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Lupron & FibroidsFrom: Joanne Bulley, MD (islesannie@yahoo.com)Fri Oct 14 20:14:30 2005
While we are talking about fibroids and the vasrious and sundry ways to treat currently ... 36 yo nulligravid woman. 15 mos ago ahd a laparoscopy turned laparotomy by another local gyn - good surgeon. She had stage 4 endometriosis, including a left endometrioma which was maximally treated (as much as possible) with excision and fulguration pending location etc. Also multiple fibroids with multiple myomectomies. One fibroid, in particular, was left as it went from the left lower uterine segment / cerivx into the broad ligament with close approximation to the ureter. Now 15 months later she has, by MRI (because adequately assessing it all by US was fruitless) she has multiple fibroids - with a 10-12 cm one from the fundus forward and another 8 cm one also from the fundus in another direction as well as the lower segment one heading out toward the left ureter. The previously operating gyn and I looked at the MRI together - with her permission and he indicates that indeed there wasn't anything like that 15 months ago. He also indicates that the pelvis was a really tough one to operate in because of the stage 4 endo. She also has a 7 cm septated cyst on the same ovary (left) that was operated on last year. She is considering at least talking with the folks in Boston who do the MRfUS ExAblation ... but she is not in an economic bracket to manage any significant out of pocket expense. She was already thinking that she would not want to go for the UAE ... partly due to the size and the degree of necrosis that would happen. Now that I have read Terrence's (once again) excellent post - I am 100% against the UAE. She is also pretty certain that she will go for hysterectomy. Her prior surgeon (in the practice I used to be with) has agreed to be my assistant (I would much rather have 2 gyns than have an RNFA on this case). We have recommended treatment with Lupron pre-op and full bowel prep pre-op and ureteral stents because of the disease we already know is in there. Any pearls (even if I may already know them) are welcome - I am sure someone here will have ones I have not heard even after 20+ years! Now for a dumb question ... It has been ages since I shrunk fibroids with Lupron before a hyst ... and I am sure someone here will have this answer on the tip of their tongue ... 1. How many weeks after Lupron do you get maximal shrinkage of fibroids? 8 weeks seems to jump out of the dusty synapses... 2. What do you like to use as add-back for vasomotor symptoms in the meantime? I have most often used Climara 0.025 with pretty good results but I know there is a suggestion out there to use Norethindrone ... Thanks. Joanne PS -- just for the record the VERY first hyst I did in this community fresh out of residency - was a TAH BSO / Sigmoid resection en-bloc for a watermelon sized uterus with a sarcoma. Three path departments never completely agreed with what it was ... one of those mixed homologous or heterologous myometrial stromal sarcoma. So ... this won't be that much different.
-- Joanne Bulley, MD Keene, NH, USA
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