Fibroids Flashcards
What are fibroids
Benign tumours arising from the myometrium of the uterus.
Types of fibroids
- Subserosal
- Intramural
- Submucosal
- Pedunculated
What is submucosal fibroid
develop near the outer serosal surface of the uterus and extend into the peritoneal cavity.
symptoms of Subserosal fibroids
Asymptomatic; may cause pressure symptoms.
What is Intramural fibroids
fibroids develop within the myometrium
symptoms of intramural fibroids
May cause HMB, dysmenorrhoea
Symptoms of submucosal fibroids
May cause HMB, pain, and subfertility.
What are submucosal fibroid
develop near the endometrial surface of the uterus and extend into the uterine cavity
What are pedunculate fibroids
attached to the myometrium by a pedicle. May cause torsion
History (symptoms and signs) of Fibroids
- Symptoms depend on the size, number, and location of the fibroids
- Heavy & prolonged bleeding (most common)
- Abdominal swelling, pelvic or abdominal pain or discomfort.
- Dyspareunia.
- Pressure symptoms – constipation or urinary symptoms such as
frequency or difficulty in voiding. - Acute, severe abdominal or pelvic pain following torsion of a pedunculated fibroid or ‘red degeneration’.
- Subfertility, miscarriage.
Abdominal examination in case of fibroids
mass arising from the pelvis, smooth/multi-nodular, firm, mobile from side-to-side.
Pelvic examination in case of fibroids
- mass arising out of the pelvis, with an irregular knobbly shape, a firm or hard consistency, and can be moved slightly from side-to- side.
- Any movement of the abdominal mass moves the cervix
Prevalence of fibroids
Prevalence increases progressively from puberty until the menopause.
- 40–60% of women have fibroids by 35 years of age.
- which is increased to 70–80% by 49 years of age.
Do fibroids resolve with age
Usually shrink after menopause as they are promoted and maintained by oestrogen and progestogen.
Prevalence of fibroids is higher in which groups?
- Black women
- Women with early onset of puberty.
- Obese women – probably due to higher oestrogen levels.
Gynecological risks due to fibroids
- HBM – anaemia, affects QOL.
- Compression of ureters by large fibroids - hydronephrosis.
- Torsion of pedunculated fibroid – acute pain.
- Leiomyosarcoma – minimal risk.
- Fertility issues
Pregnancy complications due to fibroids
- 1st and 2nd trimester miscarriage.
- Higher rates of CS
- Preterm delivery.
- Malpresentation, mechanical complications in labour.
- PPH.
- Acute pain requiring hospital admission (5–6%) – red degeneration of
fibroid owing to avascular necrosis (when rapid growth of a fibroid, promoted by high levels of sex hormones, outgrows its blood supply).
DD of fibroids
- Adenomyosis: difficult to distinguish from fibroids may be associated with it
- Pregnancy
- Benign causes of a pelvic mass: benign ovarian mass –
hemorrhagic cyst, dermoid cyst, or endometrioma. - Malignant causes of a pelvic mass: ovarian cancer,
endometrial cancer, leiomyosarcoma
Investigations for diagnosis of Fibroids
- USS
- Saline or contrast sonographyL improves assessment of SM fibroids
- 3D USS
- MRI: superior to conventional US
when to refer asymptomatic fibroids to 2ry care
- Fibroids are palpable abdominally.
- Intra-cavity fibroids.
- Uterine length on USS>12 cm.
Do we advise hysterectomy for asymptomatic fibroids
Do not advise hysterectomy for asymptomatic fibroids solely to improve detection of adnexal masses, to prevent impairment of renal function, or to rule out malignancy
Medical management of symptomatic fibroids
- NSAIDs
- Contraceptive steroids (COCs)
- LNG-IUS
- Anti-Progesterone agents (mifepristone)
- Aromatase Inhibitors
- GNRH agonists
How do fibroids cause HMB ?
- Mass effect causing increased surface area
- Interferes with uterine contractility
- Increased vascularity
- Altered prostaglandin production
FIGO classification for fibroids ?
submucosal
0 submucosal
1- <50% intramural
2 ->50% intra mural
OTHERs
3- contacts endometrium but is intramural
4-intramural
5-subserosal but> 50% intra mural
6- subserosal <50% intramural
7-oendunculated
STEPW
Routes for myomectomy ?
- Hysteroscopic
- Abdominal - Open, Lap, Robotic
- Hysteroscopic for submucosal - 0,1
- Rest - Abdominal route
(fibroids) When is the risk of malignancy higher ? and how to minimize risk of malignancy spreading
Postmenopausal
Premenopausal - if solitary large lesion not responding to GnrH or ulipristal
1 in 2000
Avoid morcellation. If done - use bags for removal
Disadvantage of using Gnrh prior to myomectomy?
