CNE Overview of Latest Evidence on Uterine Fibroids William F. McCool Dawn Durain Meredith Davis

Upon completion of this activity, the learner will be able to:

1. Identify risk factors for uterine fibroids. 2. Describe the impact uterine fibroids can have on pregnancy. 3. List and describe current treatment modalities used for women with problematic uterine fibroids.

Continuing Nursing Education (CNE) Credit A total of 1.4 contact hours may be earned as CNE credit for reading “Overview of Latest Evidence on Uterine Fibroids” and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Women’s Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provider #CEP580.

William F. McCool, PhD, CNM, is director of the midwifery graduate program; Dawn Durain, MPH, CNM, is an advanced senior lecturer in the midwifery graduate program; Meredith Davis, BSN, SNM, is a student in the midwifery graduate program; all authors are at the University of Pennsylvania School of Nursing in Philadelphia, PA. The authors and planners of this activity report no conflicts of interest or relevant financial relationships. No commercial support was received for this learning activity. Address correspondence to: mccoolwf@nursing. upenn.edu

316

© 2014, AWHONN

Uterine fibroids, also known as leiomyomas or myomas, are benign masses that develop from uterine smooth muscle tissue. They are the most common type of reproductive tract mass in women of reproductive age, accounting for an estimated 27 percent of gynecologic admissions to hospital facilities (Hoffman et al., 2012). Risk and protective factors for fibroid development have been determined by age, race, heredity, onset of menses, pregnancy, use of hormonal contraception and therapy, hypertension, obesity, eating habits, substance use and other influences. Many women do not experience bothersome symptoms from fibroids. Those with symptoms typically present with abnormal uterine bleeding and/or pelvic pain and pressure (Hoffman et al., 2012; Parker, 2007). Treatment options vary widely and include pharmacotherapy, uterine artery embolization (UAE), myomectomy, hysterectomy and, more recently, magnetic resonance guided focused ultrasound. The implications of uterine fibroids for women’s health include activity restriction, sexual health issues, gastrointestinal and genitourinary effects, failure to diagnose other pelvic abnormalities, difficult placement and questionable efficacy of intrauterine contraceptives (IUCs) and anemia. The potential implications for pregnancy can include infertility, possible fetal growth restriction, preterm labor, obstructed labor, postpartum hemorrhage and uterine prolapse. In addition to accurate diagnosis, effective education of women with known fibroids is of utmost importance to ensure that women understand their specific condition, to allay fear and anxiety surrounding the disease and to promote an understanding of treatment options so that women can make informed decisions in accordance with their health goals and desires. It is the responsibility of clinicians to support women with fibroids in making informed decisions regarding reproductive life plans, contraceptive choices and treatment modalities.

PATHOPHYSIOLOGY While there are still many uncertainties regarding the pathophysiology of uterine fibroids, researchers have identified certain aspects of the etiology of these tumors. This knowledge concerns

Abstract: Uterine fibroids are the most common type of benign gynecologic mass, and are present in up to 80 percent of women. Research exploring risk factors for fibroids presents conflicting or inconclusive findings. Symptoms for up to 50 percent of women experiencing fibroids include heavy menstrual bleeding, pelvic pressure or pain and gastrointestinal and genitourinary changes. Diagnosis is made by history and symptoms, physical examination and imaging. Several treatment options are available, and are based on symptoms, preferences and reproductive plans. Given the high prevalence of fibroids and the potential for women’s health implications, it is essential that clinicians are aware of the latest evidence regarding fibroids to provide the highest quality of care for women whose health is affected by this condition. DOI: 10.1111/1751-486X.12137 Keywords: fibroid | leiomyoma | menorrhagia | myoma | pelvic pain

http://nwh.awhonn.org

Opening photo © LucidWaters / dreamstime.com

Objectives

INTRODUCTION

Estimations of fibroid incidence range from 20 percent to 40 percent in women reporting symptoms, while sonographic and autopsy examinations have increased this estimate to a prevalence of 70 percent to 80 percent of the female population (Hoffman et al., 2012; Peddada et al., 2008; Stewart, 2001; Verga, 2012). Black women experience a higher prevalence of fibroids (Rice, Secrist, Woodrow, Hallock, & Neal, 2012; Verga, 2012). In a study of hysterectomy specimens that were examined in 2-mm sections, premenopausal women had an average of 7.6 fibroids at the time of examination (Cramer & Patel, 1990). The prevalence of fibroids decreases in older women, as most women have shrinkage of leiomyomas during the perimenopausal transition and following menopause (Younger, Baig-Ward, Segars, & Al-Hendy, 2013).

RISK FACTORS Several risk factors have been linked to the development or presence of uterine fibroids (see Box 1). In addition, there have been other variables postulated to be related to fibroid development or growth. Several studies have suggested that infection of the uterus may be associated with an increased risk of fibroids, a finding that is consistent with the hypothesis that uterine irritation and injury may lead to fibroid formation (Faerstein et al., 2001b; Laughlin, Schroeder et al., 2010). Faerstein et al. (2001b) discussed an association between fibroid incidence and chlamydia infection, which is a common cause of pelvic inflammatory disease (PID); this association did not exist with infections that mainly affected the external genitalia, such as the herpes simplex virus (HSV). However, the data reviewed by Laughlin, Schroeder et al. (2010) did not reflect a significant relationship between pelvic infection and fibroids.

August

September 2014

The potential implications for pregnancy can include infertility, possible fetal growth restriction, preterm labor, obstructed labor, postpartum hemorrhage and uterine prolapse tential pathophysiology supporting a link between stress and increased fibroid risk has been that stress may increase progesterone levels in the body, which may in turn promote fibroid development and growth (Wirth, Meier, Fredrickson, & Schultheiss, 2007).

SYMPTOMS AND PRESENTATION While the majority of fibroids are asymptomatic, approximately 20 percent to 50 percent of women with fibroids experience one or more symptoms, including heavy menstrual bleeding, pelvic pain and gastrointestinal and genitourinary changes (Rice et al., 2012). The number, size, and location of the fibroids determine the severity of these symptoms (Marino et al., 2004). Women with large fibroids may grow accustomed to or fail to notice a gradually increasing feeling of pelvic fullness, and therefore report few symptoms or little pain (Hoffman et al., 2012). Alternatively, women may report chronic pelvic pain or lower abdominal pressure (Nodler & Segars, 2013). While acute pelvic pain is less common, it may occur when a fibroid degenerates or prolapses (Hoffman et al., 2012). In premenopausal women, the typical bleeding symptom of fibroids is heavy and/or prolonged menses, rather than intermittent or irregular bleeding between menses (Olufowobi et al., 2004). However, during the menopausal transition, fibroids may cause abnormal uterine bleeding both with and between menses (Hoffman et al., 2012). The bleeding caused by uterine fibroids can be significant enough to cause anemia with resultant symptoms such as fatigue and headache (Nodler & Segars, 2013). Fibroids can also cause urinary frequency, rectal pressure or pain during intercourse (Younger et al., 2013). Infrequently, a fibroid will present with transcervical prolapse, a situation that may result in ulceration or infection (Hoffman et al., 2012). Finally, a woman may seek evaluation if she is having difficulty conceiving or maintaining a pregnancy. Infertility issues related

Nursing for Women’s Health

317

http://JournalsCNE.awhonn.org

PREVALENCE

While research has shown that stress is related to an increased risk of disease in general, there have been few studies examining a possible relationship between stress and fibroids (Laughlin, Schroeder et al., 2010). In their analysis of data from the Black Women’s Health Study, Wise, Palmer, Cozier et al. (2007) reported an association between the chronic stressor of perceived racism and an increased risk of fibroids. The po-

CNE

certain aspects of the masses’ molecular biology, as well as genetic, hormonal and growth factors that affect fibroid development (Parker, 2007). It has been established that uterine fibroids are benign, monoclonal tumors that arise from the smooth muscle of the uterus and that consist of an abundant and altered extracellular matrix (Leppert, Fouany, & Segars, 2013). Genetic factors affecting uterine fibroid development and growth are described below as part of the discussion of risk factors. Researchers have identified transforming growth factor beta (TGF-beta) as having a major role in fibroid enlargement, as it is responsible for creating and depositing the extracellular matrix that composes the fibroids; fibroids have been found to have an increased number of TGF-beta receptors when compared to normal cells (Leppert et al., 2013). Studies have demonstrated the dependence of fibroids on the hormones estrogen and progesterone for growth, which is the basis of the use of gonadotropin-releasing hormone (GnRH) agonists in their treatment (DeVivo et al., 2011; Ishikawa et al., 2010; Laughlin, Herring et al., 2010).

BOX 1 RISK FACTORS FOR DEVELOPING FIBROIDS FACTOR

FINDINGS

Age

Incidence of fibroids increases with age during the reproductive years; decreases following menopause (Evans & Brunsell, 2007). Cumulative incidence of fibroids by age 50 is 70 percent in white women and more than 90 percent in black women (Baird, Dunson, Hill, Cousins, & Schectman, 2003).

Race

Incidence of fibroids is two to three times greater in black women than in nonLatina white women (Baird et al., 2003; Marshall et al., 1997; Templeman et al., 2009). Black women develop fibroids at an earlier age, experience more severe symptoms and have a greater number of fibroids in their lifetimes (Baird et al., 2003; Parker, 2007). Both black and Latina women had higher rates of surgery for fibroids than nonLatina white women (Templeman et al., 2009). A specific genotype of estrogen receptors is more common among black women and is associated with higher rates of fibroids (Al-Hendy & Salama, 2006). Aromatase, the key enzyme in the production of estrogen, is more present in the uterine fibroids of black women, possibly contributing to the higher prevalence and earlier incidence of fibroids in black women (Ishikawa et al., 2009). Data are limited regarding the risk of uterine fibroids among Asian women.

