دکتر مریم هاشمی - PowerPoint Presentation

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دکتر مریم هاشمی

15 دی ماه 1392 – تالار زیتون

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vaginitis

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 Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Symptoms include vaginal discharge, odor, .pruritus, and/or discomfort

The most common causes of vaginal discharge, odor, pruritus, and/or discomfort are bacterial vaginosis, candida vulvovaginitis, and trichomoniasis. These disorders account for over 90 percent of cases.

Less common causes of these symptoms include vaginal atrophy/atrophic 

vaginitis

,

cervicitis

, foreign body, irritants and allergens, and several rarer entities, including some

.

systemic medical disorders

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PATHOGENESIS

  

The

nonkeratinized

stratified

squamous

epithelium of the vagina in premenopausal women is rich in glycogen. Glycogen from sloughed cells is the substrate for

Döderlein's

lactobacilli, which convert glucose into lactic acid, thereby creating an acidic vaginal environment (pH 4.0 to 4.5). This acidity helps maintain the normal vaginal flora and inhibits growth of pathogenic organisms. Disruption of the normal ecosystem can lead to conditions favorable for development of

vaginitis

.

Some of these potentially disruptive factors include phase of the menstrual cycle, sexual activity, contraceptive choice, pregnancy, foreign bodies, estrogen level, sexually transmitted diseases, and use of hygienic products or antibiotics

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PATIENT PRESENTATION

 

Women with

vaginitis

typically present with one or more of the following

vulvovaginal

symptoms:

●Change in the volume, color, or odor of vaginal discharge

●

Pruritus

●Burning

●Irritation

●

Erythema

●

Dyspareunia

●Spotting

●

Dysuria

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Vaginal discharge

is a prominent symptom of

vaginitis

, but may be difficult to distinguish from

normal vaginal

discharge.

In reproductive aged women,

normal vaginal discharge

consists of

1 to 4

mL

fluid (per 24 hours), which is

white or transparent

,

thick or thin

, and mostly

odorless.

This physiologic discharge is formed by

mucoid

endocervical

secretions in combination with sloughing epithelial cells, normal vaginal flora, and vaginal

transudate

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GENERAL PRINCIPLES

 Empiric therapy

based on history and physical examination alone should be

avoided

because of frequent misdiagnosis and inappropriate therapy.

However, 25 to 40 percent of patients with genital symptoms do not have a specific cause identified after initial diagnostic testing.

The

three main steps

in the evaluation of women

with symptoms of

vaginitis

are:

●Obtain a

history

and perform

a physical examination

●

Test

for bacterial

vaginosis

,

vulvovaginal

candidiasis

, and

trichomoniasis

since these disorders account for over 90 percent of

vaginitis

in premenopausal women and can be diagnosed by pH testing, microscopy, and/or culture (or rapid antigen and nucleic acid amplification test].

●If this evaluation does not lead to a diagnosis, then evaluate for less common and rare causes of

vaginitis

.

Patients who continue to exhibit symptoms and/or have positive tests for sexually transmitted infections after treatment are most likely to have been re-infected by their sexual partner

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Bacterial

vaginosis

(BV) is the

most common

cause of

vaginal discharge

in women of childbearing age, accounting for 40 to 50 percent of cases.

The absence of inflammation is the basis for the term "

vaginosis

" rather than "

vaginitis

."

Bacterial

vaginosis

(BV) represents a complex change in the vaginal flora characterized by a

reduction in concentration of the normally dominant hydrogen-peroxide producing lactobacilli

and an increase in concentration of other organisms, especially anaerobic gram negative rods .The major bacteria detected are

Gardnerella

vaginalis

,

Prevotella

species,

Porphyromonas

species,

Bacteroides

species,

Peptostreptococcus

species,

Mycoplasma

hominis

,

Ureaplasma

urealyticum

, and

Mobiluncus

species.

