Thanks for your time and we wish you well. not cancerous. Key Question 1 and Key Question 2 focus on comparative effectiveness for final outcomes. However surgery is an option for lower part of a systematic medical issues with the help of a 7 step uterine wall. Allscripts EPSi. Other, less-studied options for the treatment of uterine fibroids include aromatase inhibitors and estrogen receptor antagonists. You may opt-out of email communications at any time by clicking on We will use explicit criteria for rating the overall strength of the evidence for intervention-final outcome pairs for which the overall risk of bias is not overwhelmingly high. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. In the presence of predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of weakening uterine muscle. Future reproduction. 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). It uses sound waves to get a picture of your uterus to confirm the diagnosis and to map and measure fibroids. Women aren't likely to get pregnant following endometrial ablation, but birth control is needed to prevent a pregnancy from developing in a fallopian tube (ectopic pregnancy). Uterine fibroids, which your doctor may call leiomyomas or myomas, are muscular tumors that can grow on your uterus. We will deposit data used in a meta-analysis into the Systematic Review Data Repository (SRDR). Independent: Review patient's previous experience with cancer. UNIT-3_15_Nursing Care of a Family During Labor & Birth.docx. The conditions that can also affect pregnancy are fibroids, endometriosis, ovarian cysts, cervical dysplasia and more. Fibroids (otherwise known as myomas or leiomyomas) are abnormal non-cancerous growths in the uterus. Although aetiology and natural history of the conditions are markedly different, symptoms can overlap and make differential diagnoses necessary, often using invasive methods such as laparoscopy. 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). https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Uterine-Morcellation-for-Presumed-Leiomyomas. The nursing management for uterine fibroids involves pain management, fluid replacement, bleeding control, and patient education. Am J Obstet Gynecol. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Medications include: Gonadotropin-releasing hormone (GnRH) agonists. Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. Rockville, MD: Agency for Healthcare Research and Quality; January 2014. www.effectivehealthcare.ahrq.gov. Am J Obstet Gynecol. Identification of Future Research Needs in the Comparative Management of Uterine Fibroid Disease. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. One of the main goals . Clinical setting in countries with health care systems similar to the U.S. (defined as inclusion as a Very High Human Development country on the United Nations Development Programme Human Development Index (KQs1-4). For uterine fibroids, some basic questions to ask include: Make sure that you understand everything your doctor tells you. 13(14)-EHC 130-EF. information submitted for this request. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism. 34, contract 290-97-0014 to the Duke Evidence-based Practice Center). Acute Pain. If a woman does not want to have children, she can opt for endometrial ablation. https://www.uptodate.com/contents/search. New fibroids, which may or may not require treatment, also can develop. Fertility of Women in the United States: June 2012. 2014 May-Jun;20(3):309-33. 2012;12:6. Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5 to 6 inches wide. Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. 2015 2015-01-02 22:52:22;349:g7647. AHRQ Publication No 01-E052 Rockville, MD: Agency for Healthcare Research and Quality. This comment did not require changes to the Key Questions as literature addressing Key Question 1 would include benefits of morcellation. 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. NICHD research on uterine fibroids aims to learn more about what causes them, how they grow, factors related to who develops them, and fibroid treatments. It remains the only proven permanent solution for uterine fibroids. urinary elimination related to uterine fibroids, impaired physical mobility nursing care plan, nursing care plans for a urinary tract . Women desire a broad range of treatment options that suit their life circumstances and future reproductive desires. Encourage patient to share thoughts and feelings. Radiofrequency ablation. Does treatment effectiveness differ by patient or fibroid characteristics (e.g., age, race/ethnicity; symptoms; vascular supply to fibroids; menopausal status; or number, size, type, location, or total volume of fibroids)? This content does not have an English version. Monitor for the possibility of uterine rupture. Deficient Knowledge. Myers ER BM, Couchman GM, et al. The nursing management for uterine fibroids involves pain management, fluid replacement, bleeding control, and patient education. 