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By J. Darmok. California State Polytechnic University, Pomona.

Symptoms are triggered by airborne allergens viagra with fluoxetine 100/60 mg fast delivery, which bind to immunoglobulin E (IgE) antibodies on mast cells buy cheapest viagra with fluoxetine, and thereby cause release of inflammatory mediators order viagra with fluoxetine with amex, including histamine, leukotrienes, and prostaglandins. Allergic rhinitis is the most common allergic disorder, affecting almost one out of every six people living in the United States. Seasonal rhinitis, also known as hay fever, occurs in the spring and fall in reaction to outdoor allergens such as fungi and pollens from weeds, grasses, and trees. Perennial (nonseasonal) rhinitis is triggered by indoor allergens, especially the house dust mite and pet dander. Principal among these are (1) glucocorticoids (intranasal), (2) antihistamines (oral and intranasal), and (3) sympathomimetics (oral and intranasal). Sympathomimetics Oral/nasal Activate vascular alpha receptors and thereby cause1 Oral: Restlessness, vasoconstriction, which reduces nasal congestion; insomnia, increased do not decrease sneezing, itching, or rhinorrhea. Antileukotrienes Oral Block leukotriene receptors and thereby reduce nasal Rare neuropsychiatric effects congestion. Approaches to rhinitis management are based in large part on The Diagnosis and Management of Rhinitis: An Updated Practice Parameter (2008), an evidence-based guideline developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. Actions and Uses Intranasal glucocorticoids are the most effective drugs for prevention and treatment of seasonal and perennial rhinitis. Because of their antiinflammatory actions, these drugs can prevent or suppress the major symptoms of allergic rhinitis: congestion, rhinorrhea, sneezing, nasal itching, and erythema in 90% of patients who use them properly. Three of these—budesonide [Rhinocort Aqua], fluticasone propionate [Flonase], and triamcinolone [Nasacort Allergy 24 hours]−are available in the United States without a prescription. The most common are drying of the nasal mucosa and a burning or itching sensation. Of greatest concern are adrenal suppression and slowing of linear growth in children (whether final adult height is reduced is unknown). Systemic effects are least likely with ciclesonide, fluticasone, and mometasone, which have very low bioavailability (see Table 61. Preparations, Dosage, and Administration Intranasal glucocorticoids are administered using a metered-dose spray device. After symptoms are under control, the dosage should be reduced to the lowest effective amount. For patients with seasonal allergic rhinitis, maximal effects may require a week or more to develop. For patients with perennial rhinitis, maximal responses may take 2 to 3 weeks to develop. If nasal passages are blocked because of nasal congestion, they should be cleared with a topical decongestant before glucocorticoid administration. Oral Antihistamines Oral antihistamines (histamine-1 [H ] receptor antagonists) are first-line drugs1 for mild to moderate allergic rhinitis. For therapy of allergic rhinitis, antihistamines are most effective when taken prophylactically and less helpful when taken after symptoms appear. Actions and Uses These drugs can relieve sneezing, rhinorrhea, and nasal itching; however, they do not reduce nasal congestion. Because histamine is only one of several mediators of allergic rhinitis, antihistamines are less effective than glucocorticoids. Antihistamines should be administered on a regular basis throughout the allergy season, even when symptoms are absent, to prevent an initial histamine receptor activation. Because histamine does not contribute to symptoms of infectious rhinitis, antihistamines are of no value against the common cold. Some patients take first-generation antihistamines for their drying effect; however, this may complicate treatment of colds by increasing the viscosity of secretions. The most common complaint is sedation, which occurs frequently with the first-generation antihistamines (e. Accordingly, second-generation agents are clearly preferred for students who need to remain alert in class and for patients who do work that requires alertness. Preparations, Dosage, and Administration Dosages for some popular H antagonists are presented in 1 Table 61. Intranasal Antihistamines Two antihistamines—azelastine [Astelin, Astepro] and olopatadine [Patanase]— are available for