From the Guidelines
For this 44-year-old woman with a large 17 x 10 x 8 cm uterine adenoma (likely leiomyoma/fibroid) causing symptoms of constipation and sexual dysfunction, hysterectomy (option B) is the most appropriate treatment. This recommendation is based on the fact that the patient has completed childbearing (gravida 4, para 4) and has a significantly enlarged uterus causing mechanical symptoms. The size of the mass (17 x 10 x 8 cm) indicates a substantial fibroid that is unlikely to respond adequately to medical management, such as oral contraceptive pills (OCPs) or Leuprolide, a GnRH agonist 1.
While OCPs might help control menstrual bleeding associated with fibroids, they would not reduce the size of such a large fibroid or alleviate the mechanical symptoms of constipation and sexual dysfunction. Leuprolide could temporarily shrink the fibroid and might be used pre-operatively, but it's not suitable as definitive therapy due to side effects with long-term use and rapid regrowth of fibroids after discontinuation.
Some may consider alternative treatments such as uterine artery embolization (UAE), which has been shown to have clinical success rates of 81% to 100% and significant improvement in symptoms such as menorrhagia, dysmenorrhea, and urinary frequency 1. However, given the patient's age, completed childbearing, and symptomatic large fibroids, hysterectomy offers the most reliable long-term solution with high satisfaction rates and elimination of future fibroid-related problems.
Key points to consider in this decision include:
- The patient's age and completed childbearing status
- The size and symptoms caused by the uterine adenoma
- The effectiveness and limitations of alternative treatments such as OCPs, Leuprolide, and UAE
- The long-term benefits and reliability of hysterectomy as a definitive treatment option.
From the Research
Treatment Options for Uterine Leiomyomas
The patient presents with symptomatic uterine leiomyomas, constipation, sexual dysfunction, and an irregular menstrual cycle. The treatment options provided are:
- a. Oral contraceptive pills (OCP)
- b. Hysterectomy
- c. Leuprolide
Evaluation of Treatment Options
Considering the patient's symptoms and the size of the adenoma (17,10, 8cm), the following points are relevant:
- Hysterectomy is a definitive and effective surgical treatment for leiomyoma, as stated in the ACOG Practice Bulletin, Number 228 2.
- OCPs can be used to manage symptoms associated with uterine leiomyomas, but the evidence regarding their effectiveness is limited and of low quality 3, 4.
- Leuprolide is a gonadotropin-releasing hormone agonist that can be used to treat uterine leiomyomas, but its use is not discussed in the provided studies.
Considerations for Treatment Choice
When choosing a treatment option, the following factors should be considered:
- The patient's desire for future childbearing, if any
- The size and symptoms of the uterine leiomyomas
- The patient's overall health and medical history
- The potential risks and benefits of each treatment option
Recommended Treatment Option
Based on the provided studies, hysterectomy (option b) is a definitive and effective treatment for symptomatic uterine leiomyomas, especially for patients with large adenomas and significant symptoms 2, 5. However, the patient's individual circumstances and preferences should be taken into account when making a treatment decision.
Key points to consider:
- Hysterectomy is a major surgery with potential risks and a longer recovery time 5.
- OCPs may be used to manage symptoms, but their effectiveness is limited and of low quality 3, 4.
- Leuprolide is not discussed in the provided studies, and its use would require further consideration of its potential benefits and risks.