Heredity

Risk of fibroid formation is approximately twice as high in women who have first-degree relatives with fibroids (Gross & Morton, 2001; Sato, Mori, Nishi, Kudo, & Miyake, 2002; Vikhlyaeva, Khodzhaeva, & Fantschenko, 1995). Fibroids that occur in women with a family history result in a different pattern of symptoms and molecular features than those that occur in individuals without a significant family history (Okolo, Gentry, Perrett, & Maclean, 2005). Hereditary leiomyomatosis and renal cell cancer (HLRCC), a rare hereditary condition, involves the growth of benign masses on the skin and in the uterus, and carries with it an increased risk of kidney cancer. HLRCC is caused by a genetic mutation, and has only been identified in approximately 200 families worldwide (Pithukpakorn & Toro, 2010).

Onset of menses

Early menarche (before age 11) is associated with an increased risk of developing fibroids (D’Aloisio, Baird, DeRoo, & Sandler, 2010; Dragomir et al., 2010; Marshall, Spiegelman, Manson et al., 1998; Wise et al., 2004b). Because menarche occurs earlier in black women than others, early onset of menses may be a contributing factor to the earlier onset of fibroids in black women (Dragomir et al., 2010; Huyck et al., 2008).

Pregnancy

Full-term pregnancy is related to lower rates of fibroids (Chen, Buck, Courey, Perez, & Wactawksi-Wende, 2001; Lumbiganon et al., 1996; Marshall, Spiegelman, Goldman et al., 1998; Parazzini, Negri, La Vecchia, Chatenoud, & Guarnerio, 1996; Ross et al., 1986; Wise et al., 2004a). Parous women experience lower rates of fibroids when compared with nulliparous women, and lower rates are found in women whose first birth occurs at an earlier age (Wise et al., 2004a).

318

Nursing for Women’s Health

Volume 18

Issue 4

CNE

BOX 1 RISK FACTORS FOR DEVELOPING FIBROIDS continued FACTOR

FINDINGS

Pregnancy (continued)

Early spontaneous or induced abortions are not related to risk of fibroids, but pregnancies closer to full-term are (Chen et al., 2001; Laughlin, Hartmann, & Baird, 2011; Parazzini, Negri, La Vecchia, Chatenoud et al., 1996). Postpartum involution may contribute to the elimination of fibroids as the tissues of the uterus return to prepregnancy weight, blood flow and cell size (Baird & Dunson, 2003; Laughlin, Herring et al., 2010; Parker, 2007). Hormonal contraception offers either a null (Templeman et al., 2009; Wise et al., 2004a) or protective (Chiaffarino, Parazzini, La Vecchia, Marsico et al., 1999) effect against the development or growth of uterine fibroids.

http://JournalsCNE.awhonn.org

Hormonal contraception

Use of progestin-only injectable contraceptives, such as DMPA, has been related up to a 40 percent reduction in fibroid risk (Lumbiganon et al., 1996; Wise et al., 2004a). Hormonal therapy

Women undergoing hormonal therapy during menopause have a higher risk of the presence of uterine fibroids (Reed, Cushing-Haugen, Daling, Scholes, & Schwartz, 2004; Templeman et al., 2009; Yang, Lee, Hsu, Kuo, & Tsai, 2002). Women with a low amount of body fat who have used hormonal therapy during menopause are at an increased risk of developing fibroids (Reed et al., 2004).

Hypertension

Hypertension, especially when treated with pharmacological therapy, is related to an increased risk of uterine fibroids (Boynton-Jarrett, Rich-Edwards, Malspeis, Missmer, & Wrights, 2005; Faerstein, Szklo, & Rosenshein, 2001b; Luoto, Rutanen, & Auvinen, 2001; Silver, Raghuvir, Fedirko, & Elser, 2005). Some researchers (Radin et al., 2012) have challenged the relationship between hypertension and fibroid development, stating that any relationship between the two is likely to be related to other factors (e.g., obesity). Data do not exist to suggest whether women with well-controlled hypertension fare better than those with uncontrolled hypertension.

Diabetes

Past researchers hypothesized that diabetes may increase fibroid risk because insulin-like growth factor (IGF-1) is associated with fibroid growth (Burroughs et al., 2002; Englund et al., 2000; Giudice et al., 1993; Gloudemans et al., 1990; Poretsky & Galin, 1987). More recent investigators have found no increase in fibroid risk with increased blood levels of insulin and IGF-1, and in fact, have found lower rates of fibroids among women with diabetes (Baird et al., 2009; Wise, Palmer, Stewart, & Rosenberg, 2007). Diabetes may cause vascular dysfunction, thus decreasing blood supply to fibroids and causing their degeneration (Laughlin, Schroeder, & Baird, 2010; Walocha, Litwin, & Miodonski, 2003).

Obesity

Researchers have documented a relationship between fibroids and high body mass index (BMI; Faerstein, Szklo, & Rosenshein, 2001a; Marshall, Spiegelman, Goldman et al., 1998; Shikora, Niloff, Bistrian, Forse, & Blackburn, 1991; Templeman et al., 2009; Terry et al., 2007; Wise et al., 2005). Weight gain since age 18 and central distribution of body fat are specific obesity risk factors for fibroids (Terry et al., 2007). continued on next page

August

September 2014

Nursing for Women’s Health

319

BOX 1 RISK FACTORS FOR DEVELOPING FIBROIDS continued FACTOR

FINDINGS

Dietary habits

There is a lack of significant and cohesive evidence on the relationship between nutritional habits and fibroid incidence. Consumption of beef, other red meats or ham has been associated with an increased risk of fibroids, while consumption of green vegetables, fruit and dairy products has been associated with a decreased risk (Chiaffarino, Parazzini, La Vecchia, Chatenoud et al., 1999; Wise et al., 2010, 2011). Soy intake, which was theorized to be protective against fibroids in premenopausal women, has had no effect on fibroid risk (Atkinson et al., 2006; Nagata et al., 2009).

Substance use

There is a lack of significant and cohesive evidence on the relationship between substance use and fibroid incidence. Consumption of alcohol, particularly beer, appears to increase the risk of developing fibroids (Marshall et al., 1997; Wise et al., 2004b). While early studies showed that cigarette smoking actually was protective for fibroid development (Faerstein et al., 2001a; Lumbiganon et al., 1996; Parazzini, Negri, La Vecchia, Rabaiotti et al., 1996; Romieu, Walker, & Jick, 1991), more recent research has demonstrated that cigarette smoking has no effect on risk for fibroids (Marshall, Spiegelman, Manson et al., 1998; Wise et al., 2004b). Caffeine consumption is neither a risk nor protective factor for the development of uterine fibroids (Chiaffarino, Parazzini, La Vecchia, Chatenoud et al., 1999; Wise et al., 2004b).

to uterine fibroids are discussed below. Other rare presenting symptoms that may be related to ectopic hormone production include polycythemia, hypercalcemia and hyperprolactinemia

entirely understood, the rapid growth of a fibroid during pregnancy may predispose the fibroidx to torsion and/or degeneration as a result of insufficient blood supply (Johnson et al., 2013). The effects of fibroids in pregnancy are further discussed below.

DIAGNOSIS

Approximately 20 percent to 50 percent of women with fibroids experience one or more symptoms, including heavy menstrual bleeding, pelvic pain and gastrointestinal and genitourinary changes

Once diagnosed, fibroids are described based on their location. Subserous, or subserosal, fibroids exist just under the uterine serosa and are located outside of the uterus. They are attached to the uterus by a large or small base and may be easily palpated on abdominal examination. Intramural fibroids are located within the uterine myometrium and may give the uterus an irregular shape. Submucous, or submucosal, fibroids are located in the uterine endometrium and are usually palpable as an enlarged uterus (Hoffman et al., 2012). (See Figure 1 for fibroid locations in the uterus.)

(Cordiano, 2005; Ravakhah, Gover, & Mukunda, 1999; Yoshi-

HEALTH HISTORY AND SYMPTOMS

da, Koshiyama, Fujii, & Konishi, 1999).

Diagnosis is based on an accurate health history and a history of the presenting concern. A woman with a history of fibroids is at risk for recurrence or incidence of additional fibroids (Hoffman

Large fibroids can cause pain during pregnancy (Johnson, Norwitz, & Segars, 2013). While the cause of this pain is not

320

Nursing for Women’s Health

Volume 18

Issue 4

PHYSICAL EXAMINATION

IMAGING STUDIES Fibroids can usually be visualized on ultrasound, a tool that is frequently used to assess and monitor the size, location, and growth of fibroids (Rice et al., 2012). While transvaginal ultrasonography is the most cost-efficient method for fibroid evaluation, it has also been shown to be the least sensitive and

MANAGEMENT Historically, hysterectomy was used as the preferred treatment for a wide variety of pelvic issues, including for uterine fibroids and resultant abnormal bleeding. This practice was primarily due to misconceptions regarding potential effects on cancer

The bleeding caused by uterine fibroids can be significant enough to cause anemia with resultant symptoms such as fatigue and headache risk, morbidity and quality of life if fibroids were left to continue to grow in size (Hoffman et al., 2012). By the end of the 20th century, concerns regarding both cancer- and size-related

FIGURE 1 UTERINE FIBROIDS

Source: King, T. L., Brucker, M. C., Kriebs, J. M., Fahey, J. O., Gegor, C. L., & Varney, H. (2015). Varney’s Midwifery, Fifth Edition. Burlington, MA: Jones & Bartlett Learning. Reprinted with permission.

