Fibroids

Question 1

Definition of fibroids

• Classification

Answer 1

Benign tumours of the myometrium (leiomyomas)

• Classification
  
  • Submucosal (beneath endometrium)
  • Intramural (within myometrium)
  • Subserosal (bulge out of the uterus)

Question 2

Risk factors for uterine fibroids

Answer 2

Uterine fibroids are common (20% of women)

• Increased age
• Afro-carribean
• FHx

Question 3

Natural history of fibroids

Answer 3

• Oestrogen-dependent
  
  • Enlarge during pregnancy/COCP/HRT
  • Atrophy (+ calcify) after the menopause
• Degenerate due to inadequate blood supply
  
  • Gradually
  • Suddenly (red degeneration)
    
    • Common in pregnancy
    • Characterised by pain and uterine tenderness
• Malignant transformation (rarely)
  
  • Leiomyosarcoma

Question 4

Complications of fibroids

Answer 4

• Significant bleeding, anaemia
• Torsion
• Pregnancy loss
• Labour and delievery
  
  • Premature labour
  • Malpresentations
  • Transverse lie
  • Obstructed labour
  • PPH
• Infertility
• Urinary/bowel problems
  
  • Ureteral obstruction → hydronephrosis
• Malignanct transformation

Question 5

Clinical features of fibroids

Answer 5

• Asymptomatic (50%)
• Menorrhagia
  
  • Heavy or prolonged periods
• Fertility problems
  
  • Submucosal fibroids may interfere with implantation
• Pain
  
  • Dysmenorrhoea
  • Torsion of a pedunculated fibroid
  • ‘Red degeneration’ following thrombosis of the fibroid blood supply
• Mass
  
  • Large fibroids may affect:
    
    • Bladder → frequency
    • Veins → oedematous legs, varicose veins
    • Ureters → urinary retention, hydronephrosis

Question 6

Investigations for fibroids

Answer 6

• Pelvic/abdominal examination (mass)
• Ultrasound
  
  • ‘Whorled’ appearance

Question 7

Management of fibroids

Answer 7

Asymptomatic patients with small/slow-growing fibroids do not require treatment.

Medical treatment

• GnRH agonists
  
  • Induce a temporary menopausal state with amenorrhoea, result in fibroid shrinkage (pre-op utility)
  • Side effects and bone density loss restrict use to 6 months
• Goserelin (LHRH analogue)
  
  • Reversible menopausal state
• Mifepristone (anti-prostaglandin)
  
  • Shrinks fribroids by 50% over 6 months (pre-op utility)

Menorrhagia

• NSAIDs (mefenamic acid)
  
  • Reduce menstrual blood loss and dysmenorrhoea
• Antifibrinolytic agents (tranexamic acid)
• Danazol
  
  • Suppresses gonadotrophin secretion and abolishes cyclical ovarian function
• Mirena intrauterine device
  
  • Significantly decreases bleeding

Surgical treatment

• Hysterectomy
• Myomectomy (preserve fertility)
  
  • Massive blood loss
  • Post-op adhesions (may affect fertility)
• Uterine artery embolisation (UAE)
  
  • Interventional radiology
  • Shrinks fibroids, resolving menorrhagia