Week 6 DB #2 Uterine Fibroid Protocol
What are uterine fibroids? Uterine Fibroids are also called leiomyomas or myomas, which are benign smooth muscle cell tumors. Uterine fibroids occur in 70% of women, but only 30% of women become symptomatic. Uterine fibroids are the most common clinical indication for hysterectomy, which may prematurely end a woman’s reproductive life. Statistically, African American women are more likely to experience symptoms and develop uterine fibroids at an early age when compared to Caucasian women (Navarro et al., 2021).
What kind of pain is present when someone has uterine fibroids? Uterine fibroids typically cause heavy and prolonged bleeding during menses. They may cause pressure and compression pain which can be acute or prolonged and severe in quality, depending on tumor location and its impact on surrounding uterine structures and organs.
What are the different characteristics included in this diagnosis? Uterine fibroids cause heavy prolonged menses which are associated with fatigue, dyspnea, infertility, palpitations, pelvic pressure or fullness, recurrent pregnancy loss, acute or severe pelvic pain, constipation, tenesmus (posterior myomas), and urinary frequency or urgency (anterior myomas) (Navarro et al., 2021).
What is the pathophysiology? – Are there different types of uterine fibroids?
Uterine Fibroids cause increased vascularity, venous congestion, and increased surface area of the uterine cavity. They are considered to be estrogen-dependent tumors, that overexpress certain estrogen and progesterone receptors when compared to normal surrounding myometrium (Barjon et al., 2023). The fibroids may be sub-serosal which project into the pelvis, intramural, occurring within the uterine wall, or submucosal, which project into the uterine cavity. They may also arise from the cervix or broad ligament and range from being microscopic to easily palpable as large solid masses, occurring as single or multiple tumors (Barjon et al., 2023).
Endometriosis
Endometriosis is caused by the presence of endometrial tissue that develops outside the uterus into the pelvic and abdominal cavity, most commonly found on or around the ovaries. It is believed to be caused by the reflux of menstrual tissue causing inflammation, scarring, and cyclical pain. It is believed that endometrial cell resorption commonly occurs in 90% of menstrual females with patent fallopian tubes. Endometriosis is typically diagnosed in 30 % of women 25 to 35 years old who report chronic pelvic pain. Signs and symptoms of endometriosis include pelvic pain occurring 1-2 days before menstruation, heavy menstrual bleeding, premenstrual spotting, dysmenorrhea, cyclic bleeding at distant sites such as bowel, bladder, or pleural cavities, pain with intercourse, and difficulty conceiving (Chauhan et al., 2022). Laparoscopy is the preferred method for diagnosis to visualize endometrial implants. Serum CA 125 may be elevated but is insufficient for an accurate diagnosis. NSAIDS are considered first-line therapy and may be administered with low-dose ethinyl estradiol monophasic oral contraceptives to suppress ovulation and menstruation (Cash, 2024).
Subjective data
What patient history should be included here?
Assessing the patient’s onset of menses is an important consideration. Early menarche is a risk factor for uterine fibroids, as is nulliparity. Asking about the frequency of menses as well as the duration and how heavy the bleeding is important for identifying common signs and symptoms of fibroids. The patient should be asked about their use of oral contraceptives, history of STIs, sexual history, history of hypertension, excessive alcohol, tobacco use, red meat consumption, genetic factors such as having Reed’s syndrome, Bannayan-Zonaya syndrome (Navarro et al., 2021). The patient should also be asked if they are planning to become pregnant within the next year, or if they desire to have children in the future. Uterine fibroids are found to have a familial genetic component. Assessing a family history with the mother, grandmother, and siblings is an important consideration (Cash, 2024).
What presenting symptoms or presenting factors are essential to note that qualify this patient to be in the protocol?
Subjective Data:
Example of CC: A 27-year-old female complains of pelvic pain and pressure that is “severe 8/10” and intermittent occurring for 3 months with heavy bleeding for 10-14 days every 21 days. The patient started menses at 10 years of age and was regular every 28 days with moderate bleeding up until 3 months ago. The pain is mildly relieved with “OTC NSAIDS and a heating pad.” The patient is sexually active with her husband, has no history of STIs, and would like to get pregnant in the next year. The patient had a normal pap with co-testing one year ago (-) HPV. The patient reports that her mother and sister have a history of painful fibroids.
A patient with uterine fibroids may report an early onset of menses, familial history of fibroids, use of OCP before the age of 16, symptoms of heavy, prolonged menses, dyspnea, pelvic pressure or fullness, acute pelvic pain, heart palpitations, constipation, and/or urinary frequency or urgency.
Objective Data: (Example of Expected Physical Exam Findings)
VS: HR 95, BP 130/80, RR 20, O2 98%, Height: 5’6”, Weight: 127 BMI: 20.5 (healthy weight)
ROS
General/Constitutional: The patient denies fever, chills, and unintentional weight loss.
Respiratory: (+) Shortness of breath.
Cardiovascular: (+) Irregular rate and rhythm, elevated heart rate. (+) Anemia HgB >12 g/dL.(+) Conjunctival pallor.
Gastrointestinal: (+) Abdominal guarding, distension, firm palpable masses, constipation, tenesmus.
Genitourinary/Reproductive: (+) Urinary frequency and/or urgency. (+) Heavy bleeding and/or prolonged bleeding with menses. (+) Pelvic pain and pressure or fullness. (+) Enlarged, firm, or irregular uterus findings.