intranasal administration. Both drugs are indicated for allergic rhinitis in adults and children older than 12 years. Additionally, some patients experience nosebleeds and headaches with both azelastine and olopatadine. P ro t o t y p e D r u g s f o r A l l e r g i c R h i n i t i s, C o u g h, a n d C o l d s Intranasal Glucocorticoid Beclomethasone Antihistamines Azelastine (intranasal, nonsedating) Loratadine (oral, nonsedating) Intranasal Sympathomimetics (Decongestants) Phenylephrine (short acting) Oxymetazoline (long acting) Opioid Hydrocodone Nonopioid Dextromethorphan Intranasal Cromolyn Sodium The basic pharmacology of cromolyn sodium is discussed in Chapter 60. Actions and Uses For treatment of allergic rhinitis, intranasal cromolyn [NasalCrom] is extremely safe but only moderately effective. Cromolyn reduces symptoms by suppressing release of histamine and other inflammatory mediators from mast cells. Accordingly, the drug is best suited for prophylaxis and hence should be given before symptoms start. Responses may take a week or two to develop; patients should be informed of this delay. Adverse reactions are minimum—less than with any other drug for allergic rhinitis. Preparations, Dosage, and Administration For treatment of allergic rhinitis, cromolyn sodium is available in a metered-dose spray device that delivers 5. If nasal congestion is present, a topical decongestant should be used before cromolyn. Like the antihistamines and glucocorticoids, cromolyn should be dosed on a regular schedule throughout the allergy season. Sympathomimetics (Decongestants) Actions and Uses Sympathomimetics reduce nasal congestion by activating alpha -adrenergic1 receptors on nasal blood vessels. This causes vasoconstriction, which in turn causes shrinkage of swollen membranes followed by nasal drainage. In addition to their use in allergic rhinitis, sympathomimetics can reduce congestion associated with sinusitis and colds. Adverse Effects Rebound Congestion Rebound congestion develops when topical agents are used more than a few days. With prolonged use, as the effects of each application wear off, congestion becomes progressively worse. To overcome this rebound congestion, the patient must use progressively larger and more frequent doses. Once established, rebound congestion can lead to a cycle of escalating congestion and increased drug use. The cycle can be broken by abrupt decongestant withdrawal; however, this tactic can be extremely uncomfortable. An even better option is to use an intranasal glucocorticoid (in both nostrils) for 2 to 6 weeks, starting 1 week before discontinuing the decongestant. Development of rebound congestion can be minimized by limiting topical application to 3 to 5 days.

Both spironolactone and eplerenone promote renal retention of potassium and hence pose a risk for hyperkalemia buy cheap viagra with fluoxetine 100 mg line. Accordingly buy viagra with fluoxetine 100/60mg without prescription, they should not be given to patients with existing hyperkalemia and should not be combined with potassium-sparing diuretics or potassium supplements buy generic viagra with fluoxetine 100/60mg on line. Spironolactone is discussed in Chapter 35, and eplerenone is discussed in Chapter 36. As shown in the algorithm at this link, lifestyle changes should be instituted first. If needed, another drug may be added (if the initial drug was well tolerated but inadequate) or substituted (if the initial drug was poorly tolerated). However, before another drug is considered, possible reasons for failure of the initial drug should be assessed. Among these are insufficient dosage, poor adherence, excessive salt intake, and the presence of secondary hypertension. If treatment with two drugs is unsuccessful, a third and even fourth may be added. Initial Drug Selection Initial drug selection is determined by the presence or absence of a compelling indication, defined as a comorbid condition for which a specific class of antihypertensive drugs has been shown to improve outcomes. Initial drugs for patients with and without compelling indications are discussed next. For initial therapy in the absence of a compelling indication, a thiazide diuretic is currently recommended for most patients. This preference is based on long-term controlled trials showing conclusively that thiazides can reduce morbidity and mortality in hypertensive patients and are well tolerated and inexpensive too. Accordingly, these drugs should be reserved for special indications and for patients who have