August

September 2014

Nursing for Women’s Health

321

http://JournalsCNE.awhonn.org

On bimanual examination, fibroids will be firm and the uterus may be irregular in shape. Only 42 percent of large fibroids (>5 cm in diameter) and 12.5 percent of smaller fibroids (from 3 to 5 cm in diameter) have been shown to be diagnosed by physical examination (Muram, Gillieson, & Walters, 1980). Clinicians must take caution not to overlook or misdiagnose other abdominal masses or pelvic abnormalities, many of which may be ruled out using imaging studies. Upon noting a fibroid during an examination, clinicians should share this information with the woman, provide information on the condition and discuss appropriate follow-up steps.

specific of the imaging options available (Griffin, Ellis, Wilder, & DeArmond, 2005). The more invasive methods of sonohysterography and hysteroscopy may be useful, especially in the evaluation of submucosal fibroids (Griffin et al., 2005). Magnetic resonance imaging (MRI) may be used in addition to ultrasound as needed, especially when accurate mapping of fibroids is required prior to surgery (Griffin et al., 2005).

CNE

et al., 2012). A comprehensive history should include consideration of the woman’s report of symptoms of pain, changes in bleeding pattern, interference with sexual activity, urinary frequency and/or gastrointestinal changes. Laboratory results may indicate anemia in an otherwise healthy woman, which may result from heavy bleeding caused by fibroids (Nodler & Segars, 2013).

morbidity had been disproven, and currently, asymptomatic women, even with large fibroids, can be managed expectantly (Nodler & Segars, 2013). Nevertheless, uterine fibroids continued to be the leading cause for hysterectomy among women between the ages of 35 and 54 in the United States, and in 2004 fibroids still accounted for 38.7 percent of all hysterectomies performed (Whiteman et al., 2008). A wide variety of effective therapies are currently available for uterine fibroids, ranging from expectant management to surgery. Treatment should be individualized based on considerations concerning the presence and severity of symptoms, a woman’s desire for treatment, her preference regarding preservation of childbearing capacity, her potential history of infertility and previous pregnancy complications related to fibroids (Evans & Brunsell, 2007).

EXPECTANT MANAGEMENT Because fibroids generally grow slowly, it is difficult to predict the course of fibroid growth and the progression of symptoms (DeWaay, Syrop, Nygaard, Davis, & Van Voorhis, 2002). Mavrelos et al. (2010) found that fibroid growth was highly variable and that fibroids could regress spontaneously. This finding emphasizes the importance of planning interventions only after a period of observation to establish fibroid behavior in each individual case. Therefore, watchful waiting in women without significant or debilitating physical symptoms may be the best approach to the management of uterine fibroids. An acceptable management plan will include careful documentation of

Watchful waiting in women without significant or debilitating physical symptoms may be the best approach to the management of uterine fibroids fibroid size and shape at each examination along with a thorough history of any change in symptoms. Such examinations should be performed at least annually (Hoffman et al., 2012). When assessment of the uterus is hindered by uterine size or shape, some clinicians may choose to add annual monitoring by ultrasound or other imaging (Cantuaria, Angioli, Frost, Duncan, & Penalver, 1998; Guarnaccia & Rein, 2001). When a woman and her health care provider decide that intervention is necessary, a variety of nonsurgical procedures, including pharmacologic (see below), are available that carry few side effects and allow preservation of the uterus (Rice et al., 2012). These methods may be preferred by some women, as losing one’s uterus may be considered undesirable for a variety of cultural, social and psychological reasons (Verga, 2012).

322

Nursing for Women’s Health

Researchers have explored a variety of alternative therapies for the treatment of uterine fibroids, including the use of acupuncture, bodywork, imagery and traditional Chinese medicine, but results have been limited and further research is needed in this area (Liu, Yang, Xia, & Cardini, 2009).

DRUG TREATMENT Pharmacologic methods of treating fibroids include the traditional use of GnRH agonists, such as leuprolide acetate (Lupron), to reduce the size of fibroids, as well as levonorgestrel-based IUCs (LNG-IUCs, or Mirena and Skyla) and progestin-only injectable contraceptives (depot medroxyprogesterone acetate[DMPA, or Depo Provera]) to reduce excessive bleeding and resultant anemia associated with fibroids (Rice et al., 2012; Zapata et al., 2010). The rate of success in diminishing the size or symptoms of fibroids varies with these methods. While the greatest success in shrinking fibroids has been obtained with the use of GnRH agonists, significant side effects, such as hot flashes, headaches and osteoporosis, discourage many women from their use, especially on a long-term basis (Hoffman et al., 2012). To date there is no evidence that the use of the etonogestrel implant (Nexplanon) has any effect on fibroid reduction or symptoms.

UTERINE ARTERY EMBOLIZATION Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE), is a nonsurgical treatment option for premenopausal women with fibroid-related symptoms who wish to retain their uterus, avoid side effects associated with prolonged medical therapy and avoid surgery (Goldberg, Pereira, & Berghella, 2002; McLucas et al., 2001). The procedure involves the injection of embolic agents, using radiologic techniques for guidance, into the uterine arteries that supply blood to the uterus, particularly in the region of any fibroids. This therapeutic approach is based on the concept that bilateral reduction in arterial blood flow to the uterus will result in the infarction of fibroids and thus control symptoms (Ravina et al., 1995). This procedure is not usually indicated after menopause, because fibroids tend to naturally regress during this period (American College of Obstetricians and Gynecologists [ACOG], 2004). Other contraindications include current pregnancy, plans for future pregnancy, active or untreated uterine infection, suspicion of leiomyosarcoma or adnexal malignancy, extensive adenomyosis, presence of submucosal fibroids and concurrent use of a GnRH agonist (Hovsepian et al., 2009). However, the consideration of many of these contraindications is based on the judgment and experience of the clinician (Hovsepian et al., 2009). In a small investigation, Smeets, Nijenhuis, Boekkooi et al. (2010) concluded that presence of an IUC did not contraindicate UAE. The presence of large fibroids is not usually considered a contraindication to UAE (Smeets, Nijenhuis, van Rooij et al., 2010).

Volume 18

Issue 4

HYSTERECTOMY Fibroids are the most common diagnosis associated with hysterectomy (ACOG, 2008). While there are clearly disadvantages to hysterectomy, such as irreversible infertility and risks associated with surgery, it also carries its advantages, such as permanent alleviation of fibroid symptoms and elimination of the risk of recurrence (Rice et al., 2012). Indeed, in a prospective study by Spies et al. (2010), women who had undergone hysterectomy had the greatest improvement in symptoms when compared with women who had UAE and myomectomy. However, the current recommendation for the majority of women is expectant management, as described above, especially since many fibroids degenerate after menopause (Hoffman et al., 2012; Rice et al., 2012; Verga, 2012).

Myomectomy, or surgical removal of fibroids by laparotomy, laparoscopy or hysteroscopy, is an option for women who wish to retain their uterus for fertility or other reasons the use of morcellation for removal of fibroids, followed shortly by a major manufacturer of morcellators announcing that they were suspending sales (FDA, 2014).

MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND Magnetic resonance guided focused ultrasound surgery (MRgFUS) is a relatively new option for the treatment of uterine fibroids in premenopausal women who have completed childbearing. MRgFUS is a noninvasive, thermoablative technique that destroys fibroids with heat by focusing ultrasound waves on diseased tissue (Hesley et al., 2006; Hindley et al., 2004; Smart, Hindley, Regan, & Gedroyc, 2006; Stewart et al., 2003). One of the benefits of this treatment is that it can be performed as an outpatient procedure. Researchers are uncertain of the maximum fibroid size for which this procedure would be effec-

Because estrogen and progesterone promote fibroid growth, fibroids may grow in size during pregnancy and then recede in size during the postpartum period

MORCELLATION Some surgeons use laparoscopic power morcellations when they perform a hysterectomy or myomectomy for women with fibroids. A morcellator is a device that uses sharp edges to enable tissue to be divided into pieces that can then be extracted through the small laparoscopic incision(s). Although morcellation has gained popularity since its introduction in the 1990s, recent concerns have emerged. Most concerning is the fact that there can be no assurance that a mass is a benign fibroid prior to the morcellation. Thus, this extraction process could

August

September 2014

tive, and treatment is often limited by factors in addition to size, such as vascularity, and ease of access to the fibroid (Hesley, Gorny, Henrichsen, Woodrum, & Brown, 2008; Smart et al., 2006; Yoon et al., 2008).

