Uterine fibroids are common tumors that can cause heavy menstrual bleeding, pelvic pressure symptoms, and reproductive disorders. The incidence of fibroids peaks in the fifth decade of age and they are more common in African American women. Often, fibroids are asymptomatic and require no treatment. However, the case of Ms P, a 41-year-old woman with recurrent uterine fibroids, menorrhagia, anemia, and fatigue who wishes to retain fertility, illustrates the symptoms that require treatment. Evaluation usually begins with a pelvic examination and an ultrasound to determine both the size and location of the fibroids within the uterus. Standard treatment of symptomatic fibroids is surgical removal by myomectomy or hysterectomy, depending in part on the desire for future fertility; new treatment options include uterine artery embolization via interventional radiologic techniques as well as various medical interventions. Several new therapies show promise but are still experimental at this time. The evidence for treatment options for Ms P and symptomatic patients with fibroids in general is discussed.
A, Abdominal ultrasound shows large fibroids distorting the shape of the uterus. B, Illustration of anatomical structures in view. (See also interactive eFigure.)
Abnormal uterine bleeding is influenced by the size and location of fibroids. Larger fibroids and fibroids located in or near the endometrial cavity tend to cause more bleeding symptoms and reproductive disorders. In a representative tissue sample, a fascicular pattern of smooth muscle bundles can be seen, separated by vascularized connective tissue. Individual smooth muscle cells are elongated with eosinophilic cytoplasm, distinct cell membranes, and uniform “boxcar-shaped” nuclei. Mitoses, in this case and in most fibroids, are extremely rare and, if present, raise the possibility of leiomyosarcoma, a malignant tumor of smooth muscle origin.
A, During UAE, a catheter is introduced along a guide wire into the femoral artery and advanced through the external iliac artery into the common iliac artery. The catheter is then guided into the internal iliac artery and then into the uterine artery. Microspheres injected through the catheter embolize the distal branches of the uterine artery that supply the fibroid and block perfusion, causing necrosis and shrinkage of the fibroid. B, Angiogram prior to UAE shows the blood supply of a large fibroid. After embolization of the uterine artery, absence of contrast in the distal branches confirms occlusion.
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Abdominal Ultrasound of a Woman with Uterine Fibroids
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