not responded to thiazides. Certain other alternatives—centrally acting sympatholytics and direct-acting vasodilators—are associated with a high incidence of adverse effects and hence are not well suited for initial monotherapy. One last alternative—alpha blockers1 —is no longer recommended as first-line therapy. As noted, when the alpha blocker doxazosin was compared with the diuretic chlorthalidone, doxazosin was associated with a much higher incidence of adverse cardiovascular events. Drugs shown to improve outcomes for six comorbid conditions are indicated in Table 39. Management of hypertension in patients with diabetes and renal disease—two specific comorbid conditions—is discussed further under “Individualizing Therapy. Adapted from The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. When using two or more drugs to treat hypertension, each drug should come from a different class. In contrast, it would be inappropriate to combine two thiazide diuretics or two beta blockers or two vasodilators. Second, when drugs are used in combination, each can be administered in a lower dosage than would be possible if it were used alone. Third, when proper combinations are selected, one agent can offset the adverse effects of another. However, if a vasodilator is combined with a beta blocker, reflex tachycardia will be minimal. Dosing For each drug in the regimen, dosage should be low initially and then gradually increased. As a result, sympathetic reflexes offer less resistance to the hypotensive effects of therapy. Individualizing Therapy Patients With Comorbid Conditions Comorbid conditions complicate treatment. Two conditions that are especially problematic—renal disease and diabetes—are discussed here. Preferred drugs for patients with these and other comorbid conditions are shown in Table 39. Drugs to avoid in patients with specific comorbid conditions are summarized in Table 39. Verapamil Diltiazem Coronary artery Hydralazine Reflex tachycardia induced by hydralazine can precipitate an anginal disease attack. Post–myocardial Hydralazine Reflex tachycardia induced by hydralazine can increase cardiac infarction work and oxygen demand. Diuretics Renal K -sparing diuretics+ Use of these agents can lead to dangerous accumulations of insufficiency K supplements+ potassium. Diabetes Thiazides Thiazides and furosemide promote hyperglycemia, and beta blockers mellitus Furosemide suppress glycogenolysis and can mask signs of hypoglycemia. Furosemide Hyperkalemia K -sparing diuretics+ These drugs cause potassium accumulation. Furosemide Collagen Hydralazine Hydralazine can precipitate a lupus erythematosus–like syndrome. Nephrosclerosis secondary to hypertension is among the most common causes of progressive renal disease. Pathophysiologic changes include degeneration of renal tubules and fibrotic thickening of the glomeruli, both of which contribute to renal insufficiency. Hence, in the absence of contraindications, all patients should get one of these drugs. In patients with advanced renal insufficiency, thiazide diuretics are ineffective, hence a loop diuretic should be employed. In diabetic patients, as in nondiabetic patients, beta blockers and diuretics can decrease morbidity and mortality. Keep in mind, however, that beta blockers can suppress glycogenolysis and mask early signs of hypoglycemia and therefore must be used with caution. Thiazides and loop diuretics promote hyperglycemia and hence should be used with care. Hypertension develops earlier, has a much higher incidence, and is likely to be more severe. As a result, black people face a greater risk for heart disease, end-stage renal disease, and stroke. Compared with the general population, blacks experience a 50% higher rate of death from heart disease, are twice as likely to die of stroke, and are 6 times more likely to experience hypertension-related end-stage renal disease. We know that blacks and whites respond equally to treatment (although not always to the same drugs). The primary problem is that, among black people, hypertension often goes untreated until after significant organ damage has developed. If hypertension were diagnosed and treated earlier, the prognosis would be greatly improved. Because blacks have a high incidence of salt sensitivity and cigarette use, lifestyle modifications are an important component of treatment. Controlled trials have shown that diuretics can decrease morbidity and mortality in blacks. The incidence of secondary hypertension in children is much higher than in adults.