Loss of surgical planes
Which is better in ttt of fibroids Total or subtotal hysterectomy?
Total obviates the need for further surgery as it removes the cervix
Subtotal associated with lesser morbidity and faster recovery
So let the patient decide
How do we decide the route of hysterectomy in ttt of fibroids
Abdominal preferred if no prolapse or associated pelvic pathology - adnexal mass, adhesions, endometriosis
Vaginal - preferred in presence of prolapse
In Abdominal - Lap preferred
Overall complication rate of hysterectomy?
4%
Hysterectomy accounts for what portion of genitourinary tract injury ?
75%
1-2% is the rate for all gynaecological procedures combined
Of these, 75% due to hysterectomy
Injury to GI tract during hysterectomy?
0.1-1%
Vaginal cuff dehiscence most common after which procedure?
TLH
Urinary tract injury more common after which procedure?
TLH
Out of ablation and hysterectomy
More likely to undergo future gynecological surgery in terms of repeat procedure?
More likely to have surgery for incontinence, prolapse ?
Ablation - more common on the 1st 2 years
Hysterectomy- more likely to undergo surgery for prolapse, Incontinence
Mode of action of anti progesterone
Mifepristone acts at the level of the progesterone receptors,
found in high concentration in fibroids.
effect of anti-progesterone on fibroids
-Reduction in fibroid volume of 26–74% (comparable to GnRHa, slower rate of recurrent growth after cessation of mifepristone treatment).
- amenorrhoea rates up to 90%
- stable bone mineral density.
SE of Anti-progesterone
- endometrial hyperplasia without atypia (14–28%)
- transient elevations in transaminase levels (4%) requiring LFT monitoring.
Mode of action of Aromatase inhibitors in ttt of fibroids
Aromatase inhibitors block ovarian and peripheral oestrogen production and decrease oestradiol levels.
Small studies showed reduction in leiomyoma size and symptoms.
efficacy of GNRHa in ttt fibroids
35–65% reduction in fibroid volume within 3 months.
Preoperative use of GNRHa in ttt of fibroids
Preoperative in women with anaemia and to reduce the size of fibroids and blood loss during surgery.
no significant difference in blood loss with preop. GnRHa has shown
Sequential regimen of GNRHa in ttt of fibroids
- GnRHa is first used to achieve downregulation
- to which steroids are added after 1–3 months of therapy, gives maximal results.
- However, the addition of progestin add-back therapy results in an increase in mean uterine volume to 95% of baseline within 24 months.
Disadvantages of use of preoperative GNRHa
it may make the fibroids softer and the surgical planes less distinct, leading to difficulty in dissection.
GNRH antagonist effect in ttt of fibroids
- advantage of not inducing an initial steroidal flare as seen with GnRH agonists.
- Rapid effect of the GnRH antagonist
allows a shorter duration of side effects with pre-surgical treatment. - Reduce fibroid volume by 25–40% in 19 days, thereby allowing surgery to be scheduled sooner
interventions to reduce blood loss during myomectomy
evidence from a few RCTs is limited: misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, tourniquet, and mesna may reduce bleeding during myomectomy.
Surgical management of fibroids
- hysterectomy
- myomectomy (abd., laparoscopic, hysteroscopic)
- UAE
Advantages of hysterectomy in ttt of fibroids
- Relieves symptoms
- prevents recurrence
- provides permanent contraception
- allows treatment with oestrogen-only HRT.
Risks of Abdominal myomectomy
hysterectomy
blood loss
risk of transfusion
adhesions.
Rate pf recurrence of fibroids after abd myomectomy
depends on the number of fibroids;
single leiomyoma – 27% risk
multiple leiomyomas – 59% risk.
** preoperative use of GnRH agonists affects recurrence risk.**
Advantages of laparoscopic myomectomy over abdominal
- less haemoglobin drop
- reduced operative blood loss
- quicker recovery, diminished postoperative pain
- fewer overall complications but longer operation time.
Cautions during Patient selection to laparoscopic myomectomy
be cautious if:
- fibroids > 5–8 cm
- multiple fibroids
- or presence of deep IM leiomyomas
as it may be associated with increased operative time and blood loss.
Recurrence rate pf fibroids after laparoscopic myomectomy
- 12% at 1 year
- up to 84% at 8 years.
Conversion rate of laparoscopic to abdominal myomectomy
11%
Rate of complication of laparoscopic myomectomy
8-11%
Indications for hysteroscopic myomectomy
abnormal uterine bleeding caused by SM fibroids.
Classification for hysteroscopic myomectomy
Classified based on the amount of leiomyoma within the uterine cavity:
* Type 0 – completely intra-cavitary.
