{"paper_id":"ef6a7941-93d3-4521-ac25-bae60b6fafaa","body_text":"Abstract\nPatients often present to primary care with symptoms related to benign structural gynecological conditions. Uterine fibroids (also called leiomyomas), endometriosis, and ovarian cysts are among the most common and may present with chief complaints ranging from pelvic pain to vaginal bleeding to infertility. This chapter addresses the relevant history, physical exam, diagnostic work-up, and treatment strategies appropriate for the management of leiomyomas, endometriosis, and ovarian cysts.\nAccess this chapter\nTax calculation will be finalised at checkout\nPurchases are for personal use only\nSimilar content being viewed by others\nReferences\nBaird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100–7.\nFortin C, Flyckt R, Falcone T. 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Diagnostic value of pelvic examination, ultrasound, and serum CA 125 in postmenopausal women with a pelvic mass. An international multicenter study. Cancer. 1994;74(4):1398–406.\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEditor information\nEditors and Affiliations\nReview Questions\nReview Questions\n-\n1.\nA 31-year-old woman presents to your office with menorrhagia and anemia. Her transvaginal ultrasound demonstrates a large submucosal fibroid. She is considering having a third child. What is the best management option?\n-\nA.\nHysteroscopic myomectomy to remove the fibroid\n-\nB.\nIUD insertion to manage bleeding until she is ready to have her third child\n-\nC.\nUterine artery embolization\n-\nD.\nEndometrial ablation\nThe correct answer is A. Myomectomy should be the first-line treatment for women considering additional children because there is evidence that it may improve pregnancy rates. A progesterone IUD could help manage bleeding symptoms and if she is opposed to procedural options could be considered appropriate. Both uterine artery embolization and endometrial ablation should be reserved for women who have completed childbearing [7, 9].\n-\nA.\n-\n2.\nA 54-year-old postmenopausal woman presents to your office with a complaint of heaviness in her pelvis and urinary incontinence for the last several years. On exam, her uterus is enlarged. A transvaginal ultrasound demonstrates a large subserosal fibroid that abuts her bladder. What is the best management option for her symptoms?\n-\nA.\nGnRH agonist\n-\nB.\nHysterectomy\n-\nC.\nEndometrial ablation\n-\nD.\nHysteroscopic myomectomy\nThe correct answer is B. A GnRH agonist would not be appropriate as she is already postmenopausal. Endometrial ablation and hysteroscopic myomectomy would not address her bulk symptoms [7, 9].\n-\nA.\n-\n3.\nA 26-year-old woman presents with dyspareunia and dysmenorrhea. She has tenderness with her gynecological exam particularly with deep palpation in the posterior fornix. She denies any bowel or bladder symptoms. You suspect endometriosis and obtain a transvaginal ultrasound to exclude other pathology; it is normal. What would be the best next step?\n-\nA.\nEmpiric treatment with combined oral contraceptive pills.\n-\nB.\nRefer to gynecologist for diagnostic laparoscopy.\n-\nC.\nTrial of NSAIDs for relief of her dysmenorrhea.\n-\nD.\nStart GnRH agonist.\nThe correct answer is A. While NSAID therapy is often used to treat dysmenorrhea, combined oral contraceptive pills are more effective. While endometriosis can only be definitely diagnosed via laparoscopy, empiric treatment is recommended for most patients [48].\n-\nA.\n-\n4.\nWhich woman would benefit from referral to gynecology oncologist?\n-\nA.\nA 36-year-old woman with a 4-cm hemorrhagic cyst on ultrasound and CA-125 of 3 U/ml\n-\nB.\nA 27-year-old woman with a 5-cm endometrioma on ultrasound and CA-125 of 40 U/ml\n-\nC.\nA 56-year-old woman with a 4-cm cyst with multiple thick septations and CA-125 of 30 U/ml\n-\nD.\nA 66-year-old woman with an 8-cm simple cyst on ultrasound and CA-125 of 2 U/ml\nThe correct answer is C. Even though her CA-125 is less than 35 U/ml in a postmenopausal woman, her cyst has multiple thick septations which is concerning for malignancy. All the other women have benign-appearing cysts on ultrasound, and in premenopausal women there is no definitive cutoff for CA-125 [72].\n-\nA.\n-\n5.\nA 35-year-old woman presents after a transvaginal ultrasound obtained for heavy menstrual bleeding demonstrated a 6-cm simple cyst without septations or solid components. She has no risk factors for ovarian cancer and no family history of breast or ovarian malignancy. She asks if this could be ovarian cancer. How would you advise her?\n-\nA.\nYou recommend referral to gynecology oncologist for consideration of surgical excision of the cyst.\n-\nB.\nYou recommend a repeat ultrasound in 6–12 weeks and reassure her that the risk of malignancy is low.\n-\nC.\nYou recommend a repeat ultrasound in 6–12 weeks with a CA-125 and reassure her that the risk of malignancy is low.\n-\nD.\nYou recommend she obtain a MRI to better categorize the cyst before making a decision on referral to gynecology oncologist.\nThe correct answer is B. Her cyst is simple appearing on ultrasound. She is premenopausal, and given that she has no concerning features on ultrasound, she does not need to have a CA-125 drawn. It would be appropriate to reimage her in 6–12 weeks to assess for resolution or stability of the cyst. Should the cyst change and become more concerning for malignancy, a CA-125 would be indicated [72].\n-\nA.\nRights and permissions\nCopyright information\n© 2020 Springer Nature Switzerland AG\nAbout this chapter\nCite this chapter\nFarkas, A.H., Tilstra, S.A., Gonzaga, A.M.R. (2020). Fibroids, Endometriosis, and Ovarian Cysts. In: Tilstra, S.A., Kwolek, D., Mitchell, J.L., Dolan, B.M., Carson, M.P. (eds) Sex- and Gender-Based Women's Health. Springer, Cham. https://doi.org/10.1007/978-3-030-50695-7_10\nDownload citation\nDOI: https://doi.org/10.1007/978-3-030-50695-7_10\nPublished:\nPublisher Name: Springer, Cham\nPrint ISBN: 978-3-030-50694-0\nOnline ISBN: 978-3-030-50695-7\neBook Packages: MedicineMedicine (R0)","source_license":"CC0","license_restricted":false}