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On the other hand 100mg viagra with fluoxetine mastercard, if the patient wit h the right colon cancer is profoundly anemic from bleeding or has obst ruct ive sympt oms viagra with fluoxetine 100 mg discount, t he pat ient will undergo resect ion of t he colon prior t o syst emic adju- van t t h er ap y purchase generic viagra with fluoxetine. P at ien t s wit h ad van ced co lo r ect al can cer s are m o st o p t im ally m an - aged by a mult ispecialt y team made up of surgeons, medical oncologist s, radiat ion oncologist s, radiologist s, nurses, and social workers. N early all patient s with colon can cer s wit h lymph n od e involvem ent will ben efit from adjuvant syst emic t h er apy following colon resect ion s. Re c t a l Ca n c e r The rectum is generally defined as the last 12 to 15 cm of the most distal end of the large bowel. From the oncologic standpoint, the rectum differs from the colon in that it is extraperitoneal in location, it is not covered by the visceral peritoneum, and it is in close proximit y to neighboring st ructures. For these reasons, invasive rect al cancers have a much great er ri sk o f lo cal recurrences followi ng t reat ment. Another important difference between the rectum and colon is the difference in venous drainage. Venous drainage of the colon and upper part of the rectum is por- tal venous, therefore making the liver the most common site of distant metastasis. For the lower rect um the ven ou s, drain age event u ally en ds up in the ven a cava, making the lung a common site of distant metastases. Due to the increased risk of local recurrence, patients with rectal cancers not only benefit from resection of the rectum with total mesorectal resection, most patients also seek benefit from adjuvant radiation therapy. Rig h t c o le c t o m y (A), rig h the m ico le ct o m y wit h d ivisio n o f middle colic pedicle (B), t ra n sve rse co le ct o m y (C), re se ct io n o f sp le n ic fle xu re sp arin g le ft co lic art e ry (D), le ft h e m ico le ct o my (E), sig m o id co le ct o m y sp arin g le ft co lic art e ry (F). While receiving their radiation therapy, patients are usually given adjuvant ch em ot h er apy t o in cr ease the effect iven ess of r ad iat ion t r eat m ent s. In select ive cases wh en the t u mor is locally advan ced, ch emor adiat ion t h er apy is given befor e surgery t o h elp improve t he probabilit y of having a complet e resect ion. Similar to patients with colon cancers, patients with node-positive rectal can- cer s also b en efit from syst em ic ch em ot h er apy u sin g the r egim en s that h ave b een described for colon carcinoma. An important difference regarding rectal cancer is that aggressive local resection with radiation therapy can frequently cause sexual and urinary dysfunct ion in male pat ient s, and urinary and fert ilit y dysfunct ion in female pat ient s. T h ese pot ent ial complicat ion s sh ou ld be discu ssed an d addressed wit h each pat ient prior to t he init iat ion of t reat ment s. Because of these additional concerns, rectal cancer patients should be provided with extensive counseling and appropriate support before, during, and after treatment. H ow- ever, t here are small subset s of pat ient s wit h hepat ic or pulmonary met ast ases who benefit from local treatments such as surgical resection or ablation of the metas- tases. Metastases are classified as synchronous (identified the same time as the primary tumor) or metachronous (identified after the primary had been treated). Prognostically, the patients with metachronous metastases do better than patients wit h synchronous met ast ases. R ep eat colo n o sco p y in 5 year s, an d if n egat ive, r ep eat ever y 5 t o 1 0 year s C. Su r gical r esect io n, r ad iat io n t h er ap y, an d ch em o t h er ap y if n o d e p o sit ive C. A m an wit h a 2 0 - year h ist o r y of u lcer at ive co lit is in volvin g the left co lo n wit h pseudopolyps in t he rectum C. A 48-year-old woman with a pedunculated adenomatous polyp in the sigmoid colon measuring 1. The pathology of the polyp reveals well-differentiated, invasive adenocarcinoma ext ending int o t he submucosa, and t he st alk and t he margin of resection are not involved with cancer. Sigmoid colectomy followed by resection, and ablative therapy for the liver met ast ases followed by syst emic ch emot h erapy E. The 60-year-old man with a single small pedunculated polyp without cancer resected should receive a repeat colonoscopy in 5 years followed by another colonoscopy in 5 to 10 years. Patients with cancerous polyps, on the other hand, need to have earlier and more intensive follow-up with a colonoscopy at 1 year, and then the colon oscopy can be sch edu led ever y 5 t o 10 year s d ep en d in g on the fin d in gs. This 43-year-old woman h as a n on obst r uct ing rect al can cer locat ed 7-cm from the an al ver ge. T h e best t r eat m en t ch oice for h er is su r gical r esect ion, radiation therapy, followed