Speculum Exam: (-) for cervical or vaginal pathology.
Bimanual Exam: (+) Enlarged uterus with (+) adnexal tenderness.
POCT: Urine pregnancy test (-), (+) HgB 10.9 g/dL, (-)Speculum exam, (+) bimanual exam. (+)Transvaginal Ultrasound to confirm diagnosis and evaluate for ovarian neoplasms or other uterine abnormalities. Fibroids are visualized as firm, hypoechoic, well-circumscribed masses and measured (Barjon et al., 2023).
Assessment (Diagnosis):
1. D25.9 Leiomyoma of the Uterus, unspecified. Pertinent (+) The patient has a familial history of fibroids in their mother and sister. The uterus is enlarged and adnexal tenderness is present upon examination.
2. D64.9 Anemia, unspecified. Pertinent (+) HgB 10.9 g/dL.
DDX:
1. N93.9 Abnormal uterine bleeding and vaginal bleeding, unspecified. Abnormal changes in menstrual frequency, duration, and volume. Pertinent (+) The patient reports heavier bleeding, occurring for 10-14 days every 21 days. Pertinent (-) The patient denies any abdominal or pelvic pain or pressure, constipation, urinary urgency, heart palpitation, or dyspnea.
2. N80.9 Endometriosis. The presence of endometrial tissue found outside of the uterus causes pain 1–2 days before menses, premenstrual spotting, heavy menstrual bleeding, pain with intercourse, and infertility (Cash, 2024). Pertinent (-) The patient reports her pain is constant and not cyclical.
3. O00.9 Ectopic Pregnancy, unspecified. Pertinent (-) Negative Beta HCG pregnancy test.
Plan:
Diagnostic Tests: Beta HCG, CBC, CMB, Total Ferritin, TSH and Free T4, Lipids, and Vitamin D to assess for endocrine and metabolic imbalances and disorders. A Transvaginal Ultrasound to confirm diagnosis and evaluate for ovarian neoplasms rule out ectopic pregnancy. and assess for endocrine and metabolic imbalances and disorders (Cash, 2024). If the Transvaginal ultrasound is inconclusive, an MRI or sonohysterograph may be indicated to detect submucous or intramural fibroids. An endometrial biopsy may also be indicated to rule out our endometrial neoplasms (Epocrates, 2024).
Pharmacologic: (For a woman desiring pregnancy)
Ferrous Sulfate 325 mg tablet PO 3x weekly (90 tablets with 3 refills) for Anemia.
Primary options for uterine fibroids for a woman desiring pregnancy:
Leuprolide 3.75 mg intramuscularly once a month injection for three months.GnRH antagonists in combination with estradiol and norethindrone are approved for the management of heavy menstrual bleeding associated with uterine fibroids in premenopausal women. (Epocrates, 2024).
Levonorgestrel intrauterine device insert 52 mg device into the uterine cavity and remove and replace in 6 years or sooner, when pregnancy is desired.
Mifepristone 5-50 mg tablet PO once daily for 3 to 6 months.
Elagolix/estradiol/norethindrone acetate and elagolix 300 mg/1mg/0.5 mg tablet PO twice daily in the morning and evening for up to 24 months (180 tablets with 3 refills).
Mifepristone 5-50 mg tablet PO once daily for 3 to 6 months.
Secondary options:
Naproxen: 500 mg tablet PO twice daily as needed (60 tablets with 3 refills)NSAIDS should be taken with food and are effective in managing pain associated with pelvic pain (Epocrates, 2024).
Tranexamic acid 1300 mg tablet PO TID for a maximum of 5 days during menstruation (15 tablets with 3 refills). Tranexamic acid reduces heavy menstrual bleeding and causes necrosis of fibroids (Epocrates, 2024).
Non-Pharmacologic: A surgical myomectomy can preserve fertility and promote successful pregnancy when the fibroid (s) distort the uterine cavity and symptoms are not resolved with medication therapies (Epocrates, 2024).
A hysterectomy is the preferred treatment for women with recurring myomas who do not want to desire pregnancy.
Patient Education: Maintaining weight with a healthy diet, and physical exercise helps to prevent the occurrence of fibroids. Fibroids are benign tumors a majority of the time, but it is important to monitor them for changes (Barjon et al., 2023). The risks of a myomectomy include recurrence of fibroids and hemorrhage. Pregnancy should be postponed for 6 months after a myomectomy and Cesarean delivery may be the preferable option post-myomectomy. Prolonged use of GnRH agonists such as leuprolide may cause bone loss. Mifepristone has been noted to cause endometrial hyperplasia in 28% of women treated for uterine fibroids (Epocrates, 2024). Report any worsening pain to your health care provider and CALL 911 for bleeding that is uncontrolled and saturates two maxi pads for two hours.
Referral: Refer to a fertility specialist to evaluate for other causes of infertility.
Follow-Up/RTC: Follow up in 4 weeks to discuss the efficacy of medications and symptom management. Repeat HgB screening and transvaginal ultrasound every 3 months to determine fibroid growth, and then every 6 months until stable. Annual bone density tests are indicated if the GnRH agonist is continued for >6 months (Epocrates, 2024).
Health Maintenance: Pap every 3 years or Pap with Co-testing every 5 years per Guidelines. Influenza vaccination is due annually. Vision exam and Annual Physical Due annually (USPSTF, 2023).