Fibroids Flashcards
Define
Benign tumours of the uterus, often of myometrium
Uterine fibroids are often made up of smooth muscle and fibrous connective tissue (fibroblasts) which form hard, whorled, round tumours in the myometrium
They are well-circumscribed nodules and can be:
- Subserosal- just under the uterine serosa (outer layer) - can undergo secondary changes
- Intramural- located within the muscular layer of the uterus
- Submucosal- just below the endometrial lining (innermost lining - within cavity)
- Pedunculated- subserosal or submucosal fibroids attached to the myometrium by a pedicle containing their blood supply
T0: Totally hanging inside the cavity (Pedunclated)
T1: most is into the uterine cavity but some is in the muscle
They can be single or multiple and range in size.
Also known as leiomyomata
Epidemiology
Epidemiology
By 50 years old, almost 70% of white women and > 80% of black women have at least 1 fibroid.
Less common in parous women who have taken the COCP or injectable progestogens
Aetiology
Fibroid growth and maintenance is oestrogen and progesterone dependent- so they develop in women of reproductive age
Enlarge in pregnancy (due to oestrogen) à shrink in menopause
- ‘Red degeneration’ may occur during pregnancy due to avascular necrosis
- This is when rapid growth of a fibroid outgrows its blood supply
- This rapid growth happens due to oestrogen
o Epidemiology: affect 1/3 women of reproductive age
Risk Factors
- Increasing age
- Early puberty
- Obesity
- Black ethnicity
- Family history
- Nulliparity
- Risk of fibroids is REDUCED by pregnancy and decreased with increasing number of pregnancies
Symptoms
50% ASYMPTOMATIC – discover at physical or USS examination
- Symptoms often relate to site rather than size
Abdominal distension or distortion
Menstrual problems:
- Menorrhagia - Heavy menstrual bleeding (timing UNAFFECTED)
- Intra-menstrual loss (if submucosal or polypoid)
- Erratic bleeding
Pain:
- Dysmenorrhoea
- Pelvic pain or discomfort
Bladder symptoms (Pressure effects):
- Frequency
- Urinary retention
- Hydronephrosis
Non-specific bowel problems (pressure effects)
- Bloating
- Constipation
Fertility may be impaired (subfertility)
Pressure effects - more to do with submucosal fibroids
Bleeding symp - more to do with polyploid
Signs
Irregular firm pelvic mass palpable on pelvic or abdominal examination- this can be moved side to side
Irregular central mass- large tumour
NOTE: multiple small fibroids can cause irregular ‘knobbly’ enlargement of uterus
Investigations
Obs
Bloods
FBC - anaemia
Group and save
USS (abdo + TV) is the initial screening method
Determines number, size and position of fibroids
Numerous small and diffuse intramural fibroids may appear as subtle heterogeneous echoes within the confines of the myometrium
A degenerating fibroid that has outstripped its blood supply can have cystic areas within the fibroid
Other investigations
- Hysteroscopy
- MRI
- Laparoscopy
Management - < 3 cm
NOTE: Only require treatment when symptomatic, fertility/ obstetric problems, suspicion of malignancy
If asymptomatic, most women don’t need further investigation, just arrange follow up to monitor size and growth
Fibroids < 3 cm
- Can manage this in Primary Care
Medical
1st line: LNG-IUS (levonorgestrel/ Mirena coil)- in situ for 5 years
- This CANNOT be used if the uterus is distorted
- Side effects associated with LNG-IUS include:
- irregular bleeding that may last for more than 6 months
- acne
- headaches
- breast tenderness
- in some cases, no periods at all (absent periods)
2nd line: Non-hormonal
Tranexamic acid (anti-fibrinolytics)
- Used when LNG-IUS is not suitable, e.g., when contraception is not desired
- 3 or 4 times a day during your period for up to 4 days
- Treatment should be stopped if your symptoms have not improved within 3 months
- Can cause indigestion and diarrhoea
NSAIDs (e.g. mefenamic acid)
- Taken during periods
2nd line: Hormonal
- COCP
- Cyclical oral progestogens (e.g. norethisterone)
- Can help reduce heavy periods
- Take from day 5 - 26 of menstrual cycle
- Can cause SE like weight gain, breast tenderness etc
LHRH agonist (Leuprorelin, triptorelin)- shrinks fibroids before surgery - REFER TO SPECIALIST CARE
- 3.75mg IM once monthly for 3 months
- 11.25mg IM as a single dose
Surgical- (see NICE guidance)
- Myomectomy, uterine artery ablation – depends on circumstances
- Hysterectomy (?)