by systemic chemotherapy if the disease is node positive. The average cancer risk associated with the history of serrated adenoma is approximately 5%. Because the can cer is d escr ibed as n ot t h r ou gh the submu cosa or involvin g the st alk an d margins, excision of the polyp alone is sufficient given the low risk of regional lymph n ode met ast asis an d low risk of local recurren ce. This pat ient sh ou ld not require additional treatments for this cancerous polyp. This 63-year-old woman h as an asympt omat ic carcin oma in the descen d- ing colon and has hepat ic met ast ases occupying bot h liver lobes and replacing approximately 45% of t he liver volume. Since she is asymptomat ic from the primary tumor, the treatment strategy should be directed toward the treat- ment of the systemic disease process first, and then proceed with surgical resection of the colon only if it becomes symptomatic (bleeding, obstruction, or perforation). He has been receiving infliximab (Remicade) infusions at 5 mg/kg every 8 weeks for the past 8 months. Before that time, he had taken prednisone 40 mg/d for several weeks intermittently for disease flare-ups. His a b d o m e n is m o d e ra t e ly d is t e n d e d a n d t e n d e r in the rig h t lo we r q u a d ra n t. A r e c t a l e x a m i n a t i o n r e v e a l s n o perianal disease or abnormalities. The results from the serum electrolyte studies and urinalysis are within the normal ranges. Current ly, he has nausea, vomit ing, abdominal pain, dist ension, low- gr ad e fever, an d leu kocyt osis, wh ich are su ggest ive of ch r on ic small bowel obst r u c- tion and low-grade inflammatory or infectious process. Most likely diagnosis: Crohn disease, likely ileocolic, complicated by obstruc- tion and possibly an intra-abdominal infectious process. Next step: D efin e the ext en t of d isease in volvem en t, the sit e of o b st r u ct ion, an d presence or absence of intra-abdominal abscesses. If these initial radiographic findings are suspicious for colonic involvement, t hen colonoscopy should be considered. Be familiar with the medical therapy and the role of surgery in the care of patients with Crohn disease. Despite these treatments, the patient has had disease progression as evident by his weight loss and worsening symptoms. His clinical picture associated with Crohn disease can be due to inflammation, fibrosis, penetration (fistulization), or combin at ion of t h ese processes. In flamma- tory obstructions and certain fistulizing diseases are more likely to resolve with medical treatment regimens, whereas strictures that are primarily fibrotic in nature are less likely to respond to medicat ions and may need operat ive t reat ment. The init ial management of any pat ient wit h a known h ist ory of Croh n disease needs t o st art wit h a conversat ion bet ween t he surgeon and t he pat ient’s gast roent erologist. This discussion may help us appreciate prior treatments, responses to treatments, and long-term t reat ment plans t hat have been formulated and previously discussed with the patient and his family. Coordination of care bet ween medical providers and surgical providers are especially import ant for t he opt imal and t imely t reat - ment of patients with Crohn disease.

If the mass were lateral or moved apart from the cervix viagra with fluoxetine 100 mg without a prescription, another type of pelvic mass buy viagra with fluoxetine in united states online, such as ovarian buy genuine viagra with fluoxetine line, would be suspected. This patient complains of menorrhagia (excessive bleeding during menses), the most com mon sympt om of ut er in e fibr oid s. If sh e h ad int er m en st r u al bleed in g, the clin i- cian would h ave t o con sider ot h er diseases, such as en domet r ial h yper plasia, en do- metrial polyp, or uterine cancer, in addition to the uterine leiomyomata. T h e pat ient h as anemia despite medical t herapy, const itut ing the indicat ion for intervent ion, such as hysterectomy. If t he uterus were smaller, considerat ion may be given toward anot her medical agent, such as medroxyprogesterone acet ate (Provera). Pedunculated Subserosal Submucosal In tra m u ra l Ce rvica l Prolapsed Figure 41–1. T hey occur in up t o 25% of women, and have a variety of clinical present ations. The most common clini- cal man ifest at ion is m en or r h agia, or excessive bleedin g du r in g men ses. T h e exact mechanism is unclear and may be due to an increased endometrial surface area or the disruption of hemostatic mechanisms during menses by the fibroids. Another speculat ed explanat ion is ulceration of the submucosal fibroid surfaces. Some signs of this process include rapid growth, such as an increase of more than 6 weeks’gestational size in 1 year. If the uterine leiomyomata are sufficiently large, patients may also complain of pressure to the pelvis, bladder, or rectum. Also, a submucous leiomyomata can pro- lapse t h rough the cer vix, leading t o labor-like ut erine cont ract ion