Subgroup analysis may be used to evaluate the intervention trajectory in a defined subset of the participants in a trial, or in complementary subsets. https://familydoctor.org/familydoctor/en/diseases-conditions/uterine-fibroids.html. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. The EPC solicits input from Key Informants when developing questions for systematic review or when identifying high priority research gaps and needed new research. A similar procedure called cryomyolysis freezes the fibroids. Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician. Because there's no cutting of uterine tissue, doctors consider Lap-RFA a less invasive alternative to hysterectomy and myomectomy. And that would be very dangerous for both you and the baby. Key Informants are the end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Copyright 2023 American Academy of Family Physicians. Uterine fibroids may be associated with infertility, and some experts recommend that women with infertility be evaluated for fibroids, with potential removal if the tumors have a submucosal component.14 However, there is no evidence from randomized controlled trials to support myomectomy to improve fertility.15 One meta-analysis included two studies that showed improvement in spontaneous conception rates in women who underwent myomectomy for submucosal fibroids (relative risk [RR] = 2.034; 95% confidence interval [CI], 1.081 to 3.826; P = .028).16 However, no statistically significant difference was noted in the ongoing pregnancy/live birth rate. https://www.uptodate.com/contents/search. The symptoms and treatment options are affected by the size, number, and location of the tumors.11 The most common symptom is abnormal uterine bleeding, usually excessive menstrual bleeding.12 Other symptoms include pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia.13. The nursing management for uterine fibroids involves pain management, fluid replacement, bleeding control, and patient education. Though hysterectomy and myomectomy by a variety of routes are frequently used, perhaps with insufficient consideration of alternative treatment prior to surgery,16 the range of fibroid-specific treatments including interventions like extended medical management with ulipristal acetate, magnetic resonance image-guided focused ultrasound (MRgFUS), uterine artery embolization, radiofrequency volumetric thermal ablation, and techniques for myolysis are increasingly generating comparative effectiveness data7,9 as is the clinical trials literature about improving bleeding symptoms.17 Furthermore, as the literature evolves, including larger studies of stronger design with longer followup, a clearer picture of anticipated outcomes is likely to emerge. Uterine fibroids are more common in multiparous women compared with women who have a history of giving birth frequency of 1 (one) or 2 (two) times (Khashaeva, 1992). Am J Obstet Gynecol. Uterine fibroids. How many fibroids do I have? Methods Guide for Effectiveness and Comparative Effectiveness Reviews. They are selected to provide broad expertise and perspectives specific to the topic under development. Click here for an email preview. Changes will not be incorporated into the protocol. For studies that meet the eligibility criteria from the full-text review assessment, we will extract study characteristics (e.g., study design, year, setting, funding source, etc. Frequent urination (this can happen when a fibroid puts pressure on your bladder). 2014:P20-575. Patient-Centered Outcomes Research Institute (PCORI). https://effectivehealthcare.ahrq.gov/products/uterine-fibroids/research-protocol. July 2001, Wegienka G, Baird DD, Hertz-Picciotto I, et al. Quantifying study-level heterogeneity via random effects is preferable to the use of an arbitrary variance cutoff value or statistical tests for heterogeneity, such as Q statistics or I2 scores. With laparoscopic radiofrequency ablation (Acessa), also called Lap-RFA, your doctor makes two small incisions in the abdomen to insert a slim viewing instrument (laparoscope) with a camera at the tip. Newer approaches to random effects meta-analysis, such as latent Dirichlet process and Gaussian process models, allow for robust (e.g., non-parametric) estimates of variation that do not rely on the assumption of normally distributed random effects. It should now be feasible, and most informative to guiding care, to restrict a review to randomized clinical comparisons of effectiveness, including medical management versus surgical, rather than restricting comparisons only to abdominal hysterectomy. For example, oral contraceptives can help control menstrual bleeding, but they don't reduce fibroid size. PMID: 22035951, Whiteman MK, Hillis SD, Jamieson DJ, et al. https://www.uptodate.com/contents/search. The appearance of heterogeneous areas may indicate the process of transformation . BMC Womens Health. https://www.fda.gov/medical-devices/surgery-devices/laparoscopic-power-morcellators. It does appear that fibroid growth is related to increasing weight. What is the comparative effectiveness (benefits and harms) of treatments for uterine fibroids, including comparisons among and within these interventions? Endometrial ablation. Many women who have uterine fibroids do not have symptoms. 