FERTILITY IMPLICATIONS Uterine fibroids are associated with 10 percent of infertility cases and were found to be the primary cause of infertility in

Nursing for Women’s Health

323

http://JournalsCNE.awhonn.org

Myomectomy, or surgical removal of fibroids by laparotomy, laparoscopy or hysteroscopy, is an option for women who wish to retain their uterus for fertility or other reasons. While myomectomy is effective in treating the abnormal bleeding and pelvic pressure associated with uterine fibroids, in addition to the typical risks associated with any abdominal or vaginal surgery, there is a risk that more fibroids will develop after the procedure (Rice et al., 2012). Because of this risk, if a woman undergoing myomectomy is planning on becoming pregnant, surgery may be performed at such a time as to attempt to closely precede conception, in order to decrease the risk of tumor recurrence before pregnancy (Hoffman et al., 2012). If myomectomy is indicated, a GnRH agonist may be used to shrink fibroids before the procedure (Hoffman et al., 2012). This approach is taken because smaller fibroids may be less complicated to remove than larger ones and because a reduction in size may allow for vaginal rather than abdominal surgery (Sardo et al., 2008). Myomectomy during pregnancy is generally not considered unless conservative treatment approaches have failed (Johnson et al., 2013). However, in the case of severe pain, surgical treatment may be necessary. Myomectomy of intramural fibroids during pregnancy or at the time of delivery frequently results in hemorrhage, and women must be made aware of the benefits and risks of surgery during pregnancy (Cunningham et al., 2014).

enhance seeding of the abdomen with cancerous cells in the rare event that the tumor is malignant (Kho & Nezhat, 2014). In addition, other iatrogenic surgical complications also have been reported with the technology. Therefore, in April 2014, the U.S. Food and Drug Administration (FDA) discouraged

CNE

MYOMECTOMY

BOX 2 HEALTH IMPLICATIONS IUC PLACEMENT AND EFFICACY PROBLEMS • Submucosal fibroids and/or those that distort the cervical canal increase the risk of uterine perforation during IUC insertion (Chwalisz & Winkel, 2013). • Distorted endometrial cavity due to fibroids may influence the efficacy of an IUC (Chwalisz & Winkel, 2013). • Fibroids may result in high rates of expulsion of LNG-IUDs (Zapata et al., 2010). DISRUPTION OF SEXUAL HEALTH • Dyspareunia (pain during sexual intercourse) due to fibroids may occur, and has contributed to less satisfaction with sexual intercourse than found in women without fibroids (Ertunc, Uzun, Tok, Doruk, & Dilek, 2009). • Myomectomy has been shown to alleviate dyspareunia (Yildiz, Camuzcuoqlu, Tov, Terzi, & Guldur, 2009). ACTIVITY RESTRICTION • The pain associated with uterine fibroids may result in decreased activity of daily living. • Decrease in physical exercise and social isolation are two possible negative outcomes of activity restriction. • Women who do not exercise due to discomfort caused by fibroids may be at greater risk for a variety of health conditions, including obesity and cardiovascular disease. ANEMIA • Fibroids are the medical condition that most commonly causes excessive menstrual bleeding in adult women (Younger et al., 2013). • Heavy menstrual bleeding is a common cause of iron deficiency anemia and affects nearly one in five women in the United States (National Heart Lung and Blood Institute [NHLBI], 2013). • Anemia in women with fibroids has been treated specifically with iron supplementation, erythropoietin stimulating agents or blood transfusions (Nodler & Segars, 2013). • Persistent anemia due to fibroids may result in the need for a myomectomy. GASTROINTESTINAL AND GENITOURINARY DISORDERS • Fibroids that exert pressure on the intestines may lead to constipation that may in turn cause hemorrhoids and feelings of bloating (Hoffman et al., 2012). • Fibroid compression of the ureters may lead to hydronephrosis (swelling of the kidney), which may cause flank pain, nausea, vomiting, urinary tract infection, fever, painful urination and increased urinary frequency and urgency (National Institutes of Health [NIH], 2012). MASKING OF OTHER PELVIC DISORDERS • The differential diagnoses for fibroids include other pelvic abnormalities, such as: - Adenomyosis

- Uterine sarcoma

- Endometrial polyps

- Ovarian cancer

- Endometrial hyperplasia

- Tumors of the GI tract and GU system

- Endometrial carcinoma

- Lymphomas

- Bone tumors (Evans & Brunsell, 2007) • Health history, imaging evaluation, laboratory values and potential referral for biopsy are appropriate measures for ruling out any of these alternative conditions.

324

Nursing for Women’s Health

Volume 18

Issue 4

The incidence of fibroids during pregnancy is approximately 2 percent, depending on population characteristics, as well as on the discovery of nonsymptomatic myoma by routine ultrasound (Cunningham et al., 2014). Ironically, the prevalence of fibroids during pregnancy is likely underestimated by ultrasound owing to the fact that it can be difficult to differentiate fibroids from physiologic thickening of the myometrium during pregnancy (Cooper & Okolo, 2005; Qidwai, Caughey, & Jacoby, 2006). Because estrogen and progesterone promote fibroid growth, fibroids may grow in size during pregnancy and then recede in size during the postpartum period (Baird & Dunson, 2003). Depending on their size and location, fibroids can interfere with pregnancy and can cause placenta previa, spontaneous abortion, intrauterine death, preterm labor, preterm premature rupture of membranes, placental abruption, malpresentation of a fetus during pregnancy or labor, obstructed labor progress, the need for a cesarean surgical birth and postpartum hemorrhage (Davis, Ray-Mazumder, Hobel, Baley, & Sassoon, 1990; Klatsky, Tran, Caughey, & Fujimoto, 2008; Lai, Caughey, Qidwai, & Jacoby, 2012; Qidwai et al., 2006; Rice et al., 2012; Sheiner et al., 2004; Stout et al., 2010). Additionally, fibroids of significant size during pregnancy may result in difficulty in assessing uterine and fetal growth during fundal height assessment. The presence of degenerating fibroids may also cause pain during pregnancy, and decisions regarding the treatment of pain should take into consideration the gestational age of the fetus and the severity of pain (Johnson et al., 2013). Although cumulative data and a population-based study suggested that women with fibroids were at a slightly increased risk of delivering a growth-restricted infant, these results were not adjusted for maternal age or gestational age, both of which may have been confounding factors (Coronado, Marshall, & Schwartz, 2000; Klatsky et al., 2008). To date, no definitive data are available to support the theoretical risk of growth restriction of a fetus in a woman with a known fibroid (Lai et al., 2012; Stout et al., 2010). Despite these potential complications, cesarean birth is not

August

September 2014

ADDITIONAL WOMEN’S HEALTH IMPLICATIONS Additional health and lifestyle implications can be manifested in women who have developing or existing fibroids (see Box 2). As with the investigation of any health condition, a thorough health history, coupled with a physical examination and poten-

Education for women with fibroids should include a discussion of symptoms, diagnostic processes, treatment options and the known prognosis of uterine fibroids tially subsequent imaging and obtaining of laboratory values, will do much for arriving at an accurate differential diagnosis.

EDUCATION FOR WOMEN WITH FIBROIDS Education for women with fibroids should include a discussion of symptoms, diagnostic processes, treatment options and the known prognosis of uterine fibroids. Women should be encouraged to think about their reproductive desires and plans before pursuing treatment, as this will dictate which approach is most appropriate in her case.

PRACTICAL IMPLICATIONS FOR CLINICIANS Because many women with fibroids are asymptomatic and because of the potential implications of myomas for women’s health and pregnancy, it is important that clinicians do not neglect investigation, even if a woman is not particularly bothered by fibroid-related symptoms. A history of fibroids and/or any concerns that may be fibroid-related should be investigated by physical examination and imaging studies as indicated. Attention is needed to ensure that fibroids are not obscuring other potential uterine masses, causing anemia, impairing fertility or having an adverse impact on a woman’s quality of life.

Nursing for Women’s Health

325

http://JournalsCNE.awhonn.org

PREGNANCY, LABOR AND BIRTH IMPLICATIONS

necessarily indicated when fibroids are present. Qidwai et al. (2006) found a 70 percent vaginal birth rate in women with uterine fibroids measuring ≥10 cm in diameter. Regardless of the mode of birth, careful attention must be paid to intra- and postpartum bleeding patterns given the risk of hemorrhage as a result of a uterus that is distended by fibroids. Thus, the presence of fibroids may be an indication for active management of the third stage of labor, and is definitely an indication for careful inspection of the placenta after delivery and appropriate use of uterotonic medications.

CNE

one percent to three percent of women dealing with infertility issues (Kolankaya & Arici, 2006). Submucosal or intramural fibroids with an intracavitary component may result in difficulties with conception and an increased rate of miscarriage, and myomectomy may be the most appropriate treatment in these cases (Pritts, Parker, & Olive, 2009; Somigliana et al., 2007). Data regarding the fertility effects of intramural fibroids that do not distort the endometrial cavity are limited; some researchers have demonstrated a harmful impact of intramural fibroids on assistive reproductive therapy (Hart et al., 2001; Khalaf et al., 2006), while others have failed to do so (Klatsky, Lane, Ryan, & Fujimoto, 2007; Oliveira et al., 2004).

BOX 3 AREAS FOR FUTURE RESEARCH TOPIC

RESEARCH AREA

Hypertension

Clarification of the relation between hypertension and fibroid development, addressing potentially confounding variables such as obesity and surveillance bias. Differences in fibroid presence or growth between women with well-controlled hypertension and those with uncontrolled hypertension.

Obesity

The relation between obesity and increased fibroid risk.

Pelvic infection

The relation between pelvic infection and fibroids.

Hormonal IUCs

The relation between the use of a hormonal IUC and the progestin-only implant on the risks of fibroid development or growth. Potential usefulness of a progestin-only implant, given the high rate of expulsion of IUC devices in women with fibroids. Confirmation that the presence of an IUC does not preclude certain management techniques for controlling or eliminating fibroids (e.g., UAE).

Fertility

The effect of fibroids on fertility, especially with regard to intramural myoma.

Pregnancy

The potential effect of uterine fibroid presence on intrauterine fetal growth during pregnancy.

