The Management of Chronic Gynecologic Conditions During COVID and Beyond - Episode 8
Supported by: AbbVie
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Linda Bradley, MD, reviews the ACOG recommendations regarding the management of heavy menstrual bleeding (HMB) with uterine fibroids (UF).
Ayman Al-Hendy, MD, PhD: I’m going to start with you Linda. If you can just kind of set the stage by briefly reviewing the ACOG recommendations regarding the management of heavy menstrual bleeding associated with uterine fibroids.
Linda Bradley, MD: I think the guidelines would always start with our history. I think we need to look at what our best practice is, and I think physicians all over the country or all over the world have different tools that are available to them. Through ACOG, what do we have? If we just said, in general we have an exam that we can do. Last week I examined a patient who was hemorrhaging, hemoglobin of 4, huge 8 centimeter prolapsing leiomyoma. Turns out the ultrasound didn’t even show it, okay? History and physical exam is still important. Let’s just say that that gets done and then we have imaging.
Depending on size and all that, transvaginal ultrasound. I prefer if we can and if it’s available to do saline infusion sonogram or saline infusion sonogram, big uterus up to the xiphoid, more than 20-week size, we might want to do MRI to look at the intracavitary lesions. A CT scan, I think, has limited use. If I were just looking at the history and then the physical exam because the physical will tell you; I love SIS. We know that much work has been shown in transvaginal ultrasound by itself in reproductive age women it potentially may miss 1 of 6 intracavitary lesions. We’re talking about fibroids but heavy menstrual bleeding; you could have a polyp and a fibroid. Yesterday I took, I had a case, 5 centimeter huge intracavitary polyp. It mimicked what people thought on imaging that it was a fibroid, but it was a polyp and easily removed.
Again, if we’re just looking at the landscape, these are the technologies. I think if we had to drill down, do we offer saline infusion sonogram with a 25-week size uterus? The answer would be no, your pathway needs to go a certain way. If your uterus is normal size, then I do think that if you only have one technology with an otherwise normal uterus and no pelvic discomfort, look at the cavity with saline infusion sonogram. I also failed, of course, to mention hysteroscopy hopefully done in the office setting to be able to provide the pathway for a surgical approach, knowing can you do this surgery? What technology can you determine the FIGO classification?
To summarize, history and physical first. This for me as a virtual visit is helpful, but we cannot move until I’ve examined the patient and then move to imaging or office hysteroscopy, depending on all the symptoms that fibroid-related disease may have. I’ll just give 1 example. A normal size or upper limit of normal size uterus with a lot of pelvic discomfort, I would order saline infusion sonogram. Huge uterus, 16, 18 weeks more. We have a very liberal ability to use MRI imaging at our hospital, the Cleveland Clinic, the special pathway that our MRI results are impeccable. The size, the number, the location, and the FIGO classification. When I get that report it just doesn’t say a bunch of fibroids. It gives me the larger fibroids, the location, and where they are. It’s all of those kinds of things working in concert together to get the patient to the right surgeon if there’s a surgical approach, medical approach, or combination of things.
Transcript edited for clarity.
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