Management - >3cm
Fibroids ≥ 3cm
- REFER to SPECIALIST CARE
1st line non-hormonal (not contraceptive):
- · Tranexamic acid, 1g TDS (contraindications: renal impairment, thrombotic disease)
- · Mefenamic acid / NSAIDs (contraindications: IBD)
1st line hormonal (contraceptive):
- · COCP
- · Cyclical oral progestogens
Surgical/radiological treatment:
- Injectable GnRH Agonist (short-term, usually used prior to surgery)
- Shrinks fibroids
- Induces a menopausal state (shuts down ovarian oestradiol production)
- Side effects (menopausal à hot flushes, sweating, vaginal dryness, osteoporosis)
- Ulipristal Acetate (short-term, selective progesterone receptor modulator), OD
- Shrinks fibroids, reduce bleeding (use for 6/12)
- As effective as GnRH agonists BUT no menopausal state induced
- Not yet widely accepted into clinical practice
- Long-term use associated with liver injury
· SURGICAL:
Hysteroscopic (TCRF) – indication: small submucosal or polypoid
Myomectomy [best for improving fertility]
- Open or laparoscopic
- Power morcellation is used to shrink the fibroids for removal
Side effects:
- Uncontrolled life-threatening bleed (small risk)
- More likely to require a caesarean section delivery in the future as they have to make an incision into the uterus à risk of uterine rupture
· SURGICAL: Hysterectomy
· SURGICAL: Endometrial ablation [removes fertility; must use contraception]
· RADIOLOGICAL: Uterine artery embolisation (UAE):
- May preserve fertility (may also make ovaries fail…)
- Embolise both uterine arteries à infarct/degenerate fibroids
- Patients need admission to deal with pain associated (opiate analgesia)
- Complications: fever, infection, fibroid expulsion, potential ovarian failure (COUNCIL)
o 33% of women require further medical, radiological or surgical treatment <5 years
o As effective as myomectomy for alleviating fibroid DUB and pressure symptoms
Complications
Pregnancy -> red degeneration, miscarriage, malpresentation, transverse lie, PTL, PPH
- S/S (red degeneration) = low fever, pain, vomiting
- Mx (red degeneration) = conservative – resolve in 4-7 days
Prognosis:
- 10-year recurrence rate after myomectomy is 20%
- Fibroids regress and calcify after menopause
Leiomyosarcoma (<1 per 100,000):
- Very rare cancer; smooth muscle cancer of the uterus
- Associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)
Prognosis
Many medical therapies are effective for shrinking the size of the fibroid and so reducing fibroid-related symptoms but long-term use in pre-menopausal women is NOT recommended due to serious adverse effects with prolonged use.
On cessation of medical therapy, regrowth of fibroids to pre-treatment size occurs relatively quickly (e.g. within 12 weeks when using GnRH agonists)
Myomectomy and uterine artery embolization are effective in treated related symptoms
PACES
Describe as growths in womb which are NOT cancerous and connect to the symptoms
Very common and increases with age
Ask if she wants to have any children in the future
Give an intro saying you can either do watch and wait, medical or surgical
Want to give specialist advise in clinic - hormonal and surgery (mention others but don’t spend too much time on them)
Discuss complications of surgery
Fibroids UK
Fibroids in preg - depends if there is something obstructing birth canal, if not a normal vaginal delivery is possible - recommend the pt to take iron tablets throughout preg; if the iron levels are not high then recommend an iron infusion due to the risk of bleeding with fibroids