2017;95:100. Start Here. Hysterectomy by the least invasive approach possible is the most effective treatment for symptomatic uterine fibroids.39 Vaginal hysterectomy is the preferred technique because it provides several statistically significant advantages, including shorter surgery time than total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy (70 minutes vs. 151 minutes vs. 130 minutes, respectively), decreased blood loss (183 mL vs. 204 mL vs. 358 mL), shorter hospitalization (51 hours vs. 77 hours vs. 77 hours), and shorter paralytic ileus time (19 hours vs. 28 hours vs. 26 hours); however, vaginal hysterectomy is limited by the size of the myomatous uterus.43 Abdominal hysterectomy is an alternative approach, but the balance of risks and benefits must be individualized to each patient.44, The laparoscopic extraction of the uterus may be performed with morcellation, whereby a rotating blade cuts the tissue into small pieces. These tumors are not linked to cancer and don't increase a woman's risk for uterine cancer. Additionally, because these supplements are not FDA regulated, they may be dangerous to your health. The uterus is anatomically divided into 3 regions; the fundus (uppermost part), the body (main part), and the cervix (lower part). Tranexamic acid (Cyklokapron) is an oral nonhormonal antifibrinolytic agent that significantly reduces menstrual blood loss compared with placebo (mean reduction = 94 mL per cycle; 95% CI, 36 to 151 mL).37,38 One small nonrandomized study reported a higher rate of fibroid necrosis in patients who received tranexamic acid compared with untreated patients (15% vs. 4.7%; OR = 3.60; 95% CI, 1.83 to 6.07; P = .0003), with intralesional thrombi in one-half of the 22 cases involving fibroid necrosis (manifesting as apop-totic cellular debris with inflammatory cells, and usually hemorrhage).49 However, in a systematic review of four studies with 200 patients who received tranexamic acid, none of the studies detailed the adverse effects of fibroid necrosis or thrombus formation.50, Nonsteroidal Anti-inflammatory Drugs. This nursing care plan for a Hysterectomy and includes a diagnosis and care plan for nurses with nursing interventions and outcomes for the following conditions: Risk for Infection and Grieving related to loss of body part. It is also known as Leiomyoma or Myoma. 2018;40:e747. Therefore, it is crucial for women, their care providers, and those who guide policy decisions to have timely, accurate information about the effectiveness of treatments and the associated risks. The advantage of SPRMs over GnRH agonists for preoperative adjuvant therapy is their lack of hypoestrogenic adverse effects and bone loss. Philadelphia, Pa.: Elsevier; 2019. https://www.clinicalkey.com. Best Practice and Research. A feeling of fullness in your lower abdomen/bloating. needing to urinate (wee) a lot. We will apply the same inclusion and exclusion criteria relevant to Key Questions to studies identified via SIPs. 2005 Mar;105(3):563-8. Telephone: (301) 427-1364, Powered by the Evidence-based Practice Centers, https://effectivehealthcare.ahrq.gov/products/uterine-fibroids/research-protocol, Comment on Key Questions and Draft Reports, 25 Years of the AHRQ Evidence-based Practice Center Program, http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm, http://www.pcori.org/research-results/2014/comparing-options-management-patient-centered-results-uterine-fibroids-compare, Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents, Diagnostic Errors in the Emergency Department: A Systematic Review, Strategies for Patient, Family and Caregiver Engagement, Impact of Community Health Worker Certification on Workforce and Service Delivery for Asthma and Other Selected Chronic Diseases, Maternal and Fetal Effects of Mental Health Treatments in Pregnant and Breastfeeding Women: A Systematic Review of Pharmacological Interventions, U.S. Department of Health & Human Services, Women who are being treated for uterine fibroids (KQs 1-4). 1. 2019;15:157. We will carry out hand searches of the reference lists of recent systematic reviews or meta-analyses of therapies for uterine fibroids. Factors like genetics, abnormalities in the blood vessel or vascular system, hormones and other growth factors play an [] Deficient Knowledge. 2010 May;63(5):502-12. Does risk of cancer dissemination from morcellation differ by patient or fibroid characteristics (e.g., age; race/ethnicity; symptoms; menopausal status; imaging characteristics; vascular supply to fibroids; or number, size, type, location, or total volume of fibroids)? There's no such thing as the right decision as there are many potential options that may be available to you. Other medications. Laughlin-Tommaso SK (expert opinion). PMID: 22448610, Corona LE, Swenson CW, Sheetz KH, et al. Among these instruments is the laparoscope, which contains fibre-optic camera heads or surgical heads (or both). Review/update the Her pre pregnancy weight was 250 lb, and she gained 30 lb during the pregnancy. Most fibroids are benign i.e. Divergent and conflicting opinions are common and perceived as health scientific discourse that results in a thoughtful, relevant systematic review. We summarize the inclusion criteria in Table 2. This should be determined based on the design and quality of the studies, independently of the studies' relative effect sizes. 