When a woman with fibroids has been deemed eligible for expectant management, it has been suggested that physical examinations, coupled with ultrasound imaging, should be conducted every 3 to 6 months to monitor the size, location

The variety of medical treatments now available to treat uterine fibroids has allowed women and clinicians to work together to choose the therapy that best fits women’s unique preferences, symptoms and reproductive desires

and number of fibroids (Duhan, 2011). It is important that any abnormalities on bimanual examination be followed up with an ultrasound to confirm diagnosis, as uterine fibroids may be mistaken for other serious pelvic conditions. In women with heavy menstrual bleeding as a symptom, lab work should be drawn to check for anemia. As a part of the periodic examination, it is important to rule out pregnancy, review fertility plans and discuss any fears concerning surgery or hysterectomy. Women may express anxiety regarding certain treatment

326

Nursing for Women’s Health

options, including surgery, or may actually have a fear of voicing their desire for a hysterectomy. The use of a LNG-releasing IUC (LNG-IUC [Mirena or Skyla]) or DMPA or Depo Provera may decrease the abnormal menstrual bleeding associated with uterine fibroids. However, because recent studies have questioned the efficacy of the LNGIUCs for contraception in women with fibroids that distort the endometrial cavity, it may be prudent to advise women to use an additional form of birth control, such as condoms, with the LNG-IUC for contraceptive purposes, at least until further research addresses this matter (Zapata et al., 2010). It is also important to repeat that insertion of an LNG-IUC may be made more difficult by the presence of uterine fibroids, especially if the myoma distort the cervical canal. Despite GnRH agonists (leuprolide acetate [Lupron]) being the most effective pharmacological approach at decreasing the size of fibroids, they may cause unpleasant side effects, such as hot flashes, headaches and osteoporosis, in some women. It is important to discuss these potential side effects before initiating therapy and to monitor for the impact of these side effects on a woman’s quality of life. If these side effects do occur, the provider should work with the woman to reevaluate the plan of care. Women with uterine fibroids should be monitored closely during pregnancy and labor. Fibroids may cause difficulty with assessing uterine and fetal growth during fundal height assessment, placental abruption, preterm labor, malpresentation of

Volume 18

Issue 4

FUTURE RESEARCH

CONCLUSION The presence of uterine fibroids is a common condition that requires the attention of women, clinicians and researchers alike. While researchers have investigated a variety of factors that may put women at risk for developing uterine fibroids, a lack of conclusive data surrounding many of these factors still exists. Expanding the understanding of fibroid development, risk factors, effective management strategies and the potential effects on women’s well-being could aid in the development of new approaches to prevent and treat fibroids, including improved early detection and the development of new treatment methods and health education. The variety of medical treatments now available to treat uterine fibroids has allowed women and clinicians to work together to choose the therapy that best fits women’s unique preferences, symptoms and reproductive desires. It is clearly the responsibility of clinicians to remain current in the latest literature regarding myomas in order to most effectively diagnose and treat women with fibroids and offer them the most currently effective care. NWH

REFERENCES

Baird, D. D., & Dunson, D. B. (2003). Why is parity protective for uterine fibroids? Epidemiology, 14(2), 247–250. Baird, D. D., Dunson, D. B., Hill, M. C., Cousins, D., & Schectman, J. M. (2003). High cumulative incidence of uterine leiomyoma in Black and White women: Ultrasound evidence. American Journal of Obstetrics & Gynecology, 188(1), 100–107. Baird, D. D., Travlos, G., Wilson, R., Dunson, D. B., Hill, M. C., D’Aloisio, A. A., … Schectman, J. M. (2009). Uterine leiomyomata in relation to insulin-like growth factor-1, insulin, and diabetes. Epidemiology, 20(4), 604–610. doi:10.1097/ EDE.0b013e31819d8d3f Boynton-Jarrett, R., Rich-Edwards, J., Malspeis, S., Missmer, S. A., & Wright, R. (2005). A prospective study of hypertension and risk of uterine leiomyomata. American Journal of Epidemiology, 161(7), 628–638. Burroughs, K. D., Howe, S. R., Okubo, Y., Fucks-Young, R. LeRoith, D., & Walker, C. L. (2002). Dysregulation of IGF-I signaling in uterine leiomyoma. Journal of Endocrinology, 172(1), 82–93. Cantuaria, G. H., Angioli, R, Frost, L., Duncan, R., & Penalver, M. A. (1998). Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstetrics & Gynecology, 92(1), 109–112. Chen, C. R., Buck, G. M., Courey, N. G., Perez, K. M., & Wactawksi-Wende, J. (2001). Risk factors for uterine fibroids among women undergoing tubal sterilization. American Journal of Epidemiology, 153(1), 20–26. Chiaffarino, F., Parazzini, F., La Vecchia, C., Chatenoud, L., Di Cintio, E., & Marsico, S. (1999). Diet and uterine myomas. Obstetrics & Gynecology, 94(3), 395–398. Chiaffarino, F., Parazzini, F., La Vecchia, C., Marsico, S., Surace, M., & Ricci, E. (1999). Use of oral contraceptives and uterine fibroids: Results from a case-control study. British Journal of Obstetrics & Gynaecology, 106(8), 857–860. Chwalisz, K., & Winkel, C. A. (2013). Medical management of women with symptomatic uterine fibroids. In J. H. Segars (Ed.), Fibroids (chap. 6). Retrieved from onlinelibrary.wiley.com/ doi/10.1002/9781118456996.ch6/summary Cooper, N. P., & Okolo, S. (2005). Fibroids in pregnancy common but poorly understood. Obstetrics & Gynecology, 60(2), 132–138.

Al-Hendy, A., & Salama, S. A. (2006). Ethnic distribution of estrogen receptor-alpha polymorphism is associated with a higher prevalence of uterine leiomyomas in black Americans. Fertility & Sterility, 86(3), 686.

Cordiano, V. (2005). Complete remission of hyperprolactinemia and erythrocytosis after hysterectomy for a uterine fibroid in a woman with a previous diagnosis of prolactin-secreting pituitary microadenoma. Annals of Hematology, 84(3), 200–202.

American College of Obstetricians and Gynecologists (ACOG). (2004). ACOG committee opinion: Uterine artery embolization. Obstetrics & Gynecology, 103(2), 403.

Coronado, G. D., Marshall, L. M., & Schwartz, S. M. (2000). Complications in pregnancy, labor, and delivery with uterine leiomyomas: A population-based study. Obstetrics & Gynecology, 95(5), 764–769.

American College of Obstetricians and Gynecologists (ACOG). (2008). Alternatives to hysterectomy in the management of leiomyomas. Obstetrics & Gynecology, 112(2, Pt. 1), 387–400.

Cramer, S. F., & Patel, A. (1990). The frequency of uterine leiomyomas. American Journal of Clinical Patholology, 94(4), 435–438.

Atkinson, C., Lampe, J. W., Scholes, D., Chen, C., Wahala, K., & Schwartz, S. M. (2006). Lignan and isoflavone excretion in relation to uterine fibroids: A case-control study of young to middle-

August

September 2014

Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (Eds.). (2010). Reproductive tract abnormalities. In Williams obstetrics (23rd ed.). Retrieved fromwww. accessmedicine.com/resourceTOC.aspx?resourceID=46

Nursing for Women’s Health

327

http://JournalsCNE.awhonn.org

Despite a significant amount of research investigating fibroids, including the causes, risk factors, approaches to diagnosing, treatment modalities, effectiveness of care and women’s quality of life when found to have fibroids, there is much that remains unknown about many aspects of myoma conditions. As discussed in the various sections of this article, more robust investigations in the areas delineated in Box 3 would add significantly to the understanding of fibroid development, diagnosing and management, as well as women’s knowledge about the potential effects of myoma on their health and quality of life.

aged women in the United States. American Journal of Clinical Nutrition, 84(3), 587–593.

CNE

the fetus and obstructed labor progress that may result in cesarean delivery (Stout et al., 2010). Women with fibroids also require careful postpartum management including precautions and monitoring for postpartum hemorrhage.

D’Aloisio, A. A., Baird, D. D., DeRoo, L., & Sandler, D. P. (2010). Association of intrauterine and early-life exposures with diagnosis of uterine leiomyomata by 35 years of age in the sister study. Environmental Health Perspectives, 118(3), 375–381. Davis, J. L., Ray-Mazumder, S., Hobel, C. J., Baley, K., & Sassoon, D. (1990). Uterine leiomyomas in pregnancy: A prospective study. Obstetrics & Gynecology, 75(1), 41–44. DeVivo, A., Mancuso, A., Giacobbe, A., Savasta, L. M., De Dominici, R., Dugo, N., … & Vaiarelli, A. (2011). Uterine myomas during pregnancy: A longitudinal sonographic study. Ultrasound in Obstetrics & Gynecology, 37(3), 361–365. doi:10.1002/uog.8826 DeWaay, D. J., Syrop, C. H., Nygaard, I. E., Davis, W. A., & Van Voorhis, B. J. (2002). Natural history of uterine polyps and leiomyomata. Obstetrics & Gynecology, 100(1), 3–7. Dragomir, A. D., Schroeder, J. C., Connolly, A., Kupper, L. L., Hill, M. C., Olshan, A. F., & Baird, D. D. (2010). Potential risk factors associated with subtypes of uterine leiomyomata. Reproductive Science, 17(11), 1029–1035. doi:10.1177/1933719110376979 Duhan, N. (2011). Current and emerging treatments for uterine myoma—An update. International Journal of Womens Health, 3, 231–241. doi:10.2147/IJWH.S15710 Englund, K., Lindblom, B., Carlstrom, K., Gustavsson, I., Sjoblom, P., & Blanck, A. (2000). Gene expression and tissue concentrations of IGF-I in human myometrium and fibroids under different hormonal conditions. Molecular Human Reproduction, 6(10), 915–920. Ertunc, D., Uzun, R., Tok, E. C., Doruk, A., & Dilek, S. (2009). The effect of myoma uteri and myomectomy on sexual function. Journal of Sexual Medicine, 6(4), 1032–1038. doi:10.1111/j.17436109.2008.01086.x Evans, P., & Brunsell, S. (2007). Uterine fibroid tumors: Diagnosis and treatment. American Family Physician, 75(10), 1503–1508. Exacoustos, C., & Rosati, P. (1993). Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstetrics & Gynecology, 82(1), 97–101. Faerstein, E., Szklo, M., & Rosenshein, N. (2001a). Risk factors for uterine leiomyoma: A practice-based case-control study. I. African-American heritage, reproductive history, body size, and smoking. American Journal of Epidemiology, 153(1), 1–10.

