Fibroids

Question 1

Which of these is associated with most fibroids?

1. A t(10;17) (q24;q24).
2. B t(3;19) (q22;p13).
3. C inv (6)(p21q15).
4. D trisomy 12.
5. E t(12;14)(q13-15;q23-24).

Answer 1

E

Uterine fibroids are clonal tumors. Each fibroid is a unique clonal tumor. Many fibroids have the following cytogenetic abnormality: t(12;14)(q13-15;q23-24). This abnormality is also commonly found in human lipomas.

Question 2

Define fibroid. How common are they?

Answer 2

Fibroids are benign smooth muscle tumours of the uterus. They consist of a mix of smooth muscle and fibroblasts which form hard, round, whorled tumours.

Occur in around 20% of white and around 50% of black females in later reproductive years

Question 3

What are the risk factors for fibroids?

Answer 3

• Increasing age
• Early puberty
• Obesity
• Black ethnicity
• Family history

Question 4

What are uterine fibroids aka? What causes fibroids to grow?

Answer 4

Leiomyomas

Oestrogen and progesterone control the proliferation and maintenance of uterine fibroids.

Question 5

Name 3 types of fibroids.

Answer 5

Subserosal fibroids —ommonly asymptomatic or minimally symptomatic unless large

Intramural fibroids — may cause menorrhagia and dysmenorrhea by interfering with the constriction of blood vessels during menstruation.

Submucosal fibroids —even relatively small ones may cause significant menorrhagia and dysmenorrhea or reduce fertility

Can be single/multiple and small (few mm) or large (>30cm). Pedunculated fibroids form when subserosal/submucosal fibroids become attached to myometrium by peduncle containing the ir blood supply.

Question 6

What are the clinical features of fibroids?

Answer 6

• Can be asymptomatic
• Menorrhagia –> Fe def
• Secondary dysmenorrhoea
• Crampy abdominal pain (often during menstruation)
• Bloating or constipation
• Subfertility

With larger fibroids: urinary symptoms e.g. frequency, urgency, incontinence, hydronephrosis

Rarely: polycythaemia due to autonomous production of EPO

Question 7

What are the differentials for fibroids?

Answer 7

• Malignancy - GI, urinary, ovarian, endometrial
• Uterine sarcoma e.g. leiomyosarcoma
• Endometrial polyp, hyperplasia, aenomyosis
• Pregnancy
• Full bladder

Question 8

What are the other causes of menorrhagia?

Answer 8

• Dysfunctional uterine bleeding (~50%) i.e. menorrhagia in the absence of underlying pathology
• Anovulatory cycles: these are more common at the extremes of a women’s reproductive life
• Hypothyroidism
• IUD - normal copper coil not Mirena
• PID
• Bleeding disorders, e.g. von Willebrand disease

Question 9

What investigations are done to diagnose fibroids?

Answer 9

• Abdominal and bimanual pelvic examination - should find enlarged, irregularly shaped non-tender uterus and mass can be moved from side to side
• FBC - check for Fe def anaemia
• TVUS and transabdominal US - routine

Question 10

What is the management of fibroids based on?

Answer 10

Whether they are symptomatic or asymptomatic

Question 11

When should you refer a patient with fibroids to a specialist?

Answer 11

• Compressive symptoms and other complications of fibroids
• Fertility problems
• Suspicion of malignancy
• Fibroids which are palpable abdominally or intracavity fibroids +/- with length >12cm

Question 12

What are some red flag signs/symptoms in a female with suspected fibroids?

Answer 12

Refer on a 2 week wait cancer pathway in these circumstances:

• Ascites +/- pelvic or abdominal mass that is not obviously due to uterine fibroids –> refer urgently
• Unexplained bleeding
• Weight loss

Question 13

What is the management of asymptomatic fibroids?

Answer 13

No treatment needed

Periodic review to monitor size and growth should be done

Question 14

How do you manage a patient with menorrhagia (heavy/prolonged periods) secondary to fibroids?