Fusobacterium

species and

Atopobium

vaginae

are also common

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RISK FACTORS

 

 

Sexual activity

is a risk factor for bacterial

vaginosis

(BV)

BV is highly prevalent (25 to 50 percent) in women who

have sex with women (WSW)

 

D

ouching and cigarette smoking

Use of

condoms and estrogen-containing contraceptives

may be

protective factors

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CLINICAL FEATURES

 

Fifty to 75 percent of women with bacterial

vaginosis

(BV) are

asymptomatic

.

Symptomatic

women typically present with

vaginal discharge and/or vaginal odor .

The discharge is off-white, thin, and homogeneous; the odor is an unpleasant "fishy smell" that may be more noticeable after sexual intercourse and during menses .

BV alone does not cause

dysuria

,

dyspareunia

,

pruritus

, burning, or vaginal inflammation (

erythema

, edema) .The presence of these symptoms suggests mixed

vaginitis

(symptoms due to two pathogens)

Although BV does not involve the cervix, the disorder may be associated with acute

cervicitis

(

endocervical

mucopurulent

discharge or easily induced cervical bleeding

)

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DIAGNOSIS

 

Amsel

criteria

 

 The diagnosis of BV is usually based on

Amsel

criteria, which are simple and useful in an office practice where

microscopy

is available .

The first three findings are sometimes also present in patients with

trichomoniasis

.

Amsel

criteria for diagnosis of BV (at least three criteria must be present):

●Homogeneous, thin,

grayish-white discharge

that smoothly coats the vaginal walls

●

Vaginal pH >4.5

●

Positive whiff-amine test

, defined as the presence of a fishy odor when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge

●

Clue cells

on saline wet mount . For a positive result, at least 20 percent of the epithelial cells on wet mount should be clue cells. The presence of clue cells diagnosed by an experienced

microscopist

is the single most reliable predictor of BV

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Gram's stain

 

 

Gram’s stain of vaginal discharge is the

gold standard

for diagnosis of

BV

but

is mostly performed

in research studies

Cytology

 

 

The

Papanicolaou

smear is not reliable for diagnosis of BV.

If a cytology smear suggests BV (

ie

, shift in flora from predominantly lactobacilli to predominantly

coccobacilli

with or without clue cells), the patient should be asked about symptoms, and if

symptomatic

, she should undergo standard

diagnostic testing for BV

and treatment, if appropriate.

Treatment of asymptomatic women is not routinely indicated

Culture

 

 

Because BV represents complex changes in the vaginal flora, vaginal culture has 

no

 role

in diagnosis

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TREATMENT

 

Bacterial

vaginosis

(BV)

resolves

spontaneously in up to

one-third of

nonpregnant

and

one-half of pregnant women

.

Treatment is indicated for relief of symptoms in women with

symptomatic infection

and to prevent postoperative infection in those with

asymptomatic

infection prior to abortion or hysterectomy

.

Treatment of BV may also

reduce

the risk of

acquiring

STD

s

, including

HIV

. For this reason, some experts support the concept of treating all women with BV regardless of presence or absence of symptoms; however, we agree

withCDC

recommendations to not treat asymptomatic women.

Asymptomatic pregnant women

with previous preterm births may also benefit, but screening and treatment of these women is

controversial

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Nonpregnant

women

Drugs

 — 

Metronidazole

 or 

clindamycin

 administered either orally or

intravaginally

.

Oral medication is more convenient, but associated with a higher rate of systemic side effects than vaginal administration.

 

Tinidazole

 is a reasonable oral

alternative.

Metronidazole

 — The efficacy of 

metronidazole

 has been established. The oral regimen we recommend

is 500 mg twice daily for seven days.

Treatment with a

single oral dose of 2

grams of

metronidazole

has lower efficacy and is

no

longer recommended for treatment of BV. Alcohol should not be consumed during therapy and for one day after completion of therapy.

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Vaginal therapy

with 0.75 percent 

metronidazole

 gel 5 grams once daily for

five days

is as effective as oral

metronidazole

(5 grams of gel contains 37.5 mg of

metronidazole

) .The choice of oral versus vaginal therapy should depend upon

patient preference.