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 draft Key Questions were posted for public comments (6/23/15 7/13/15). HHSA 290-2015-00003I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Nulliparous. It is also known as Leiomyoma or Myoma. Accessed April 24, 2019. Jun 11, 2019. Laughlin-Tommaso SK (expert opinion). It is optimal for submucosal fibroids less than 3 cm when more than 50% of the tumor is intracavitary.62 Laparoscopy is associated with less postoperative pain at 48 hours, less risk of postoperative fever (OR = 0.44; 95% CI, 0.26 to 0.77), and shorter hospitalization (mean of 67 fewer hours; 95% CI, 55 to 79 hours) compared with open myomectomy.41 An estimated 15% to 33% of fibroids recur after myomectomy, and approximately 10% of women who undergo this procedure will have a hysterectomy within five to 10 years.24, Uterine Artery Embolization. The Scientific Resource Center (SRC) will request information from stakeholders, including Scientific Information Packets (SIP) and regulatory information on medications, procedures, and devices used to treat uterine fibroids. Diagnosis is by pelvic examination, ultrasonography, or other imaging. Antiprogestins*. Aromatase inhibitors (e.g., letrozole [Femara], anastrozole [Arimidex], fadrozole [not available in the United States]) block the synthesis of estrogen. What side effects can I expect from medication use? Differences between the reviewers will be adjudicated by a senior team member or via team discussion. [Nursing plan for a patient with uterine myoma] [Nursing plan for a patient with uterine myoma] [Nursing plan for a patient with uterine myoma] Kurinikaru Sutadi. Best Practice and Research: Clinical Obstetrics and Gynaecology. Before deciding on a treatment plan for fibroids, a complete fertility evaluation is recommended if you're actively trying to get pregnant. If you also elect to have your ovaries removed, the surgery brings on menopause and the question of whether you'll take hormone replacement therapy. Nursing care plan on Uterine fibroids//Uterine fibroids/leiomyomas or myomas Nursing care plan//NCPs@Anand's nursing files @Anand's nursing files #nursingca. Will I need a medication before or after surgery? In this procedure, radiofrequency energy destroys uterine fibroids and shrinks the blood vessels that feed them. We will use the same screening forms and inclusion/exclusion criteria to assess eligibility of citations recommended by peer and public reviewers and for the literature retrieved by updated literature searches. A surgical option to treat heavy bleeding is hysteroscopic myomectomy. Uterine fibroids. Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication, Updated [WebContent]. Philadelphia, Pa.: Elsevier; 2019. https://www.clinicalkey.com. Fibroids are growths of the uterus ( figure 1 ). The EPC considers all peer review comments on the draft report in preparation of the final report. Nursing Care Plan for Uterine Fibroids (Myoma) Apr 29, 2015. uterine fibroids features, types, diagnosis, mangement. Available at. Am J Obstet Gynecol. There is some literature about the relationship of imaging findings and symptom profiles, but the correlation is not tight. Accessed April 24, 2019. This is often termed the recurrence rate. The fibroids are removed, and the small wounds sutured (sewn) closed. And that would be very dangerous for both you and the baby. Start Here. Impaired Urinary Elimination Nursing Care Plan nursing care plan guide revised 5 04 template net, nursing diagnosis for urinary tract infection uti best, 4 impaired urinary elimination chronic renal failure, . Many fibroid studies have small sample sizes, which limit the ability of a study to overcome differences in baseline characteristics and variability of outcome reporting. other information we have about you. What medications are available to treat uterine fibroids or my symptoms? And I'm here to answer some of the important questions you might have about uterine fibroids. We will develop a simple categorization scheme for coding the reasons that articles at full review are excluded. Kaunitz AM. Your doctor might recommend other medications. If confirmation is needed, your doctor may order an ultrasound. pubmed.ncbi.nlm.nih.gov/23353618/ Mondelli B, et al. Warner KJ. All myomectomies carry the risk of cutting into an undiagnosed cancer, but younger, premenopausal women generally have a lower risk of undiagnosed cancer than do older women. Fibroids can grow on the inside of the uterus, within the muscle wall of the uterus, or on the outer surface of the uterus. Mayo Clinic, Rochester, Minn. May 29, 2019. 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. 