time many fibroids shrink. Several factors increase the likelihood of developing fibroids, including family history, African descent, nulliparity, obesity, early menarche, and age older than 40 years. Because fibroids grow in the presence of estrogen and progesterone, the use of oral contraceptives, multiparity and late menarche decrease the likelihood of developing fibroids. Amanda has a history of African descent, a significant family history of fibroids, and has never been pregnant. She notes that her mother had a hysterectomy in her 30’s for fibroids, but the patient would like to have children someday. Amanda asks you, “Are there any treatments for my fibroids that don’t involve getting a hysterectomy?”
You are happy to tell her that there are now a number of treatments other than hysterectomy for managing fibroids and decreasing the blood loss association with them. Since she is symptomatic and would like to preserve her fertility, you recommend a combination of NSAIDs and either oral contraceptives or a levonorgestrel-releasing intrauterine system (Mirena IUD). Other options for medical treatment include tranexamic acid (Cyklokapron), a gonadotropin-releasing hormone agonist, or a selective progesterone receptor modulator. If the patient encounters any problems with infertility or would like a surgical therapy, you might also recommend a myomectomy. However, since you do not personally perform myomectomies in your practice, you would want to discuss this option with the patient’s gynecologist. What do you do next?
Because Amanda is premenopausal and the mass is clearly a fibroid, she does not require additional imaging or endometrial biopsy. Instead, you can start treatment and schedule a follow-up with her if her symptoms do not improve. Amanda tells you she would like to start management with oral contraceptives and NSAIDs for now and she will follow-up in a month.
De la cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 2017;95(2):100-107.
Dr. V. Silverstein
Published on 11/15/19