Side effects

of 

metronidazole

 include a metallic taste, nausea (in 10 percent of patients), transient

neutropenia

(7.5 percent), a

disulfiram

-like effect with alcohol, prolongation of INR in patients taking vitamin K antagonists (

eg

, 

warfarin

), and peripheral neuropathy.

Gastrointestinal side effects are less common with vaginal administration .Allergy to

metronidazole

is uncommon; it manifests as rash,

urticaria

,

pruritus

, and rarely, anaphylaxis, which can be successfully treated by oral desensitization

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Clindamycin

 

 The preferred regimen is a

seven-day

course of

2 percent

clindamycin

cream

vaginally (5 grams of cream containing 100 mg of

clindamycin

phosphate), but may

be less effective

than the 

metronidazole

 regimens

Alternative regimens include oral 

clindamycin

 (300 mg twice daily for seven

days) or

clindamycin

ovules (100 mg

intravaginally

once daily for three days.

Intravaginal

 

clindamycin

 therapy has been associated with an increased prevalence of

clindamycin

resistant anaerobic bacteria

in the vagina

posttreatment

.

This effect persisted in most women for

at least 90 days

after

clindamycin

treatment. In contrast, increased resistance to 

metronidazole

 was not observed in women treated with that drug.

Clindamycin

 cream should

not be

used concurrently with

latex condoms

, which may be weakened.

Pseudomembranous

colitis has been reported with both oral and topical 

clindamycin

.

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Tinidazole

 

 

Tinidazole

 is a second generation

nitroimidazole

. It has a longer half-life than 

metronidazole

 (12 to 14 hours versus 6 to 7 hours) and fewer side effects.

 

a single dose

regimen appears to be

as effective as

vaginal 

clindamycin

 cream

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Probiotics

 

 

Probiotics

(

live microorganisms

which confer a health benefit on the host when administered in adequate amounts) have been used alone and as adjunctive therapy to antibiotics for treatment of BV and prevention of relapse

In the United States, the content of these products is not standardized and often of poor quality

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Less effective and ineffective therapies

 

Triple-sulfa

creams, 

erythromycin

, 

tetracycline

, 

ampicillin

, 

amoxicillin

, lactic acid gel, 

acetic acid

 gel, ascorbic acid, 

azithromycin

, 

chlorhexidine

, 

hydrogen peroxide

, and

povidone

-iodine vaginal douches are significantly less effective than 

metronidazole

 and 

clindamycin

 and

should not be used

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We suggest symptomatic relapse be treated initially with a seven-day course of oral or vaginal metronidazole or clindamycin. The treatment regimen may be the same or different from the initial or previous treatment regimen.

We believe any patient with

more than three

documented episodes of BV in the previous 12 months should be offered a long-term maintenance regimen consisting of maintenance 

metronidazole

 gel.

Long-term 

clindamycin

 regimens, oral or topical, are not advised because of toxicity and lack of documented efficacy .

Accordingly, if any of the aforementioned antimicrobials fail, we prescribe

metronidazole

gel 0.75 percent or an oral

nitroimidazole

for 7 to 10 days followed by twice weekly dosing of gel for four to six months

.Secondary vaginal

candidiasis

was a common side effect.

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Pregnant women

Symptomatic BV infection

 — All women with symptomatic BV should be treated to relieve bothersome symptoms. Oral treatment is effective and has not been associated with adverse fetal or obstetrical effects. The therapeutic options include:

●

Metronidazole

 500 mg orally twice daily for 7 days

●

Metronidazole

 250 mg orally 3 times daily for 7 days

●

Clindamycin

 300 mg orally twice daily for 7 days

Some clinicians avoid use of 

metronidazole

 in the first trimester because it crosses the placenta, and thus has a potential for

teratogenicity

. However, meta-analysis has not found any relationship between

metronidazole

exposure during the first trimester of pregnancy and birth defects , and the CDC no longer discourage the use of

metronidazole

in the first trimester . An additional concern is that the drug is mutagenic in bacteria and carcinogenic in mice, but there is no evidence of harm in humans.

