Fibroids

Question 1

Fibroids

Answer 1

Benign tumours of the smooth muscle of the uterus - leiomyoma

Question 2

Risk factors for fibroids

Answer 2

Black ethnicity

Question 3

Types of fibroid

Answer 3

Intramural - within the myometrium

Subserosal - just below the outer layer of the uterus

Submucosal - just below the endometrium

Pedunculated - on a stalk

Question 4

Subserosal fibroid features

Answer 4

Grow outwards and can become very large, filling the abdominal cavity

Question 5

Presentation of fibroids

Answer 5

Often asymptomatic

Symptoms:

• Menorrhagia
• Prolonged menstruation, lasting 7+ days
• Abdominal pain, worse during menstruation
• Bloating
• Urinary or bowel symptoms due to pelvic pressure or fullness
• Deep dyspareunia
• Reduced fertility

Question 6

Examination findings for fibroids

Answer 6

May have a palpable pelvic mass or an enlarged firm non-tender uterus on bimanual or abdominal examination

Question 7

Investigations for fibroids

Answer 7

1. Hysteroscopy
2. Pelvic USS -larger fibroids
3. MRI scanning -before surgical options

Question 8

Management of fibroids < 3cm with no distortion

Answer 8

1st - Mirena coil

Symptomatic management:

• Mefenamic acid and tranexamic acid
• COCP
• Cyclical oral progestogens

Question 9

Management of fibroids < 3cm with menorrhagia

Answer 9

Endometrial ablation

Resection of submucosal fibroids during hysteroscopy

Hysterectomy

Question 10

Management of fibroids > 3cm

Answer 10

Referral to gynaecology

Symptomatic management:

• Mefenamic and tranexamic acid
• Mirena coil – depending on the size and shape of the fibroids and uterus
• COCP
• Cyclical oral progestogens

Surgery

Question 11

Surgical options for larger fibroids > 3cm

Answer 11

Uterine artery embolisation

Myomectomy

Hysterectomy

Question 12

How to reduce fibroids before surgery

Answer 12

GnRH agonists - induce a menopause like state

Question 13

Fibroid response to oestrogen

Answer 13

Oestrogen sensitive so grow in response to oestrogen

Question 14

Which artery is used to access the uterine artery for uterine artery embolisation

Answer 14

Femoral artery

Question 15

Complications of fibroids

Answer 15

Iron deficiency anaemia

Reduced fertility

Pregnancy complications, such as miscarriages, premature labour and obstructive delivery

Constipation

Urinary outflow obstruction and urinary tract infections

Red degeneration of the fibroid

Pedunculated fibroids - torsion

Malignant change to a leiomyosarcoma is very rare (<1%)

Question 16

Red Degeneration of Fibroids

Answer 16

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply

Question 17

When is red degeneration most likely to occur

Answer 17

Larger fibroids > 5 cm during the second and third trimester of pregnancy

Fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic

Question 18

Presentation of red degeneration of a fibroid

Answer 18

Severe abdominal pain

Low-grade fever

Tachycardia and often vomiting

Question 19

Management of red degeneration of a fibroid

Answer 19

Supportive - rest, fluids and analgesia