Goldberg, J., Pereira, L., & Berghella, V. (2002). Pregnancy after uterine artery embolization. Obstetrics & Gynecology, 100 (5, Pt. 1), 869–872. Griffin, K. W., Ellis, M. R., Wilder, L., & DeArmond, L. (2005). Clinical inquiries: What is the appropriate diagnostic evaluation of fibroids? Journal of Family Practice, 54(5), 458, 460, 462. Gross, K. L., & Morton, C. C. (2001). Genetics and the development of fibroids. Clinical Obstetrics & Gynecology, 44(2), 335–349. Guarnaccia, M. M., & Rein, M. S. (2001). Traditional surgical approaches to uterine fibroids: Abdominal myomectomy and hysterectomy. Clinical Obstetrics & Gynecology, 44(2), 385–400. Hart, R., Khalaf, Y., Yeong, C. T., Seed, P., Taylor, A., & Braude, P. (2001). A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception. Human Reproduction, 16(11), 2411–2417. Hesley, G. K., Felmlee, J. P., Gebhart, J. B., Dunagan, K. T., Gorny, K. B., Kesler, J. B., … Gostout, B. S. (2006). Noninvasive treatment of uterine fibroids: Early Mayo Clinic experience with magnetic resonance imaging-guided focused ultrasound. Mayo Clinic Proceedings, 81(7), 936–942. Hesley, G. K., Gorny, K. R., Henrichsen, T. L., Woodrum, D. A., & Brown, D. L. (2008). A clinical review of focused ultrasound ablation with magnetic resonance guidance: An option for treating uterine fibroids. Ultrasound Quarterly, 24(2), 131–139. doi:10.1097/RUQ.0b013e31817c5e0c Hindley, J., Gedroyc, W. M., Regan, L., Stewart, E., Tempany, C., Hynyen, K., … Jolesz, F. (2004). MRI guidance of focused ultrasound therapy of uterine fibroids: Early results. American Journal of Roentgenology, 183(6), 1713–1719. Hoffman, B., Schorge, J., Schaffer, J., Halvorson, L. M., Bradshaw, K. D., Cunningham, F. G., & Calver, L. E. (Eds.). (2012). Pelvic mass. In Williams gynecology (2nd ed.). Retrieved from www. accessmedicine.com/resourceTOC.aspx?resourceID=768 Hovsepian, D. M., Siskin, G. P., Bonn, J., Cardella, J. F., Clark, T. W. I., Lampmann, L. E., … Sacks, D. (2009). Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. Journal of Vascular Interventional Radiology, 20(7), S193–S199.

Faerstein, E., Szklo, M., & Rosenshein, N. (2001b). Risk factors for uterine leiomyoma: A practice-based case-control study. II. Atherogenic risk factors and potential sources of uterine irritation. American Journal of Epidemiology, 153(1), 1–10.

Huyck, K. L., Panhuysen, C. I., Cuenco, K. T., Zhang, K., Goldhammer, H., Jones, E. S., … Morton, C. C. (2008). The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters. American Journal of Obstetrics & Gynecology, 198(2), 168.e1–168.e9. doi:10.1016/j. ajog.2007.05.038

FDA. (2014). Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication. Issued April 17, 2014. Retrieved from www.fda.gov/MedicalDevices/ Safety/AlertsandNotices/ucm393576.htm

Ishikawa, H., Ishi, K., Serna, V. A., Kakazu, R., Bulun, S. E., & Kurita, T. (2010). Progesterone is essential for maintenance and growth of uterine leiomyoma. Endocrinology, 151(6), 2433–2442. doi:10.1210/en.2009-1225

Giudice, L. C., Irwin, J. C., Dsupin, B. A., Pannier, E. M., Jin, I. H., Vu, T. H., & Hoffman, A. R. (1993). Insulin-like growth factor (IGF), IGF binding protein (IGFBP), and IGF receptor gene expression and IGFBP synthesis in human uterine leiomyomata. Human Reproduction, 8(11), 1796–1806.

Ishikawa, H., Reierstad, S., Demura, M., Rademaker, A. W., Kasai, T., Inoue, M., … Bulun, S. E. (2009). High aromatase expression in uterine leiomyoma tissue of African-American women. Journal of Clinical Endocrinology & Metabolism, 94(5), 1752–1756. doi:10.1210/jc.2008-2327

Gloudemans, T., Prinsen, I., Van Unnik, J. A., Lips, C. J., Den Otter, W., & Sussenbach, J. S. (1990). Insulin-like growth factor gene expression in human smooth muscle tumors. Cancer Research, 50(20), 6689–6695.

Johnson, N. L., Norwitz, E., & Segars, J. H. (2013). Management of fibroids in pregnancy. In J. H. Segars (Ed.), Fibroids (chap. 4). Retrieved from onlinelibrary.wiley.com/ doi/10.1002/9781118456996.ch4/summary

328

Nursing for Women’s Health

Volume 18

Issue 4

Kho, K. A., & Nezhat, C. H. (2014). Evaluating the risks of electric uterine morcellation. Journal of the American Medical Association, 311(9), 905–906. doi:10.1001/jama.2014.1093 Klatsky, P. C., Lane, D. E., Ryan, I. P., & Fujimoto, V. Y. (2007). The effect of fibroids without cavity involvement on ART outcomes independent of ovarian age. Human Reproduction, 22(2), 521–526.

Kolankaya, A., & Arici, A. (2006). Myomas and assisted reproductive technologies: When and how to act? Obstetrics & Gynecology Clinics of North America, 33(1), 145–152. Lai, J., Caughey, A. B., Qidwai, G. I., & Jacoby, A. F. (2012). Neonatal outcomes in women with sonographically identified uterine leiomyomata. Journal of Maternal-Fetal and Neonatal Medicine, 25(6), 710–713. doi:10.3109/14767058.2011.572205 Laughlin, S. K., Hartmann, K. E., & Baird, D. D. (2011). Postpartum factors and natural fibroid regression. American Journal of Obstetrics & Gynecology, 204(6), 496e1–496e6. doi:10.1016/j. ajog.2011.02.018 Laughlin, S. K., Herring, A. H., Savitz, D. A., Olshan, A. F., Fielding, J. R., Hartmann, K. E., & Baird, D. D. (2010). Pregnancyrelated fibroid reduction. Fertility & Sterility, 94(6), 2421–2423. doi:10.1016/j.fertnstert.2010.03.035 Laughlin, S. K., Schroeder, J. C., & Baird, D. D. (2010). New directions in the epidemiology of uterine fibroids. Seminars in Reproductive Medicine, 28(3), 204–217. doi:10.1055/s-0030-1251477 Leppert, P., Fouany, M., & Segars, J. H. (2013). Understanding uterine fibroids. In J. H. Segars (Ed.), Fibroids (chap. 1). Retrieved from onlinelibrary.wiley.com/doi/10.1002/9781118456996.ch1/ summary Liu, J. P., Yang, H., Xia, Y., & Cardini, F. (2009). Herbal preparations for uterine fibroids. Cochrane Database of Systematic Reviews, 2009(2). doi:10.1002/14651858.CD005292.pub Lumbiganon, P., Rugpao, S., Phandhu-fung, S., Laopaiboon, M., Vudhikamraksa, N., & Werawatakul, Y. (1996). Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: A multicentre case-control study. British Journal of Obstetrics & Gynaecology, 103(9), 909–914. Luoto, R., Rutanen, E. M., & Auvinen, A. (2001). Fibroids and hypertension—A cross-sectional study of women undergoing hysterectomy. Journal of Reproductive Medicine, 46(4), 359–364. Marino, J. L., Eskenazi, B., Warner, M., Samuels, S., Vercellini, P., Gavoni, N., & Olive, D. (2004). Uterine leiomyoma and menstrual cycle characteristics in a population-based cohort study. Human Reproduction, 19(10), 2350–2355. Marshall, L. M., Spiegelman, D., Barbieri, R. L., Goldman, M. B., Manson, J. E., Colditz, G. A., … Hunter, D. J. (1997). Variation in the incidence of uterine leiomyoma among premenopausal