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It is the second most common cause of vaginitis symptoms (after bacterial vaginosis) and accounts for approximately one-third of vaginitis cases. Identification of vulvovaginal Candida is not necessarily indicative of candidal disease, as the diagnosis of vulvovaginitis requires the presence of vulvovaginal inflammation. 

MICROBIOLOGY

 — Candida

albicans

is responsible for 80 to 92 percent of episodes of

vulvovaginal

candidiasis

and C.

glabrata

accounts for almost all of the remainder

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RISK FACTORS

 

 

Sporadic attacks of

vulvovaginal

candidiasis

usually occur without an identifiable precipitating factor. Nevertheless, a number of factors predispose to symptomatic infection :

●

Diabetes mellitus

 — Women with diabetes mellitus who have poor

glycemic

control are more prone to

vulvovaginal

candidiasis

than

euglycemic

women .In particular, women with Type 2 diabetes appear prone to non-

albicans

Candida species.

●

Antibiotic use

 — Use of broad spectrum antibiotics significantly increases the risk of developing

vulvovaginal

candidiasis

. As many as one-quarter to one-third of women develop the disorder during or after taking these antibiotics because inhibition of normal bacterial flora favors growth of potential fungal pathogens, such as Candida. Administration of 

lactobacillus

 (oral or vaginal) during and for four days after antibiotic therapy does not prevent

postantibiotic

vulvovaginitis

.

●

Increased estrogen levels

 —

Vulvovaginal

candidiasis

appears to occur more often in the setting of increased estrogen levels, such as oral contraceptive use (especially when estrogen dose is high), pregnancy, and estrogen therapy.

●

Immunosuppression

 —

Candidal

infections are more common in

immunosuppressed

patients, such as those taking

glucocorticoids

or other immunosuppressive drugs, or with human immunodeficiency virus (HIV) infection

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●

Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices have been associated with

vulvovaginal

candidiasis

, but not consistently.

Spermicides

are not

associated with Candida infection

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TREATMENT

 

Treatment is indicated for relief of symptoms. Ten to 20 percent of reproductive age women who harbor Candida species are

asymptomatic;

these women do

not require therapy [

56

].

The treatment regimen is based on whether the woman has an

uncomplicated

infection (90 percent of patients) or

complicated

infection (10 percent of patients).

Uncomplicated infections usually respond to treatment within a couple of days. Complicated infections require a longer course of therapy and may take two weeks to fully resolve.

Treatment of sexual partners is unnecessary.

There is no medical contraindication to sexual intercourse during treatment

, but it may be uncomfortable until inflammation improves

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Uncomplicated infection

 — Criteria for uncomplicated infection include all of the following:

●Sporadic, infrequent episodes (≤3 episodes/year)

●Mild to moderate signs/symptoms

●Probable infection with Candida

albicans

●Healthy,

nonpregnant

woman

 

The absence of superiority of any formulation, agent, or route of administration suggests that

cost

,

patient preference

, and

contraindications

are the major considerations in the decision to

prescribe an anti-fungal for oral or topical administration

We suggest use of oral 

fluconazole

, given that most women consider oral drugs more convenient than those applied

intravaginally

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Complicated infections

 

— Characteristics of complicated infections include

one or more

of the following criteria :

●Severe signs/symptoms

●Candida species other than C.

albicans

, particularly C.

glabrata

●Pregnancy, poorly controlled diabetes,

immunosuppression

, debilitation

●History of recurrent (≥4/year) culture-verified

vulvovaginal

candidiasis

 

we suggest 

fluconazole

 (150 mg orally) for two to three sequential doses 72 hours apart for treatment of complicated infections, depending on the severity of the infection

If the patient prefers topical therapy, observational series report that complicated patients require 7 to 14 days of topical

azole

therapy (

eg

, 

clotrimazole

,

miconazole

, 

terconazole

) rather than a one- to three-day course

For severe Candida

vulvar

inflammation (

vulvitis

), low potency topical corticosteroids can be applied to the vulva for 48 hours until the

antifungals

exert their effec

t

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Pregnancy

 

Treatment of pregnant women is primarily indicated for

relief of symptoms

.