Answer 14

1. Levonorgestrel intrauterine system (LNG-IUS) - do not use if the uterine cavity is distorted
2. NSAIDS e.g. mefenamic acid
3. TXA
4. COCP
5. Progestogen (oral or injectible)

Question 15

When should you not use LNG-IUS for fibroids?

Answer 15

Do not use if the uterine cavity is distorted

Question 16

What are the medical options for shrinking fibroids?

Answer 16

GnRH agonist - typically only useful for short term treatment only

Ulipristal acetate - NOT currently used due to concerns over toxicity but used in the past

Question 17

What are the surgical options for fibroid removal?

Answer 17

1. Myomectomy - done abdominally, laparoscopically or hysteroscopically
2. Hysteroscopic endometrial ablation
3. Hysterectomy
4. Uterine artery embolisation

Question 18

What are the advantages of UAE?

Answer 18

Done by radiologist and has 80% success rate in fibroid treatment, causing ~50% reduction in fibroid volume

Shorter hospital stay after procedure and faster return to normal activities

Question 19

What are the complications/risks of UAE?

Answer 19

• Pain after procedure is common and requires opiate analgesia
• Fever
• Fibroid expulsion
• Concerns over premature ovarian failue
• Higher rates of readmission and further surgical intervention than with myomectomy e.g. hysterectomy may still be required.
  
  • A third of women need futher intervention within 5 years.
• Unknown effects on fertility
  
  • ​Pregnancies reported in literature
  • Effects on endometrium leading to abnormal placentation in pregnancy

Question 20

How is uterine artery embolisation carried out?

Answer 20

1. Interventional radiologists
2. Incision in groin under local anaesthetic
3. Cannula placed into femoral artery and guises into the uterine arteries
4. Embolisation particles are then injected to reduce the blood supply to the uterus
5. This induces infarction and degeneration of fibroids
6. Usually overnight admission is advised to deal with pain, requiring opiate analgesia

Question 21

What are the indications for uterine artery embolisation?

Answer 21

PPH - when other methods such as Rusch balloon and brace suture have failed

Menorrhagia due to fibroids - for women who want to retain uterus and avoid surgery

Question 22

What are the effects of UAE on fertility?

Answer 22

Unknown but likely negative without being fully contraceptive

Question 23

What is the prognosis with fibroids?

Answer 23

Generally regress after the menopause

Question 24

List 3 complications of fibroids. What is common during pregnancy regarding fibroids?

Answer 24

• Fe deficiency
• Subfertility
• Red degeneration - haemorrhage into tumour; common during pregnancy
• Polycythaemia - 2o to autonomous production of erythropoietin

Question 25

How is polycythaemia defined by laboratory investigations?`

Answer 25

Red cell mass in females >32 ml/kg (and >35ml/kg in males). But this is rare in uterine fibroids as you usually get menorrhagia which leads to blood loss.

Question 26

What are the risks associated with fibroids in pregnancy?

Answer 26

• Higher rates of caesarian delivery.
• Malpresentation.
• Pre-term delivery.
• Miscarriage

Question 27

What is the pathophysiology of fibroid degeneration?

Answer 27

1. Uterine fibroids are sensitive to oestrogen
2. During pregnancy, high oestrogen may cause them to grow and outgrow their blood supply
3. This leads to red/’carnerous’ degeneration which is avascular necrosis

Question 28

How does fibroid degeneration present? How is it managed?

Answer 28

Low-grade fever, pain and vomiting

Conservative management - rest and analgesia; should resolve within 4-7 days.

Question 29

Do leiomyosarcomas develop from fibroids?

Answer 29

It is uncertain as they can only be reliably diagnosed by histopathology

Question 30

What contraceptive options can be used in women with fibroids? Can they use HRT?

Answer 30

All if no distorsion of the uterine cavity. Copper or LNG-IUS can only be used in distored uterine cavity if specialist advice has been saught.

HRT for menopause - should inform patient of the risk of fibroids increasing in size and ask them to make their own choice. There is a small risk that it will cause symptoms.