August

September 2014

Marshall, L. M., Spiegelman, D., Goldman, M. B., Manson, J. E., Colditz, G. A., Barbieri, R. L., … Hunter, D. J. (1998). A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertility & Sterility, 70(3), 432–439. Marshall, L. M., Spiegelman, D., Manson, J. E., Goldman, M. B., Barbieri, R. L., Stampfer, M. J., … Hunter, D. J. (1998). Risk of uterine leiomyomata among premenopausal women in relation to body size and cigarette smoking. Epidemiology, 9(5), 511–517. Mavrelos, D., Ben-Nagi, J., Holland, T., Hoo, W., Naftalin, J., & Jurkovic, D. (2010). The natural history of fibroids. Ultrasound in Obstetrics & Gynecology, 35(2), 238–242. doi:10.1002/uog.7482 McLucas, B., Goodwin, S., Adler, L., Rappaport, A., Reed, R., & Perrella, R. (2001). Pregnancy following uterine fibroid embolization. International Journal of Gynaecology & Obstetrics, 74(1), 1–7. Muram, D., Gillieson, M., & Walters, J. H. (1980). Myomas of the uterus in pregnancy: Ultrasonographic follow-up. American Journal of Obstetrics & Gynecology, 138(1), 16–19. Nagata, C., Nakamura, K., Oba, S., Hayashi, M., Takeda, N., & Yasuda, K. (2009). Association of intakes of fat, dietary fibre, soya isoflavones and alcohol with uterine fibroids in Japanese women. British Journal of Nutrition, 101(10), 1427–1431. National Heart Lung and Blood Institute (NHLBI). (2013). What is iron-deficiency anemia. Retrieved fromwww.nhlbi.nih.gov/ health//dci/Diseases/ida/ida_all.html National Institutes of Health (NIH). (2012). Unilateral hydronephrosis. Retrieved from www.nlm.nih.gov/medlineplus/ency/ article/000506.htm Nodler, J. L., & Segars, J. H. (2013). Evidence-based indications for treatment of uterine fibroids in gynecology. In J. H. Segars (Ed.), Fibroids (chap. 3). Retrieved from onlinelibrary.wiley.com/ doi/10.1002/9781118456996.ch3/summary Okolo, S. O., Gentry, C. C., Perrett, C. W., & Maclean, A. B. (2005). Familial prevalence of uterine fibroids is associated with distinct clinical and molecular features. Human Reproduction, 20(8), 2321–2324. Oliveira, F. G., Abdelmassih, V. G., Diamond, M. P., Dozortsev, D., Melo, N. R., & Abdelmassih, R. (2004). Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection. Fertility & Sterility, 81(3), 582–587. Olufowobi, O., Sharif, K., Papaionnou, S., Neelakantan, D., Mohammed, H., & Afnan, M. (2004). Are the anticipated benefits of myomectomy achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital. Journal of Obstetrics & Gynaecology, 24(4), 434–440. Parazzini, F., Negri, E., La Vecchia, C., Chatenoud, L., & Guarnerio, P. (1996). Reproductive factors and risk of uterine fibroids. Epidemiology, 7(4), 440–442. Parazzini, F., Negri, E., La Vecchia, C., Rabaiotti, M., Luchini, L., Villa, A., & Fedele, L. (1996). Uterine myomas and smoking: Results from an Italian study. Journal of Reproductive Medicine, 41(5), 316–320.

Nursing for Women’s Health

329

http://JournalsCNE.awhonn.org

Klatsky, P. C., Tran, N. D., Caughey, A. B., & Fujimoto, V. Y. (2008). Fibroids and reproductive outcomes: A systematic literature review from conception to delivery. American Journal of Obstetrics & Gynecology, 198(4), 357–366. doi:10.1016/j.ajog.2007.12.039

women by age and race. Obstetrics & Gynecology, 90(6), 967–973.

CNE

Khalaf, Y., Ross, C., El-Toukhy, T., Hart, R., Seed, P., & Braude, P. (2006). The effect of small intramural uterine fibroids on the cumulative outcome of assisted conception. Human Reproduction, 21(10), 2640–2644.

Parker, W. H. (2007). Etiology, symptomatology, and diagnosis of uterine myomas. Fertility & Sterility, 87(4), 725–736.

of pregnancies with uterine leiomyomas. Journal of Reproductive Medicine, 49(3), 182–186.

Parker, W. H., Fu, Y. S., & Berek, J. S. (1994). Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstetrics & Gynecology, 83(3), 414–418.

Shikora, S. A., Niloff, J. M., Bistrian, B. R., Forse, R. A., & Blackburn, G. L. (1991). Relationship between obesity and uterine leiomyomata. Nutrition, 7(4), 251–255.

Peddada, S. D., Laughlin, S. K., Miner, K., Guyon, J. P., Haneke, K., Vahdat, H. L., … Baird, D. D. (2008). Growth of uterine leiomyomata among premenopausal black and white women. Proceedings of the National Academy of Sciences, 105(50), 19887–19892.

Silver, M. A., Raghuvir, R., Fedirko, B., & Elser, D. (2005). Systemic hypertension among women with uterine leiomyomata: Potential final common pathways of target end-organ remodeling. Journal of Clinical Hypertension, 7(11), 664–668.

Pithukpakorn, M., & Toro, J. (2010). Hereditary leiomyomatosis and renal cell cancer. In Pagon, R. A., Adam, M. P., Bird, T. D., Dolan, C. R., Fong, C., Smith, R. J. H., & Stephens, K. (Eds.), Gene Reviews. Retrieved from www.ncbi.nlm.nih.gov/books/NBK1252/

Smart, O. C., Hindley, J. T., Regan, L., & Gedroyc, W. G. (2006). Gonadotrophin-releasing hormone and magnetic-resonanceguided ultrasound surgery for uterine leiomyomata. Obstetrics & Gynecology, 108(1), 49–54.

Poretsky, L., & Galin, M. F. (1987). The gonadotropic function of insulin. Endocrine Review, 8(2), 132–141.

Smeets, A. J., Nijenhuis, R. J., Boekkooi, P. F., Vervest, H. A., van Rooji, W. J., & Lohle, P. N. (2010). Is an intrauterine device a contraindication for uterine artery embolization? A study of 20 patients. Journal of Vascular and Interventional Radiology, 21(2), 272–274.

Pritts, E. A., Parker, W. H., & Olive, D. L. (2009). Fibroids and infertility: An updated systematic review of the evidence. Fertility & Sterility, 91(4), 1215–1223. doi:10.1016/j.fertnstert.2008.01.051 Qidwai, G. I., Caughey, A. B., & Jacoby, A. F. (2006). Obstetric outcomes in women with sonographically identified uterine leiomyomata. Obstetrics & Gynecology, 107(2), 376–382. Radin, R. G., Rosenberg, L., Palmer, J. R., Cozier, Y. C., Kumayika, S. K., & Wise, L. A. (2012). Hypertension and risk of uterine leiomyomata in US Black women. Human Reproduction, 27(5), 1504–1509. doi:10.1093/humrep/des046 Ravakhah, K., Gover, A., & Mukunda, B. N. (1999). Humoral hypercalcemia associated with a uterine fibroid. Annals of Internal Medicine, 130(8), 702. Ravina, J. H., Herbreteau, D., Ciraru-Vigneron, N., Bouret, J. M., Houdart, E., Aymard, A., & Merland, J. J. (1995). Arterial embolisation to treat uterine myomata. Lancet, 346(8976), 671–672. Reed, S. D., Cushing-Haugen, K. L., Daling, J. R., Scholes, D., & Schwartz, S. M. (2004). Postmenopausal estrogen and progestogen therapy and the risk of uterine leiomyomas. Menopause, 11(2), 214–222. Rice, K., Secrist, J., Woodrow, E., Hallock, L., & Neal, J. (2012). Etiology, diagnosis, and management of uterine leiomyomas. Journal of Midwifery & Women’s Health, 57(3), 241–247. doi:10.1111/ j.1542-2011.2012.00176.x Romieu, I., Walker, A. M., & Jick, S. (1991). Determinants of uterine fibroids. Post Marketing Surveillance, 5, 119–133. Ross, R. K., Pike, M. C., Vessey, M. P., Bull, D., Yeates, D., & Casagrande, J. T. (1986). Risk factors for uterine fibroids: Reduced risk associated with oral contraceptives. British Medical Journal, 293(6543), 359–362. doi:http://dx.doi.org/10.1136/ bmj.293.6543.359 Sardo, A., Mazzon, I., Bramante, S., Bettocchi, S., Bifulco, G., Guida, M., & Nappi, C. (2008). Hysteroscopic myomectomy: A comprehensive review of surgical techniques. Human Reproduction, 14(2), 101–119. Sato, F., Mori, M., Nishi, M., Kudo, R., & Miyake, H. (2002). Familial aggregation of uterine myomas in Japanese women. Journal of Epidemiology 12(3), 249–253. Sheiner, E., Bashiri, A., Levy, A., Hershkovitz, R., Katz, M., & Mazor, M. (2004). Obstetric characteristics and perinatal outcome

