Fibroids

Question 1

What are fibroids?

Answer 1

• fibroids are benign tumours of the smooth muscle of the uterus
• also called uterine leiomyomas
• they are oestrogen senistive meaning they grow in response to oestrogen

Question 2

Describe the epidemiology of fibroids

Answer 2

• very common affecting 40-60% of women in later reproductive years
• more common in black women

Question 3

What are the types of fibroids?

Answer 3

• Intramural
• subserosal
• submucosal
• pedunculated

Question 4

Where are intramural fibroids located?

Answer 4

• within the myometrium (muscle of uterus)

- as they grow they change shape and distort the uterus

Question 5

Where are subserosal fibroids located?

Answer 5

• just below the outer layer of the uterus

- these grow outwards and can become very large, filling the abdominal cavity

Question 6

Where are submucosal fibroids located?

Answer 6

-just below the lining of the uterus (endometrium)

Question 7

Where are pedunculated fibroids located?

Answer 7

-on the stalk

Question 8

What symptoms can fibroids cause?

Answer 8

• often asymptomatic
• menorrhagia is most frequent symptom
• prolonged menstruation > 7 days
• abdo pain, worse during menstruation
• bloating or feeling full in the abdomen
• urinary or bowel symptoms due to pelvic pressure or fullness
• deep dyspareunia (pain during intercourse)
• reduced fertility
• abdo and bimanual exam may reveal a palpable pelvic mass or an enlarged firm non-tender uterus

Question 9

What are the investigations for fibroids?

Answer 9

• hysteroscopy is the initial investigation for submucosal presenting with menorrhagia
• pelvic US investigation of choice for larger fibroids
• MRI scanning may be considered before surgery where more info is needed

Question 10

What does the management of fibroids depend on?

Answer 10

-symptoms and the size of the fibroids

Question 11

What would be the management for fibroids less than 3cm?

Answer 11

same as menorrhagia:

• Mirena coil (first line) must have no distortion of uterus
• Combined OCP
• symptomatic management with tranexamic acid and NSAIDs
• Cyclical oral progestogens

Question 12

What are surgical options for small fibroids?

Answer 12

• endometrial ablation
• resection of submucosal fibroids during hysteroscopy
• hysterectomy

Question 13

What would be the management for fibroids more than than 3cm?

Answer 13

• need referal to gyaenocology
• symptomatic management with tranexamic acid and NSAIDs
• mirena coil - depending on size and shape
• combined OCP
• Cyclical oral progestogens

Question 14

What are surgical options for large fibroids?

Answer 14

• uterine artery embolisation
• myomectomy
• hysterectomy

Question 15

What may be used before surgery to reduce the size of fibroids?

Answer 15

GnRH agonists such as goserelin (zoladex) or leuprorelin (Prostap)

Question 16

What does myomectomy involve?

Answer 16

• Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy
• only known treatment that potentially improves fertility in patients with fibroids

Question 17

What does hysterectomy involve?

Answer 17

Hysterectomy involves removing the uterus and fibroids.

Question 18

What are the complications of fibroids?

Answer 18

• Heavy menstrual bleeding, often with iron deficiency anaemia
• Reduced fertility
• Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
• Constipation
• Urinary outflow obstruction and UTIs
• Red degeneration of the fibroid
• Torsion of the fibroid, usually affecting pedunculated fibroids
• Malignant change to a leiomyosarcoma is very rare (<1%)

Question 19

What does red degeneration of the fibroid involve?

Answer 19

-Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
-more likely to occur in larger fibroids
presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting
-Management is supportive, with rest, fluids and analgesia.