Vaginal

candidiasis

is not associated with adverse pregnancy outcomes .

We suggest application of a topical

imidazole

.

(

clotrimazole

 or 

miconazole

) vaginally for

seven

days

Administration of

oral azoles during the first trimester is not

recommended

Although treatment of vaginal

candida

colonization in healthy pregnant women is unnecessary, in Germany treatment is recommended in the third trimester because the rate of oral thrush and diaper dermatitis in mature healthy newborns is significantly reduced by maternal treatment

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Recurrent infection

Attempts should be made to eliminate or reduce

risk factors

for infection if present (

eg

, improve

glycemic

control, switch to lower estrogen dose oral contraceptive)

we believe that the optimal therapy for recurrent

vulvovaginal

candidiasis

in

nonpregnant

women consists of

initial induction therapy

with

fluconazole

 150 mg every 72 hours for three doses, followed by maintenance

fluconazole

therapy once per week for six months

Therapy is then discontinued, at which point some patients achieve a prolonged remission, while others relapse. A short-term relapse, with culture confirmation of the diagnosis, merits

reinduction

therapy with

three doses of

fluconazole

, followed by repeat weekly maintenance

fluconazole

therapy, this time for one year

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A minority of women persist in relapsing

as soon as

fluconazole

maintenance is withdrawn (

fluconazole

dependent recurrent

vulvovaginal

candidiasis

).

Symptoms in these patients can be controlled by months or years of weekly

fluconazole

.

Given the safety profile of low dose 

fluconazole

, most experts do not suggest any laboratory monitoring; however, if other oral

imidazoles

(

ketoconazole

,

itraconazole

) are used, particularly if taken daily, then monitoring liver function tests is recommended. Idiosyncratic

hepatotoxicity

secondary to

ketoconazole

therapy is a concern, but rare in this setting

Alternative approaches that have been suggested include:

●Treat each recurrent episode as an

episode of uncomplicated infection

●Treat each recurrent episode with longer duration of therapy (

eg

, topical

azole

for 7 to 14 days or 

fluconazole

 150 mg orally on day 1, day 4, and day 7)

●The Infectious Diseases Society of America (IDSA) recommends 10 to 14 days of induction therapy with a topical or oral

azole

, followed

by

fluconazole

 150 mg once per week for six months (

clotrimazole

 200 mg vaginal cream twice weekly is a

nonoral

alternative

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INTRODUCTION

 — 

Trichomoniasis

is caused by the protozoan

Trichomonas

vaginalis

.

It is the most common non-viral sexually transmitted disease (STD) worldwide.

Women are affected more often than men.

Trichomoniasis

is one of the three major causes of vaginal complaints among reproductive aged women, along with bacterial

vaginosis

and

candida

vulvovaginitis

[

1

], and a cause of

urethritis

in men; however, the infection is often asymptomatic

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CLINICAL FEATURES

Women

 

In women,

trichomoniasis

ranges from an

asymptomatic carrier

state to an

acute, severe inflammatory disease

.

As many as 50 percent of infected women are asymptomatic, although many of these women eventually become symptomatic. Asymptomatic carriage can persist for prolonged periods of time (at least three months), thus it is often not possible to ascertain when or from whom the infection was acquired .

Vaginitis

 — Common signs and symptoms of acute infection include a

purulent, malodorous

,

thin discharge

associated with

burning,

pruritus

,

dysuria

,

frequency

,

lower abdominal pain,

or

dyspareunia

. Symptoms may be worse during menstruation.

Postcoital

bleeding can occur.

Physical examination

often reveals

erythema

of the vulva and vaginal mucosa. The classically described green-yellow, frothy, malodorous discharge occurs in 10 to 30 percent of symptomatic women.

Punctate

hemorrhages may be visible on the vagina and cervix ("strawberry cervix" in 2 percent of cases).

In chronic infection, signs and symptoms are milder and may include

pruritus

and

dyspareunia

, with scanty vaginal secretion.