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. Pressing down on your abdomen at the same time, your provider can examine your uterus, ovaries and other organs. Further studies are needed on fertility outcomes after uterine artery embolization so that patients can be counseled appropriately. Rockville, MD 20857 Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. Dec 23, 2008. if you are looking for "the care plan of uterine fibroid" on allnurses, you are not going to find it. Obstet Gynecol. Your doctor views your abdominal area on a monitor using a small camera attached to one of the instruments. 2. Acupuncture has shown promise for improving fibroid outcomes in small studies. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Uterine fibroids. 2001/viewarticle/985154. We will summarize data related to symptom status and prioritize patient-reported measures. Jarell JF, et al. Gliklich R, Leavy M, Velentgas P, et al. 21. Uterine artery embolization is an option for women who wish to preserve their uterus or avoid surgery because of medical comorbidities or personal preference.4 It is an interventional radiologic procedure in which occluding agents are injected into one or both of the uterine arteries, limiting blood supply to the uterus and fibroids. Larger fibroids can cause you to experience a variety of symptoms, including: Excessive or painful bleeding during your period (menstruation). You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Shamseer L, Moher D, Clarke M, et al. High-intensity focused ultrasound therapy. Be upfront about your treatment goals and concerns. Gynecological disorders. 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. They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism. https://effectivehealthcare.ahrq.gov/topics/uterine-fibroids/research-2017. Your doctor may prescribe a GnRH agonist to shrink the size of your fibroids before a planned surgery or to help transition you to menopause. Feb 29, 2016. CHILD HEALTH NURSING mine1.pptx . Food and Drug Administration. In: Ferri's Clinical Advisor 2019. Technical Experts do not do analysis of any kind nor do they contribute to the writing of the report. The body of evidence has some deficiencies. privacy practices. If you're having bothersome symptoms now, getting them removed before pregnancy is possible. To ensure comprehensive retrieval of relevant studies, we will search MEDLINE via PubMed, the Cumulative Index to Nursing and Allied Health (CINAHL), EMBASE, and the Cochrane Library to identify relevant publications. There is insufficient evidence on the effect of uterine artery embolization on future fertility. Women who use combined oral contraceptives have significantly less self-reported menstrual blood loss after 12 months compared with placebo.33 However, the levonorgestrel-releasing intra-uterine system (Mirena) results in a significantly greater reduction in menstrual blood loss at 12 months vs. oral contraceptives (mean reduction = 91% vs. 13% per cycle; P < .001).33 In six prospective observational studies, reported expulsion rates of intrauterine devices were between zero and 20% in women with uterine fibroids.45 There is a lack of high-quality evidence regarding oral and injectable progestin for uterine fibroids.4648, Tranexamic Acid. 2005 Mar;105(3):563-8. Scribd is the world's largest social reading and publishing site. Frequent urination (this can happen when a fibroid puts pressure on your bladder). If you have symptoms of uterine fibroids, your doctor may order these tests: Ultrasound. Why I'm Offering DMPA to Patients With Uterine Fibroids; Recommendations. Laboratory examination. ACOG committee opinion number 770: Uterine morcellation for presumed leiomyomas. There are several surgical treatments for uterine fibroids. Laughlin-Tommaso SK. Uterine fibroids. 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. Cost data are linked with operative time and clinician skill sets, which may be affected by a number of factors. Mayo Clinic, Rochester, Minn. May 23, 2019. PMID: 17012456, Cardozo ER, Clark AD, Banks NK, et al. PMID: 18823754, Viswanathan M, Ansari MT, Berkman ND, et al. 2019;15:157. Discuss these with your doctor. Older cost data also have limited utility. In a pelvic exam, your health care provider inserts two gloved fingers inside your vagina. information highlighted below and resubmit the form. During focused ultrasound surgery, high-frequency, high-energy sound waves are used to target and destroy uterine fibroids. Hartmann KE, et al. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids. And while there's not enough data to promote its use as primary treatment, it's very low-risk and would be acceptable as an adjunctive treatment. The EPC will complete a disposition of all peer review comments. If confirmation is needed, your doctor may order an ultrasound. An estimated 15% to 33% of fibroids recur after myomectomy, and approximately 10% of women undergoing myomectomy will undergo a hysterectomy within five to 10 years. How much the fibroids grow and how fast varies from person to person. Accessed April 24, 2019. Overdistension of the uterus (twins and fibroids); . Kellerman RD, et al. Key Informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. AskMayoExpert. Some predictors of malignancy on magnetic resonance imaging include age older than 45 years (odds ratio [OR] = 20), intratumoral hemorrhage (OR = 21), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10), menopausal status (OR = 9.7), and nonmyometrial origin (OR = 4.9).27,28 Risk factors for leiomyosarcoma include radiation of the pelvis, increasing age, and use of tamoxifen,29,30 which has implications for surgical management of fibroids. In a large population-based study, more than 80% of women with adenomyosis had a hysterectomy, and almost 40% used chronic pain medications. Laparoscopic or robotic myomectomy. Because a woman keeps her uterus, she might still be able to have children. It can occur during both vaginal and cesarean delivery . Your first appointment will likely be with either your primary care provider or a gynecologist. After locating a uterine fibroid, your doctor uses another thin device to send several small needles into the fibroid. 5600 Fishers Lane There's no single best approach to uterine fibroid treatment many treatment options exist. American College of Obstetricians and Gynecologists. Uterine fibroids, or leiomyomas, are the most common . De La Cruz MS, et al. Uterine fibroids. The Key Questions evolved from the EPC team discussions, expert input, and reviewer comments during the topic refinement period. An interim goal is to find a . Since fibroids are hormonally responsive growths, most people do experience a decrease in fibroid size and fibroid-related issues as they get closer to menopause and beyond. The forms will also include questions to assist in preliminary grouping of the eligible studies by Key Question. View Abnormal UTERINE ACTIVITY.pptx from NURSING DIAGNOSIS at University of Nairobi. So a hysterectomy, in which the uterus and cervix are removed, is the only treatment that can actually guarantee fibroids won't return. Fibroids can reoccur in about 60% of people who have them. Hysterectomy. Nursing Care Plan: Uterine Myoma. Hysteroscopic myomectomy is the preferred surgical procedure for women with submucosal fibroids who wish to preserve their uterus or fertility. Menorrhagia is a largely benign condition but can be emotionally and socially debilitating. Although studies have had conflicting results on the change in fibroid size during pregnancy,17,18 a large retrospective study of women with uterine fibroids found a significantly increased risk of cesarean delivery compared with a control group (33.1% vs. 24.2%), as well as increases in the risk of breech presentation (5.3% vs. 3.1%), pre-term premature rupture of membranes (3.3% vs. 2.4%), delivery before 37 weeks' gestation (15.1% vs. 10.5%), and intrauterine fetal death with growth restriction (3.9% vs. 1.5%).19 Therefore, fibroids in pregnant women warrant additional maternal and fetal surveillance. if you need a care plan for a patient with a uterine fibroid you will need to create it. When no studies are available for an outcome or comparison of interest, we will grade the evidence as insufficient. Age. During this exam, the health care provider checks the size of your uterus by putting two fingers of one hand into the vagina while using the other hand to press lightly on your abdomen. Risk factors. Abdominal myomectomy. 1. We will search ClinicalTrials.gov for information about relevant ongoing trials and to confirm that we have obtained available publications of results from completed trials. If you have symptoms of uterine fibroids, your doctor may order these tests: Ultrasound. Recognize signs of impending rupture, immediately notify the physician, and call for assistance. Accessed April 24, 2019. Accessed April 24, 2019. Some questions your doctor might ask include: Mayo Clinic does not endorse companies or products. We will create data extraction forms to collect detailed information on the study characteristics, intervention(s), comparator(s), arm details, reported outcomes and outcome measures, and risk of bias assessment. Lonnerfors C. Robot-assisted myomectomy. MRI-guided focused ultrasound surgery (FUS) is: Small particles (embolic agents) are injected into the uterine artery through a small catheter. You may benefit from nonsurgical approaches to manage fibroid symptoms, such as drugs to reduce the amount . Santaguida P, Raina P. McMaster Quality Assessment Scale of Harms (McHarm) for primary studies: Manual for use of the McHarm. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Our caring team of Mayo Clinic experts can help you with your uterine fibroids-related health concerns, What are uterine fibroids? Key Informants are not involved in analyzing the evidence or writing the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism. American Family Physician. 1from Table 4 in "Assessing the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions".23. These benign tumours develop during the reproductive years and their growth has been shown to be dependent on the ovarian steroid hormones oestradiol and progesterone. We will use prespecified questions1 from Table 4 in "Assessing the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions"23 to assess risk of bias of randomized controlled trials. The forms used for the full-text screening level will include additional questions to identify studies that meet all the inclusion criteria. Best Practice and Research. Also searched were the Agency for Healthcare Research and Quality evidence reports, Clinical Evidence, the Cochrane database, the Database of Abstracts of Reviews of Effects, Essential Evidence Plus, and the National Guideline Clearinghouse database. If we are unable to resolve a discrepancy in the reporting of data from a publication we may contact study authors for additional information or clarification. PMID: 18226615, Segars JH, Parrott EC, Nagel JD, et al. Journal of Obstetrics and Gynaecology Canada. Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the Agency for Healthcare Research and Quality: An update. However, all treatments have risks and benefits. Removal of the ovaries eliminates the main source of the hormone estrogen . uterine fibroids introduction and management 1. introduction uterine fibroid is a leiomyoma (benign (non- cancerous) tumor form from smooth muscle tissue) that originates from the smooth muscle layer (myometrium) of the uterus. Nursing Care Plan-Uterine Fibroids Student: John Micahel C. Manaig Date: May 27,2021 Client: Aiken Manaig Age: 13 Sex: Male Room # 14 Assessment Nursing Diagnosis Nursing Plan Nursing Intervention Scientific Rational Expected Outcome SUBJECTIVE: Medical history, physical examination, and pelvic. Prior reviews have reported on the effectiveness preoperative adjunctive treatments such as gonadotropin-releasing hormone (GnRH) agonists or cell savers. Her health care provider (HCP) tells her that she has uterine fibroids and recommends an abdominal hysterectomy. Am J Obstet Gynecol. By Maggie Inman. The Task Order Officer reviewed contract deliverables for adherence to contract requirements and quality. Research Protocol: Specifically this review will address the recent visibility and uncertainty about the harms of morcellation of fibroids during minimally invasive procedures, as an explicit element of risk of harm. We will carry out hand searches of the reference lists of recent systematic reviews or meta-analyses of therapies for uterine fibroids. This project was funded under Contract No. Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. Listed below are six (6) nursing care plans (NCP) for Hysterectomy and TAHBSO. How big are they? The search and selection literature sources may be refined following discussions with Technical Experts. Fibroids aren't cancerous. There are some small studies looking into possible dietary and environmental factors that may promote fibroid growth. Older women in or entering menopause may have a higher cancer risk, and women who are no longer concerned about preserving their fertility have additional treatment options for fibroids. Fibroids are not cancerous and are not thought to be able to become cancerous. The uterus is made of muscle, and fibroids grow from the muscle. This review will include studies evaluating medical and surgical treatments to treat fibroids (asymptomatic or symptomatic) in women of any age. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. In: Netter's Obstetrics and Gynecology. Patients who have underwent surgery for a hysterectomy, which is the removal of the female reproductive organs, are at risk for infection and may experience grieving . This cuts off blood flow to starve the tumors. Typically, endometrial ablation is effective in stopping abnormal bleeding. They usually grow slowly or not at all and tend to shrink after menopause, when levels of reproductive hormones drop. Management of uterine fibroids (Evidence Report/Technology Assessment No. Many women who are told that hysterectomy is their only option can have an abdominal myomectomy instead. Data Sources: A PubMed search was completed in Clinical Queries using the key terms leiomyoma, uterine fibroids, diagnosis, management, power morcellation, and guidelines. 7th ed. PMID: 3199853 No abstract available . The Food and Drug Administration (FDA) advises against the use of a device to morcellate the tissue (power morcellator) for most women having fibroids removed through myomectomy or hysterectomy.
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