Fibroids Flashcards
What are fibroids?
- 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
Describe the epidemiology of fibroids
- very common affecting 40-60% of women in later reproductive years
- more common in black women
What are the types of fibroids?
- Intramural
- subserosal
- submucosal
- pedunculated
Where are intramural fibroids located?
- within the myometrium (muscle of uterus)
- as they grow they change shape and distort the uterus
Where are subserosal fibroids located?
- just below the outer layer of the uterus
- these grow outwards and can become very large, filling the abdominal cavity
Where are submucosal fibroids located?
-just below the lining of the uterus (endometrium)
Where are pedunculated fibroids located?
-on the stalk
What symptoms can fibroids cause?
- 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
What are the investigations for fibroids?
- hysteroscopy is the initial investigation for submucosal presenting with menorrhagia
- transvaginal US investigation of choice for larger fibroids
- MRI scanning may be considered before surgery where more info is needed
-If there is any doubt over the diagnosis a biopsy may be taken to differentiate the fibroid from other differentials such as endometrial cancer.
What does the management of fibroids depend on?
-symptoms and the size of the fibroids
What would be the management for fibroids less than 3cm?
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
What are surgical options for small fibroids?
- endometrial ablation
- resection of submucosal fibroids during hysteroscopy
- hysterectomy
What would be the management for fibroids more than than 3cm?
- need referal to gyaenocology
- symptomatic management with tranexamic acid and NSAIDs
- mirena coil - depending on size and shape
- combined OCP
- Cyclical oral progestogens
What are surgical options for large fibroids?
Where the symptoms are due to the mass effect of the fibroid (e.g. pressure on the bladder), there are several surgical options which may be used:
- Myomectomy involves removing the fibroid from the uterine wall, and is generally fertility-sparing.
- Ablation involves using a laser or radiofrequency(generates heat) to induce necrosis of the fibroid, and so the dead vessels no longer bleed.
- Uterine artery embolisation may provide a targeted degeneration of the fibroid. This may also preserve fertility.
- Hysterectomy involves removing the uterus. It is obviously extremely effective but will not preserve fertility.
What may be used before surgery to reduce the size of fibroids?
GnRH agonists such as goserelin (zoladex) or leuprorelin (Prostap)
What does myomectomy involve?
- Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy
- only known treatment that potentially improves fertility in patients with fibroids
What does hysterectomy involve?
Hysterectomy involves removing the uterus and fibroids.
What are the complications of fibroids?
- 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%)
What does red degeneration of the fibroid involve?
-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.
definitive management of menorrhagia caused by large fibroids
hysterectomy (in myomectomy fibroids can reoccur)
