Treatment for Leiomyomas and Associated Symptoms

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• Discuss the questions that would be important to include when interviewing a patient with painful periods
• Describe the clinical findings that may be present in a patient with painful period cramps.
• Are there any diagnostic studies that should be ordered on a patient with severe period cramps? Why?
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each. ( To ESSAY PRO WRITER Use Fibroids as primay diagnosis, and Adenomysosis, Chronic pelvic inflammatory disease, and Endometriosis as differential diagnosis).
• Discuss your management plan for this patient with fibroids, including pharmacologic therapies, tests, patient education, referrals, and follow-ups. TO ESSAY PRO WRITER READ BELOW FOR THIS QUESTION. YOU CAN TAKE INFORMATION FROM BELOW TO HELP YOU. Thank you
Treatment for Leiomyomas and Associated Symptoms
A Progesterone-releasing intrauterine device (IUD) is an effective option for reducing menstrual blood flow in those with
menorrhagia secondary to fibroids. Another advantage is that it can be left in for five to seven years (potentially longer but not yet
widely accepted). There are potential complications, particularly during the procedure to place the device, but after appropriately
discussing these with a patient it is a viable option. In studies, the progesterone-releasing IUD (levonorgestrel-releasing
intrauterine system) has clearly demonstrated decreased menstrual flow in those with fibroids. In one smaller study, the device
decreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Through
decreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In people
who hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with the fewest side
effects. Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potential
side effects are lower abdominal pain and breast tenderness. The risk of uterine perforation is more likely at the time of insertion.
The risk of infection is within the first 20 days of insertion. Routine STI testing may be performed prior to or during insertion with
immediate treatment if any infection is found. Good patient instructions to monitor for foul-smelling discharge and signs of
systemic infection or perforation are key.
Acupuncture has been used for many pain conditions. Some studies demonstrate effectiveness for dysmenorrhea without uterine
pathology when compared to sham or placebo treatments. In further studies, acupuncture improves the quality of life but may be
associated with higher health costs for the patient.
Combined hormonal contraceptives would be an effective option if the patient has not experienced side effects from these in
the past. Oral contraceptive pills (OCPs) have been proven effective when used for dysmenorrhea related to anovulation only
without a structural problem, especially in a patient who needs birth control. In those with isolated dysmenorrhea, small trials
have demonstrated benefit. However, a meta-analysis of these found insufficient evidence that oral combined hormonal pills are
effective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause both
menorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and may decrease dysmenorrhea by
thinning the endometrial lining. OCPs are commonly known to patients and providers making them often the initial step in
management. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, such
as the vaginal ring and the hormonal patch, are worth considering. These may cause less nausea and vomiting as they bypass the
gastrointestinal system altogether. All types of combined hormonal contraceptives have a slightly increased risk of venous
thromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35
years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The vaginal ring has risks of
leukorrhea and vaginitis in approximately 5% of patients; the other types do not. None of these worsen cervical dysplasia or have
been proven to increase the risk of breast cancer.
Injectable medroxyprogesterone is another potential treatment for leiomyomas and the symptoms associated with them.
However, recent literature does demonstrate that there is bone density loss after several years of use. Other side effects may
include weight gain, irregular menses for weeks to months, and potential mood changes. However, there is no risk of venous
thromboembolism and this can be used in a smoker older than 35. This is a great choice for transgender men as it can help
decrease periods without additional estrogen or a traumatizing procedure.
Hysterectomy is the definitive surgical option for those with secondary dysmenorrhea and those with menorrhagia who no
longer desire to bear children. In a meta-analysis, surgery has been proven to reduce bleeding more at one year than any other
medical treatment. However, medical treatments may have less morbidity depending on the exact etiology of menorrhagia. Some
surgeons will offer hysterectomy to a person with a uterus 14 to 16 weeks in size or greater whether or not the patient has
symptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication for
hysterectomy. For a patient who has failed other management, hysterectomy may be an option. Myomectomy, in which the
clinician removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient’s future
reproductive plans are important in distinguishing these two options. Other procedural options for dysmenorrhea unrelated to
uterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy, though there is insufficient
evidence to recommend those in most cases.
The copper IUD is another effective form of birth control. This device may stay inside the uterus for up to 10 years. For those
who are not planning any children in the near future, this may be a viable option for birth control. An advantage of the copper IUD
is that it has no hormones. However, in people using this, there is an increased risk of dysmenorrhea and menorrhagia just from
the IUD. It is not a treatment for leiomyomas at all. In this case, it could potentially make the symptoms worse.
Since all patients undergoing uterine artery embolization must understand the potential for urgent hysterectomy, consideration
of future fertility is imperative. Some consider this a relative contraindication. Post-procedure, the patient usually has pelvic pain
for at least 24 hours, sometimes lasting up to 14 days. “Post-embolization syndrome” is a group of signs and symptoms that
include pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure to
consider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis of
fibroids, and vaginal discharge, and bleeding for up to two weeks. This treatment is usually reserved for those who cannot tolerate
other hormonal treatments or who do not want those treatments for other reasons.

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