2003 Mar;101(3):431-7. Examples include: baseline characteristics of the patients (e.g., age, menopausal status; symptom status) and fibroid characteristics (e.g., size, volume, location, type, and vascularity). Fibroids have a very typical appearance on an ultrasound, and because they're so common, they're almost always accurately diagnosed. Don't be afraid to ask for a second opinion or referral to a fibroid specialist. Rockville, MD: Agency for Healthcare Research and Quality; 2011. https://www.uptodate.com/contents/search. Accessed April 24, 2019. Fibroids do not regrow after surgery, but new fibroids may develop. There are several surgical treatments for uterine fibroids. Fibroids (leiomyoma) are non-cancerous tumors of the uterine muscle. The growth promoting effects of these steroid hormones appear to be mediated . Best Practice and Research: Clinical Obstetrics and Gynaecology. In a small prospective trial of 18 patients, tamoxifen did not reduce fibroid size or uterine volume, but did reduce menstrual blood loss by 40% to 50% and decrease pelvic pain compared with the control group.56 Based on its adverse effects (e.g., hot flashes, dizziness, endometrial thickening), the authors concluded that its risks outweigh its marginal benefits for fibroid treatment. We will extract information from the SIPs that is not already captured by published study results or other sources. A fibroid specialist will be able to tell you what options are possible based on the size, number and location of the fibroids and your treatment goals. The final search strategies will be peer reviewed by an independent information specialist. Most women with uterine fibroids may be able to choose to keep their ovaries. It remains the only proven permanent solution for uterine fibroids. The transcervical or through the cervix approach to radiofrequency ablation (Sonata) also uses ultrasound guidance to locate fibroids. Dec 23, 2008. if you are looking for "the care plan of uterine fibroid" on allnurses, you are not going to find it. Rockville, MD: Agency for Healthcare Research and Quality; January 2014. www.effectivehealthcare.ahrq.gov. But just because they come back doesn't mean they need to be treated. In addition, its staff members are equipped to address serious or complex medical needs. If the fibroids are few in number, you and your doctor may opt for a laparoscopic or robotic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. They can grow as a . pain or pressure in the pelvic area. Because a woman keeps her uterus, she might still be able to have children. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. TAHBSO is usually performed in the case of uterine and cervical cancer. Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs. This content does not have an English version. CHILD HEALTH NURSING mine1.pptx . Anti-progesterone effect - reduces action and number of progesterone receptors in fibroids and myometrium. Future reproduction. Stewart EA. plans (NCP) and nursing diagnosis for Hysterectomy and TAHBSO. The dye traces the shape of your uterine cavity and fallopian tubes and makes them visible on X-ray images. Inpatient hysterectomy surveillance in the United States, 2000-2004. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Age. Fibroids are made of muscle cells and fibrous tissues that grow in and around the wall of the uterus. In particular, we hope to estimate probabilities of an outcome associated with potential trajectories of care for women under differing circumstances (e.g., likelihood of progressing to increasingly invasive options, particularly hysterectomy). Most women will develop one or more uterine fibroids (i.e., leiomyomata), with roughly $4,624 in costs per women in the first year of diagnosis.10,11. Ongoing observational studies such as COMPARE21 will provide data about sequencing of treatments when completed. The U.S. Food and Drug Administration recommends limiting the use of laparoscopic morcellation to reproductive-aged women who are not candidates for en bloc uterine resection.58 The American College of Obstetricians and Gynecologists recommends morcellation as an option, but emphasizes the importance of informed consent and notes that the technique should not be performed in women with suspected or known uterine cancer.59,60 Approximately one in 10 women have new symptoms after hysterectomy with bilateral salpingo-oophorectomy.61, Myomectomy. We may limit the report of key findings from studies assessed as high risk of bias to summary tables. Uterine fibroids are common benign neoplasms, with a higher prevalence in older women and in those of African descent. GnRH agonists include leuprolide (Lupron Depot, Eligard, others), goserelin (Zoladex) and triptorelin (Trelstar, Triptodur Kit). Additionally, public comments noted the need to assess effectiveness of morcellation in addition to harms. The updated document . Diagnosis/definition: Uterine fibroids are the most common benign gynecologic tumors This ongoing growth does not mean the fibroids are cancerous or that they even need to be treated. Hysteroscopic myomectomy - the fibroids are removed via the dilated cervix, so no abdominal incisions are . Patient information: A handout on this topic is available at https://familydoctor.org/familydoctor/en/diseases-conditions/uterine-fibroids.html. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF). MRI-guided focused ultrasound surgery (FUS) is: Small particles (embolic agents) are injected into the uterine artery through a small catheter. Larger fibroids can be removed through smaller incisions by breaking them into pieces (morcellation), which can be done inside a surgical bag, or by extending one incision to remove the fibroids. Medications include: Gonadotropin-releasing hormone (GnRH) agonists. Subgroup analysis can be undertaken in a variety of ways, from completely separate models at one extreme, to simply including a subgroup covariate in a single model at the other, with multilevel and random effects models somewhere in the middle. We anticipate performing a meta-analysis to describe the effects of treatment decisions on outcomes including likelihood of maintaining fertility or needing additional treatment, including, ultimately, hysterectomy. We assign an overall grade (high, moderate, low or insufficient) for the strength of evidence for each key outcome (Table 4). Uterine leiomyomas. is sometimes performed for removing fibroids while sparing the uterus. New England Journal of Medicine. Hartmann KE, et al. Risk factors. Many women with uterine fibroids experience no signs or symptoms, or only mildly annoying signs and symptoms that they can live with. Uterine fibroids: An update on current and emerging medical treatment options. So those are usually removed before pregnancy is attempted. If you have fibroids, your . But depending on the size and location of the fibroids, your doctor may advise that you have a C-section in a future pregnancy because the scar on the uterus can open during labor. We collected a list of outcomes from a prior review of relevant studies and prioritized that list to establish a core minimum set of outcomes for quantitative analyses. Which nursing statement would best assess the client's coping abilities?, A 39-year-old female client has been experiencing intermittent vaginal bleeding for several months. Stewart EA. Abdominal myomectomy. Limited data have shown that they help reduce fibroid size as well as decrease menstrual bleeding, with adverse effects including hot flashes, vaginal dryness, and musculoskeletal pain.53,54 Overall, there is insufficient evidence to support the use of aromatase inhibitors for the treatment of uterine fibroids.55 Selective estrogen receptor modulators act as partial estrogen receptor agonists in bone, cardiovascular tissue, and the endometrium. Myolysis is a minimally invasive procedure targeting the destruction of fibroids via a focused energy delivery system such as heat, laser, or more recently, magnetic resonanceguided focused ultrasound surgery (MRgFUS). Randomized controlled trials are best suited to provide data for comparative effectiveness and there has been substantial growth in the variety and sophistication of trials since the prior review. Shamseer L, Moher D, Clarke M, et al. AskMayoExpert. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Mayo Clinic is a not-for-profit organization. Acute pain related to surgical intervention. Uterine carcinosarcoma (considered an epithelial neoplasm), Uterine sarcoma (leiomyosarcoma, endometrial stromal sarcoma, mixed mesodermal tumor), Preoperative treatment to decrease size of tumors before surgery or in women approaching menopause, Decrease blood loss, operative time, and recovery time, Long-term treatment associated with higher cost, menopausal symptoms, and bone loss; increased recurrence risk with myomectomy, Levonorgestrel-releasing intrauterine system (Mirena), Treats abnormal uterine bleeding, likely by stabilization of endometrium, Most effective medical treatment for reducing blood loss; decreases fibroid volume, Irregular uterine bleeding, increased risk of device expulsion, Yes, if discontinued after resolution of symptoms, Anti-inflammatories and prostaglandin inhibitors, Do not decrease fibroid volume; gastrointestinal adverse effects, Treat abnormal uterine bleeding, likely by stabilization of endometrium, Reduce blood loss from fibroids; ease of conversion to alternate therapy if not successful, Selective progesterone receptor modulators, Decrease blood loss, operative time, and recovery time; not associated with hypoestrogenic adverse effects, Headache and breast tenderness, progesterone receptor modulatorassociated endometrial changes; increased recurrence risk with myomectomy, Reduces blood loss from fibroids; ease of conversion to alternate therapy, Does not decrease fibroid volume; medical contraindications, Surgical removal of the uterus (transabdominally, transvaginally, or laparoscopically), Definitive treatment for women who do not wish to preserve fertility; transvaginal and laparoscopic approach associated with decreased pain, blood loss, and recovery time compared with transabdominal surgery, Surgical risks higher with transabdominal surgery (e.g., infection, pain, fever, increased blood loss and recovery time); morcellation with laparoscopic approach increases risk of iatrogenic dissemination of tissue, Magnetic resonanceguided focused ultrasound surgery, In situ destruction by high-intensity ultrasound waves, Noninvasive approach; shorter recovery time with modest symptom improvement, Heavy menses, pain from sciatic nerve irritation, higher reintervention rate, Surgical or endoscopic excision of tumors, Resolution of symptoms with preservation of fertility, Recurrence rate of 15% to 30% at five years, depending on size and extent of tumors, Interventional radiologic procedure to occlude uterine arteries, Minimally invasive; avoids surgery; short hospitalization, Recurrence rate > 17% at 30 months; postembolization syndrome, Infertile women with distorted uterine cavity (i.e., submucosal fibroids) who desire future fertility, Symptomatic women who desire future fertility, Symptomatic women who do not desire future fertility but wish to preserve the uterus, Medical treatment, myomectomy, uterine artery embolization, magnetic resonanceguided focused ultrasound surgery, Symptomatic women who want definitive treatment and do not desire future fertility, Hysterectomy by least invasive approach possible.