pain. The physical examination typical of uterine leiomyomata is an irregular, midline, firm, nontender mass that moves contiguously with the cervix. Most of the time, ultrasound examination is per- formed t o con firm the diagn osis. The differential diagnosis includes ovarian masses, tubo-ovarian masses, pelvic kidney, and endometrioma. Tr e a t m e n t The initial treatment of uterine fibroids is pharmacological, such as with non- st eroidal ant i-inflammat ory agent s or progest in t herapy. G onadot ropin-releasing hormone agonists lead to a decrease in uterine fibroid size, reaching its maximal effect in 3 mont h s. Aft er t he discont inuat ion of t his agent, t he leiomyomat a usually regrow t o t he pret reat ment size. W it h in t r acavit ar y ( su bm u cosal) u t er in e fib r oid s, h yst er oscop ic r esect ion is the best conservative treatment option. Hysterectomy is considered the proven treatment for symptomatic uterine fibr oid s wh en fu t u r e p r egn an cy is u n d esir ed. T h e in d icat ion for su r ger y is p er sis- tent symptoms despite medical therapy. Myomectomy is still considered the pro- cedu r e of ch oice for women wit h sympt omat ic ut er in e leiomyomat a wh o d esir e pregnancy. One in four women who undergo myomectomy will require a hysterec- tomy in the following 20 years. Myomectomy can be accomplished through several approaches including hysteroscopic, open abdominal, laparoscopic and robot ically. M yom ect omy is n ot in d icat ed in wom en wh o have uterine fibroids unless there have been pregnancy complications due to uter- ine fibroids in t he past. Uterine artery embolization is a technique performed by cannulizing the femo- ral artery and catheterizing both uterine arteries directly, and infusing emboliza- tion particles that preferentially float to the fibroid vessels. Short-term results appear promising; init ial studies wit h follow-up over 5 years show sympt om relief for approximat ely 75% of patients. This intervention should not be used in women who want to get pregnant in the future since there is an increased risk of placentation abnormalities. Ver y lar ge u t er i ( > 2 0 week s siz e) o r ver y lar ge fib r o id s m ay n o t r esp o n d as well; also, submucosal fibroids may cause bleeding, pain, cramping, and expulsion which can be u npleasant for the pat ient. This was due to con- cer n s r aised by the case of an u n su sp ect ed Bost on an est h esiologist wh o u n d er went laparoscopic power morcellat ion for suspect ed fibroids. After an evaluat ion for the recurrent abortions including karyotype of the parents, hysterosalpingogram, vaginal sonogram, and test- ing for ant iphospholipid syndrome, t he obst et rician concludes t he ut erine fibr oid s are the et iology. Which of the followin g t yp es of ut er in e fibr oid s would most likely lead t o recurrent abort ion? She is cur- rently asymptomatic and expressed surprise that she had “growths” of the uterus. If she were to develop symptoms, which of the following would be the most common manifestation? W hile push ing during t he second st age of labor, she is noted to have fetal bradycardia associated with some vaginal bleeding. The fet al head, which was previously at + 2 st ation, is now noted to be at – 3 st a- tion. O ver t he course of 1 year, sh e is not ed t o have enlargement of her uterus from approximately 12 weeks’size to 20 weeks’size. The pat ient has finished her childbearing, but ada- mantly refuses surgical management for her fibroids. A 45-year-old G2P2 woman has significant heavy menstrual bleeding due to uterine fibroids. The pelvic ultrasound shows two large uterine fibroids— one in the anterior corpus and one in the uterine fundal region. Which of the following is t he best way t o ensure t hat the ut erine fibroids are not leiomyosarcoma? Submucousal fibroids are the fibroids most likely to be associated with recurrent abortion because of their effect on the uterine cavity. The contours of the endometrium are altered and therefore, less favorable for implantation. There may be insufficient vasculature to provide adequate blood supply to the growing embryo if it were to implant along the side of the endometrium cont ain in g a submu cosal fibr oid. In the secon d t r imest er of pr egn an cy, the other answer choices are not associated with an increased risk of recurrent abort ion because they do not alt er t he int egrit y of t he endomet rium. Menorrhagia is the most common symptom of uterine fibroids, and severe menorrhagia often leads to anemia. Infert ilit y and recurrent abort ion may occur with submucosal fibroids due to the effects on the uterine cavity, wh ereas impingement on the uret ers is most likely t o occur wit h subsero- sal fibroids, but t hese are much less common t han menorrhagia. Pelvic pain is not very common, and many ut erine fibroids are asympt omat ic and only require monitoring. If the uterine leiomyomata are large enough, patients may complain of pressure to the pelvis, bladder, or rectum.