Uterine Fibroids and Adenomyosis Test Questions

CPT Laurie Kwolek
Uterine Fibroids and Adenomysosis

The key difference between uterine fibroids and adenomyosis is

Uterine fibroids seldom exceed 5lbs whereas adenomyosis tumors can exceed the size of a watermelon.
Uterine fibroids can vary grossly in size and occur as one or clusters of abnormal tissue whereas in adenomyosis, endometrial tissue discretely penetrates into fibrous tissue of the myometrium causing either a focal or diffuse inflammatory-like process particularly during menses.
Uterine fibroid proliferation is largely moderated by immunologic responses of TNF alpha whereas adenomyosis is more affected by circulating levels of IL6.
Uterine fibroids can only be truly cured via a hysterectomy whereas adenomyosis can only be truly cured by removal of affected area of the myometrium.

The correct answer is b. Uterine fibroids to vary in extremes of size so much that some can only be seen under a microscope and others can grow up to 50lbs (largest recorded 140lbs!!! Adenomyosis, on the other hand, is resultant of endometrial tissue that finds its way into the muscular layer of the myometrium thus exposing the muscle tissue to the cyclic endometrial changes which leads to swelling, bleeding, and discomfort. Answer a. is incorrect because there is no report to date that states the typical size of fibroids and adenomyosis is not a tumor. Answer c. is incorrect because there is no evidence that either of these immunologic factors influence either uterine disorder. Answer d. is also incorrect because there are many therapeutic agents available that mediate the severity of these uterine abnormalities however with uterine fibroids, to “cure” a particular fibroid means to remove the fibroid (myomectomy) but removal of the uterus is often not necessary. However, because adenomyosis is not tumor like/or encapsulated, in order to remove the involved tissue requires removal of the uterus. Recall, too that there are new procedures, ultrasound and laser, which are improving each day and getting closer to this “cure” like state for both abnormalities so hysterectomies may become a thing of the past for women who suffer from fibroids and adenomyosis.

Most clients with either uterine fibroids and or adenomyosis will present with

Predictable monthly uterine colic, malaise, excessive bleeding and back pain.
No symptoms
A classic triad of increased uterine size, menometrorrhagea, pelvic fullness
Infertility, urinary frequency, irregular uterine bleeding and abdominal pain.

The correct answer is b. MOST women with either uterine fibroids or adenomyosis are asymptomatic. Answer a. is incorrect because symptoms are not always predictable-symptoms care vary largely depending on the growth of the fibroid or uterine tissue. Answer c. is incorrect because while this is the classic triad for adenomyosis, it is not for uterine fibroids and still MOST women are asymptomatic for both. Answer d. is incorrect because these are additional symptoms not the MOST common.

Special points to consider when preparing a female active duty service member for deployment include

Ensuring that the female has a current profile to limit her duties to CONUS operations only just in case her status changes.
Ensuring that the female has a current profile to limit her physical activities to walking at own pace, no stair climbing, no swimming, no heavy lifting to prevent any undue stress to her pelvic anatomy.
Complete a thorough obstetric and gynecological exam, obtain a CBC, urine hCG, and provide an updated physical profile limiting her physical activities to swimming, biking, no road march, no heavy lifting.
Complete a thorough gynecologic exam, obtain serum labs, correct any existing anemia, hCG to rule out pregnancy (may need to do ultrasound to rule out ectopic), ensure her condition is stable and that an adequate treatment plan is in place prior to her departure.

The correct answer is d. This is not all you can do but definitely should be done to ensure optimal health of the deploying female. Answer a. b. and c. are all incorrect specifically because the administration of a physical profile is seldom necessary; if the female’s condition is so fragile that normal activities are limited to walking at own pace, swimming, or biking, due to fibroids, this might be the point that surgical intervention is a consideration in order to make her return to deployable status. Answer c is also incorrect because if you are doing an OB exam on this female, she is pregnant and will not be deploying until after the birth of her child and a urine hCG is only quantitative for positive or negative; it would behoove you to obtain a more sensitive serum level and if hCG>0 continue with the algorithm of pregnancy we’ve previously reviewed.

Of the options listed below, what is the number one teaching point for all patients with uterine fibroids or adenomyois?

Eat a diet high in Vitamins A, D, E, and K to help decrease the growth of uterine fibroids.
Abstain from sexual intercourse during your menstrual cycle to prevent potential rupture of swollen uterine fibroids and adenomyotic tissue.
Avoid pregnancy due to the high risk of uterine rupture or preterm delivery.
Ensure you have, at a minimum, your annual gynecologic exam and notify your provider promptly when you experience changes in your typical symptoms.

The correct answer is d. It is very important for women with established diagnosis of uterine fibroids or adenomyosis to get regular annual gynecologic exams to maintain accurate surveillance of uterine anatomical changes. It is imperative that the woman notify her provider when she experiences changes in the typical presentation of symptoms associated with fibroids or adenomyosis because changes in symptoms could imply involvement of other pelvic or abdominal organs or progression of tissue histology to a malignant status whereby a change in therapeutic management is might be required. As a key point mentioned by Dr. Seibert, keep your radar out for older women presenting with uterine bleeding…it is CA until proven otherwise! Answer a. is incorrect because while these vitamins in normal dosing might be a nice supplement, in high doses for anyone can become toxic (they are the fat soluble vitamins) and they have no proven influence on uterine abnormalities. Answer b. is incorrect because there is no evidence that women should abstain from sexual intercourse, regardless of menses or not, however she will likely prefer not to engage in these activities due to the pain associated with edematous tissue and fibroid growth. Answer c. is incorrect because fertility is often a specific goal for women with these conditions and providers often strive to facilitate a successful pregnancy. Rarely will a fibroid grow so large during a pregnancy that is results in uterine rupture, and it is not the fibroid itself that does, it is the forces of labor that often stretches the uterus beyond the point of tolerance, so women with large fibroids should be monitored closely throughout their pregnancy and consideration for c-section might be the only option for some to prevent complications associated with the passage of the fetus during the birthing process; and possibly to avoid uterine rupture. The risk for preterm labor and delivery exist for many reasons and is not a reason to encourage women with these uterine conditions to not become pregnant.

Which of the following classifications of uterine fibroids is THE MOST likely to the greatest impact on a woman’s fertility?

Subserous (outer wall of uterus)
Intramural (within the uterine wall)
Submucous
Pedunculated (subserous fibroid that grows on a stalk)

The correct answer is c. The submucous fibroid has been identified as the most likely type of fibroid that effects a woman’s fertility because of its potential to prevent implantation. The other options are incorrect because they don’t share the same direct potential to impact fertility however depending on size and displacement of normal uterine anatomy they can have an untoward effect on success of a term pregnancy.

Due to the technical difficulties of this blog taking my original script I have also sent this bb and gw! Thanks