Slide34

Men

 

— In men, T.

vaginalis

infection is

asymptomatic

in over three-quarters of cases and

often transient

(spontaneous resolution within 10 days)

However, untreated infection can persist for months . Symptoms, when present, are the same as those for

urethritis

from any cause and consist of a clear

or

mucopurulent

urethral discharge and/or 

dysuria

.

They may also have mild

pruritus

or burning sensation in the penis after sexual intercourse

Slide35

CONSEQUENCES

Women

 — Untreated

trichomonal

vaginitis

may progress to

urethritis

or cystitis

. In addition, T.

vaginalis

has been associated with a range of adverse reproductive health outcomes, including

cervical

neoplasia

,

posthysterectomy

cuff

cellulitis

or abscess ,atypical pelvic inflammatory disease in women infected with HIV ,

and

infertility

.It may also increase women's susceptibility to HIV-1 infection by up to two-fold.

Men

 — T.

Vaginalis

in men has been associated with

prostatitis

,

balanoposthitis

,

epididymitis

,

infertility,

and

prostate cancer

Slide36

DIAGNOSIS

Women

 — The diagnosis of

trichomonas

is based on

laboratory testing

(motile

trichomonads

on wet mount, positive culture, positive nucleic acid amplification test, or positive rapid antigen or nucleic acid probe test).

As with other types of

vaginitis

, none of the clinical features of

trichomoniasis

is sufficiently sensitive or specific to allow a diagnosis based upon signs and symptoms alone

Slide37

TREATMENT

 

 Treatment is indicated

for

both symptomatic and asymptomatic women and men

.

Treatment

reduces the prevalence of T.

vaginalis

carriage in the population

,

relieves symptoms

, and

reduces the risk of

sequelae

(including acquisition/transmission of human immunodeficiency virus [HIV]).

The 5-nitroimidazole drugs (

metronidazole

 or 

tinidazole

) are the only class of drugs that provide curative therapy of

trichomoniasis

.

Patients should be instructed to avoid intercourse until they and their partners have completed treatment and are asymptomatic, which generally takes about a week

.

Clinicians should also screen the patient for other STDs when she presents with

trichomoniasis

Slide38

Nonpregnant

women

5-nitroimidazole drugs

 — The 5-nitroimidazole drugs (

metronidazole

 or 

tinidazole

) are the only class of drugs that provide curative therapy of

trichomoniasis

.

We recommend treatment with a single 2 gram oral dose of either 

tinidazole

 or 

metronidazole

 (

ie

, four 500 mg tablets)

An alternative

multidose

regimen is 

metronidazole

 500 mg orally twice a day for seven days

Oral is preferred to vaginal therapy since systemic administration achieves higher drug levels and therapeutic drug levels in the urethra and

periurethral

glands, which serve as endogenous reservoirs of organisms that can cause recurrence

Patients should be advised to not consume alcohol for 24 hours after 

metronidazole

 treatment and for 72 hours after 

tinidazole

 treatment because of the possibility of a

disulfiram

-like (

Antabuse

effect) reaction

Slide39

Allergy to 5-nitroimidazole drugs — Given the low efficacy of any drug other than the 5-nitroimidazole drugs (see '5-nitroimidazole drugs' above), we suggest patients with allergies to metronidazole or tinidazole be referred for desensitization rather than using an alternative class of drugs

Follow-up

 — Follow-up is

unnecessary

for women who become

asymptomatic

after treatment or who were initially asymptomatic, given the high efficacy of 5-nitroimidazole drugs

Sex partners

 — Treatment of sex partners is indicated because maximal cure rates in infected women are achieved when their sexual partners are treated

simultaneousl

Slide40

Pregnant women

Symptomatic pregnant women

 

— 

Metronidazole

 is the drug of choice for treatment of symptomatic

trichomoniasis

in pregnancy. Some clinicians avoid its use in the first trimester because it crosses the placenta, thus there is a potential for

teratogenicity

. The drug is mutagenic in bacteria and carcinogenic in mice; however, these effects have never been observed in humans.

