Fibroids Flashcards
What are fibroids?
Benign tumours of the smooth muscle of the uterus.
Also known as uterine leiomyomas
What is the incidence of fibroids?
Affect 40-60% in later reproductive years
More common in black women compared to other ethnic groups
What are fibroids sensitive to?
Oestrogen
Name 4 types of fibroid.
- Intramural
- Subserosal
- Submucosal
- Pedunculated
What is an intramural fibroid?
Lies within the myometrium (the muscle of the uterus).
As they grow, they change the shape and distort the uterus.
What is a subserosal fibroid?
Grows just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
What is a submucosal fibroid?
Lies just below the lining of the uterus (the endometrium).
What is a pedunculated fibroid?
Fibroid on a stalk.
How might fibroids present?
- Heavy menstrual bleeding (most frequent presenting symptom)
- Prolonged menstruation (7+ days)
- Abdominal pain, worse during menstruation
- Bloating or feeling full in abdomen
- Urinary or bowel symptom due to pelvic pressure/ fullness
- Deep dyspareunia
- Reduced fertility
What might abdominal and bimanual examination show in a patient with fibroids?
Palpable pelvic mass or enlarged firm non-tender uterus.
When is hysteroscopy used for fibroid investigation?
For initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.
When is pelvic ultrasound the investigation of choice?
For larger fibroids.
When might MRI scanning be needed when investigating fibroids?
May be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.
What is the medical management of fibroids less than 3cm?
Medical management same as with heavy menstrual bleeding:
- Mirena coil (1st line)
- Symptomatic management with NSAIDs and transexamic acid
- COCP
- Cyclical oral progestogens
In what situations is the mirena coil used for fibroid management?
If they are <3cm with no distortion of the uterus.
Name three surgical options for managing smaller fibroids with heavy menstrual bleeding.
- Endometrial ablation
- Resection of submucosal fibroids during hysteroscopy
- Hysterectomy
Name three surgical options for managing larger fibroids.
- Uterine artery embolisation
- Myomectomy
- Hysterectomy
What can be used to reduce the size of fibroids before surgery?
GnRH agonists e.g. goserelin (Zoladex) or leuprorelin (Prostap).
How do GnRH reduce the size of fibroids?
Inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.
Usually only used in the short term.
What is a myomectomy?
Surgical removal of fibroid via laparoscopic surgery or laparotomy.
What is the only treatment known to potentially improve fertility in patients with fibroids?
Myomectomy
What are potential complications of fibroids?c
- 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 urinary tract infections
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What is red degeneration of a fibroid?
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
In what fibroids is red degeneration most likely to occur and when?
Larger fibroids (>5cm) during second and third trimester of pregnancy.
Why does red degeneration occur?
Fibroid rapidly enlarges during pregnancy, outgrowing its bloody supply and becoming ischaemic.
May also occur due to kinking in blood vessels as the uterus changes shape and expands during pregnancy.
How does red degeneration of a fibroid present?
- Severe abdominal pain
- Low grade fever
- Tachycardia
- Sometimes vomiting
How is red degeneration managed?
Supportively, with rest, fluids and analgesia.