330

Nursing for Women’s Health

Smeets, A. J., Nijenhuis, R. J., van Rooij, W. J., Weimar, E. A., Boekkooi, P. F., Lampmann, L. E., … Lohle, P. N. (2010). Uterine artery embolization in patients with a large fibroid burden: Longterm clinical and MR follow-up. Cardiovascular & Interventional Radiology, 33(5), 943–948. doi:10.1007/s00270-009-9793-2 Somigliana, E., Vercellini, P., Daguati, R., Pasin, R., De Giorgi, O., & Crosignani, P. G. (2007). Fibroids and female reproduction: A critical analysis of the evidence. Human Reproduction, 13(5), 465–476. Spies, J. B., Bradley, L. D., Guido, R., Maxwell, G. K., Levine, B. A., & Coyne, K. (2010). Outcomes from leiomyoma therapies: Comparison with normal controls. Obstetrics & Gynecology, 116(3), 641–652. doi:10.1097/AOG.0b013e3181ed36b3 Stewart, E. A. (2001). Uterine fibroids. Lancet, 357(9252), 293–298. Stewart, E. A., Gedroyc, W. M., Tempany, C. M., Quade, B. J., Inbar, Y., Ehrenstein, T., … Rabinovici, J. (2003). Focused ultrasound treatment of uterine fibroid tumors: Safety and feasibility of a noninvasive thermoablative technique. American Journal of Obstetrics & Gynecology, 189(1), 48–54. Stout, M. J., Odibo, A. O., Graseck, A. S., Macones, G. A., Crane, J. P., & Cahill, A. G. (2010). Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstetrics & Gynecology, 116(5), 1056–1063. Stovall, T. G., Summit, R. L., Washburn, S. A., & Ling, F. W. (1994). Gonadotropin-releasing hormone agonist use before hysterectomy. American Journal of Obstetrics & Gynecology, 170(6), 1744–1748. Templeman, C., Marshall, S. F., Clarke, C. A., Henderson, K. D., Largent, J., Neuhausen, S., … Bernstein, L. (2009). Risk factors for surgically removed fibroids in a large cohort of teachers. Fertility & Sterility, 92(4), 1436–1446. doi:10.1016/j. fertnstert.2008.08.074 Terry, K. L., De Vivo, I., Hankinson, S. E., Spiegleman, D., Wise, L. A., & Missmer, S. A. (2007). Anthropometric characteristics and risk of uterine leiomyoma. Epidemiology, 18(6), 758–763. Verga, C. (2012). Benign gynecologic conditions. In K. Schuiling & F. Likis (Eds.), Women’s gynecologic health (pp. 669–699). Burlington, MA: Jones & Bartlett.

Volume 18

Issue 4

Walocha, J. A., Litwin, J. A., & Miodonski, A. J. (2003). Vascular system of intramural leiomyomata revealed by corrosion casting and scanning electron microscopy. Human Reproduction, 18(5), 1088–1093. doi:10.1093/humrep/deg213 Whiteman, M., Hillis, S., Jamieson, D. J., Morrow, B., Podgornik, M. N., Brett, K. M., & Marchbanks, P. A. (2008). Inpatient hysterectomy surveillance in the United States, 2000-2004. American Journal of Obstetrics & Gynecology, 198(1), 34.e1–34.e7.

Wise, L. A., Palmer, J. R., Cozier, Y. C., Hunt, M. O., Stewart, E. A., & Rosenberg, L. (2007). Perceived racial discrimination and risk of uterine leiomyomata. Epidemiology, 18(6), 747–757. Wise, L. A., Palmer, J. R., Harlow, B. L., Spiegelman, D., Stewart, E. A., Adams-Campbell, L. L., & Rosenberg, L. (2004a). Reproductive factors, hormonal contraception, and risk of uterine leiomyomata in African-American women: A prospective study. American Journal of Epidemiology, 159(2), 113–123. Wise, L. A., Palmer, J. R., Harlow, B. L., Spiegelman, D., Stewart, E.A., Adams-Campbell, L. L., & Rosenberg, L. (2004b). Risk of uterine leiomyomata in relation to tobacco, alcohol and caffeine consumption in the black Women’s Health Study. Human Reproduction, 19(8), 1746–1754. Wise, L. A., Palmer, J. R., Harlow, B. L., Spiegelman, D., Stewart, E. A., Adams-Campbell, L. L., & Rosenberg, L. (2005). Influence of body size and body fat distribution on risk of uterine leiomyomata in U.S. black women. Epidemiology, 16(3), 346–354. Wise, L. A., Palmer, J. R., Stewart, E. A., & Rosenberg, L. (2007). Polycystic ovary syndrome and risk for uterine leiomyomata. Fertility & Sterility, 87(5), 1108–1115. doi:10.1016/j.fertnstert. 2006.11.012

August

September 2014

Wise, L. A., Radin, R. G., Palmer, J. R., Kumanyika, S. K., Boggs, D. A., & Rosenberg, I. (2011). Intake of fruit, vegetables, and carotenoids in relation to risk of uterine leiomyomata. American Journal of Clinical Nutrition, 94(6), 1620–1631. doi:10.3945/ ajcn.111.016600 Yang, C. H., Lee, J. N., Hsu, S. C., Kuo, C. H., & Tsai, E. M. (2002). Effect of hormone replacement therapy on uterine fibroids in postmenopausal women—A 3-year study. Maturitas, 43(1), 35–39. Yildiz, F., Camuzcuoqlu, H., Tov, H., Terzi, A., & Guldur, M. E. (2009). A rare cause of difficulty with sexual intercourse: Large retroperitoneal leiomyoma. Journal of Sexual Medicine, 6(11), 3221–3223. doi:10.1111/j.1743-6109.2009.01472.x Yoon, S. W., Lee, C., Cha, S. H., Jeong-Sik, Y., Na, Y. J., Kim, K.A., … Kim, S. J. (2008). Patient selection guidelines in MR-guided focused ultrasound surgery of uterine fibroids: A pictorial guide to relevant findings in screening pelvic MRI. European Radiology, 18(12), 2997–3006. doi:10.1007/s00330-008-1086-7 Yoshida, M., Koshiyama, M., Fujii, H., & Konishi, M. (1999). Erythrocytosis and a fibroid. Lancet, 354(9174), 216. doi:10.1016/ S0140-6736(99)02273-4 Younger, J., Baig-Ward, K. M., Segars, J. H., & Al-Hendy, A. (2013). The clinical spectrum of fibroid disease. In J. H. Segars (Ed.), Fibroids (chap. 2). Retrieved from onlinelibrary.wiley.com/ doi/10.1002/9781118456996.ch2/summary Zapata, L. B., Whiteman, M. K., Tepper, N. K., Jamieson, D. J., Marchbanks, P. A., & Curtis, P. A. (2010). Intrauterine device use among women with uterine fibroids: A systematic review. Contraception, 82(1), 41–55. doi:10.1016/j.contraception.2010.02.011

Nursing for Women’s Health

331

http://JournalsCNE.awhonn.org

Wirth, M. M., Meier, E. A., Fredrickson, B. L., & Schultheiss, O. C. (2007). Relationship between salivary cortisol and progesterone levels in humans. Biological Psychology, 74(1), 104–107.

Wise, L. A., Radin, R. G., Palmer, J. R., Kumanyika, S. K., & Rosenberg, I. (2010). A prospective study of dairy intake and risk of uterine leiomyomata. American Journal of Epidemiology, 171(2), 221–232. doi:10.1093/aje/kwp355

CNE

Vikhlyaeva, E. M., Khodzhaeva, Z. S., & Fantschenko, N. D. (1995). Familial predisposition to uterine leiomyomas. International Journal of Gynaecology & Obstetrics, 51(2), 127–131.

CNE

Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.

http://JournalsCNE.awhonn.org

1.

Which of the following is a common menstrual cycle change associated with uterine fibroids in premenopausal women? a. Intermenstrual bleeding b. Menstrual cycle bleeding that is abnormally light c. Menstrual cycle bleeding that is excessively heavy

2.

Which of the following imaging modalities is the most specific and sensitive imaging modality currently available for evaluation of uterine fibroids? a. Abdominal ultrasound b. Magnetic resonance imaging c. Pelvic ultrasound with transvaginal probe

3.

Which of the following statements is true with regard to the use of uterine artery embolization (UAE) for the treatment of uterine fibroids? a. Concurrent gonadotropin-releasing hormone (GnRH) agonist use precludes the use of UAE. b. The presence of an intrauterine device is a contraindication for the use of UAE. c. UAE is contraindicated in patients with plans for future pregnancies.

4.

The presence of uterine fibroids is a potential risk factor for which of the following obstetric complications? a. Placenta accreta b. Polyhydramnios c. Postpartum hemorrhage

5.

Which of the following is known to be a risk factor for uterine fibroids? a. High BMI b. Low BMI c. Pregnancy weight gain >30 lbs

6.

7.

332

Current evidence supports a link between an increased risk of uterine fibroids and which of the following lifestyle habits? a. Alcohol use b. Caffeine use c. Cigarette smoking Which of the following factors in a woman’s health history may increase the risk of uterine fibroids? a. Menarche after the age of 15 years old b. Menarche before the age of 11 years old c. Menopause before the age of 50 years old

Nursing for Women’s Health

8.

Which of the following statements is true with regard to the most common growth pattern of uterine fibroids? a. Fibroids most commonly decrease in size during pregnancy and increase in size postpartum. b. Fibroids most commonly increase in size during pregnancy and decrease in size postpartum. c. Fibroids most commonly increase in size during pregnancy and continue to increase in size postpartum.

9.

Which of the following uses of exogenous hormones is associated with an increased risk of uterine fibroid growth? a. Combined oral contraceptives b. Progestin-only hormonal implant (e.g., Nexplanon) c. Progestin-only intrauterine contraceptive device (e.g., Mirena or Skyla)

10. Which of the following is a potential pregnancy complication as a result of the presence of uterine fibroids? a. Fetal growth restriction b. Multiple gestation c. Placenta previa 11. Which of the following is a correct constellation of historical factors associated with a higher incidence of uterine fibroids? a. Asian women with late onset of menses b. Black or Latina women with a family history of uterine fibroids c. Caucasian women with a family history of menopause after the age of 55 years old 12. Current treatment of uterine fibroids correctly includes which contraceptive category? a. Combined oral contraceptives b. Copper containing intrauterine device (e.g., Paraguard) c. Progestin-only injectable contraception (e.g., Depo Provera) 13. Which of the following is a true statement about pregnant women with fibroids? a. They have been demonstrated to have an increased risk for a growth restricted fetus. b. They may be candidates for active management of the third stage of labor c. They will require a cesarean birth.

Volume 18

Issue 4