Asymptomatic pregnant women

 — 

We suggest not treating asymptomatic infections during pregnancy

because randomized trials have found that it does not prevent, and in some trials even increased, the risk of preterm delivery

Sex partners

 — 

Treatment of sexual partners is indicated

. In cases where an asymptomatic pregnant woman is not treated,

reinfection

of the treated partner can be minimized by avoidance of sexual intercourse or use of condoms

Slide41

Uterine fibroids

Slide42

Common

25-30% of women over 35

Often

asymtomatic

Incidentally detected on pelvic ultrasound

Slide43

Symptoms related to fibroids:

menorrhagia

irregular menstruation (only for

submucosal

fibroids)

urinary (frequency, retention)

abdominal distention

Slide44

How to follow up asymptomatic fibroids?

Ultrasound?

Usually no needed

Check symptoms and uterine size clinically every 6 months or ask patient to return if symptomatic

Slide45

Post-

myomectomy

follow up:

fibroids can recur after

myomectomy

advice for pregnancy?

When?

Caesarean delivery needed?

Slide46

Asymptomatic women

●We suggest

expectant management

of asymptomatic women,

except

in the case of a woman with moderate or severe

hydronephrosis

or a woman with a

hysteroscopically-resectable

submucous

leiomyoma

who is

pursuing pregnancy .

Postmenopausal

women

●

In the absence of postmenopausal hormonal therapy,

leiomyomas

generally become smaller and asymptomatic in postmenopausal women; therefore, intervention is not usually indicated.

We

suggest evaluation to exclude sarcoma in a postmenopausal woman with a new or enlarging pelvic mass .The incidence of sarcoma is 1 to 2 percent in women with a new or enlarging pelvic mass, abnormal uterine bleeding, and pelvic pain

.

Slide47

Submucosal

leiomyomas

●We recommend

hysteroscopic

myomectomy

for women with

appropriate

submucosal

leiomyomas

that are

symptomatic (

eg

, bleeding, miscarriage).This procedure allows future childbearing, usually without compromising the integrity of the

myometrium

, but is also an appropriate option in women who have completed childbearing since it is minimally invasive.

Abdominal

myomectomy

is performed in women with significant symptoms and a

submucous

leiomyoma

(s) not amenable to

hysteroscopic

resection

.

Slide48

Premenopausal

women

Women who desire fertility

●We

recommend

abdominal

myomectomy

for treatment of

symptomatic intramural and

subserosal

leiomyomas

in women who wish to preserve their childbearing potential and who have no major contraindications to a surgical approach.

Hysteroscopic

myomectomy

is the preferred approach to

submucosal

leiomyomas

.

.

Slide49

Laparoscopic

myomectomy

is an option for women with a

uterus less than 17 weeks' size

or with

a small number of

subserosal

or intramural

leiomyomas

. Future childbearing is possible; however, the integrity of the uterine incision during pregnancy has not been evaluated adequately and may be inferior to abdominal

myomectomy

.

Due

to reports of uterine rupture in pregnancy following some laparoscopic

myomectomies

, surgeons should discuss the risks and benefits of each option with patients, including possible risk of uterine rupture, as well as provide information regarding their experience with laparoscopic suturing.

Slide50

Women who do not desire fertility

●

Hysterectomy

is the definitive procedure for relief of symptoms and prevention of recurrent

leiomyoma

-related problems.

We suggest use of

GnRH

agonists prior to a potentially complicated hysterectomy (or

myomectomy

) if the surgeon feels reduction in uterine/

myoma

volume will significantly facilitate the procedure or if there is significant anemia which has not responded to iron therapy.

●For women with abnormal uterine bleeding related to

leiomyomas

who wish to undergo the least invasive procedure, we suggest a trial of placement of a

levonorgestrel

-releasing intrauterine contraception over other drug therapies

.

Slide51

●

Several more invasive options, both surgical and using interventional radiology, are available to symptomatic women (bleeding, pain, pressure) who have completed childbearing but wish to retain their uterus. There is no high quality evidence to recommend one procedure over another.

Since fertility and pregnancy outcome may be adversely affected after many of these procedures, we suggest not performing these procedures (other than

myomectomy

) for women wishing to optimize future pregnancy.