* Type I – < 50% intramural.
* Type II – > 50% intramural.
Rate of Successful removal at the initial hysteroscopy myomectomy
85–95%
Rate of subsequent surgery after hysteroscopic myomectomy
Subsequent surgery is needed in ≈ 5–15% of cases,
and most of these cases involve a second hysteroscopic procedure.
Complications of hysteroscopic myomectomy
Complication rate of 1–5%
* fluid overload with secondary hyponatraemia
* pulmonary oedema
* cerebral oedema
* intraoperative and postoperative bleeding
* uterine perforation
* gas embolism
*infection.
How is UAE is done?
Femoral artery is cannulated and an embolic agent is injected into the uterine arteries to impair the blood supply to the uterus and fibroids.
This has a differential effect on f ibroids (that have a higher blood supply than the surrounding myometrium).
Effect of UAE on fibroids
Fibroid shrinkage – 60% by the end of 6 months with further shrinkage up to one year.
Indications for UAE
- surgery is CI.
- unwilling to have a blood transfusion.
- previous unsuccessful surgery for fibroids.
Absolute CI for UAE in case of fibroids
- Current or recent infection of genital tract.
- Patient refusing hysterectomy under any circumstances.
- Doubtful diagnosis due to the clinical factors or inadequate imaging.
UAE has more benefits in ttt of large or small fibroids
the outcome for smaller fibroids is better than for larger fibroids with similar complication rates.
Large fibroid is not a contraindication.
However, volume reduction might not be sufficient to satisfy patient’s expectations.
Pre-requisites begore UAE
Do not give GnRHa within 2 months prior to the procedure
Which is better in diagnosing fibroids and adnemyosis MRI or USS
MRI is superior
Action of UAE on Fibroids in presence of adenomyosis
Less effective
Immediate complications of UAE
- Groin Hematoma
- Arterial thrombosis
- Pseudo-aneurysm
- Non-target embolization (presence of ovarian–uterine anastomoses can compromise the ovary.)
Early complications of UAE
- post-embolization syndrome: pain, nausea, fever, flu-like symptoms with raised inflammatory markers and white cell count.
frequent and self-limiting
Management of post-embolization syndrome
- Frequent and self-limiting.
- Manage with analgesics and anti-inflammatory drugs.
- Re-admission may be required in 3–5% of cases.
Late complications of UAE
- Vaginal discharge (self-limiting) – 20–30%.
- Fibroid expulsion – 10%, more w/ SM
- Sexual dysfunction – 12%
- Infection (endometritis) – 0.5%.
- Amenorrhoea (POI) – 1.5–7%, but the majority of these patients are > 45 years old (25% risk in this age group)
Precentage of further treatment of fibroids after UAE
- repeat UAE
- exploration of uterine cavity
- myomectomy
- hysterectomy
* 25% if < 40 years
* 10% if 40–50 years of ag
What kind of contraception to be used in case of fibroids
- W/o no uterine distortion: all methods can be used
- W/ distortion: not IUD or IUS if can’t be fitted easily
not clear if hormonal methods has any effect on size of fibroids
Clinical sign to Leiomyosarcoma
rapid growth in uterine size
Incidence of leiomysarcoma
rare 2-3/1000
Risk factors for sacrcomas
- Increasing age
- a history of prior pelvic radiation
- tamoxifen use
- a rare genetic predisposition.
How to differentiate between sarcomas and other intrauterine lesions
MRI and Endometrial Biopsy
Do Fibroids do absolute subfertility?
no, many women can concieve w/o interventions
How can fbroids cause subfertility
- mechanical effect due to cavity distortion with IM and SM fibroids
- possible effect on uterine blood flow
- impaired implantation with IM fibroids.
rate of fibroids presence in women w/ infertility
5–10% of women with infertility
fibroids are the sole factor in 1–2.4% of women with infertility.
IVF outcome in women with fibroids
- SM/IM fibroids distorting the uterine cavity cause a 70% reduction in pregnancy
- Removal of these fibroids
restores the pregnancy rate to that of the control group.
Management of subfertility due to fiborids
- Try naturally for 2 years, unless the woman is ≥ 34 years
- SM fibroids: hysteroscopic resection.
- Myomectomy: consider for a woman with fibroids who has undergone unsuccessful IVF cycles despite appropriate ovarian response and
good quality embryos. - UAE: has not effect on pregnancy outcome after IVF
SBA
What proportion of women using ulipristal acetate will develop Progesterone receptor modulator associated endometral changes PAEC?
- 60%
- up to 2/3 of women using it
- resolve after 6 months of discontinuation
SBA
Most common benign tumor in females
Uterine Leiomyoma
prevelance= 30%
