Fibroids

Question 1

What are the proper name of fibroids?

Answer 1

Leiomyomata

Question 2

What are fibroids?

Answer 2

Benign tumours of the myometrium

Question 3

What percentage of women have fibroids by age 50?

Answer 3

By age 50, nearly 70% of white women and >80% of black women have at least one fibroid

Question 4

RFx for fibroids?

Answer 4

Increasing age during reproductive years
Black and Asian women (also more likely to have multiple fibroids)
Obese women
Early menarche (before age 11)
Affected 1st degree relative

Question 5

Factors that make you less likely to have fibroids?

Answer 5

Parous women
Taken OCP
Taken injectable preogesterones

Question 6

What sizes can fibroids range between?

Answer 6

A few millimetres to huge tumours filling the abdomen

Question 7

Types of fibroid?

Answer 7

Intramural
Subserosal
Submucosal
(Submucosal can also form intercavity polyps)

Question 8

What types of tissue make up a fibroid?

Answer 8

Smooth muscle and fibrous tissue

Question 9

What does a transverse section of a fibroid look like?

Answer 9

A ‘whorled’ appearance of smooth muscle and fibrous tissues

Question 10

What does fibroid growth depend on?

Answer 10

Oestrogen and progesterone

Question 11

What is likely to happen to fibroids during pregnancy?

Answer 11

Grow, shrink or show no change

Question 12

What happens to fibroids after the menopause and why?

Answer 12

Regression due to reduction in circulating sex hormones

Question 13

What percentage of fibroids are asymptomatic and how are these discovered?

Answer 13

50%, discovered only at physical or US examinatiob

Question 14

What are Sx related to?

Answer 14

Site rather than size of fibroid

Question 15

What type of fibroid are most likely to cause Sx?

Answer 15

Intercavity and submucosal

Question 16

What Sx can fibroids cause?

Answer 16

Menstrual problems (prolonged, heavy periods and intermenstrual bleeds)
Pain
Urinary frequency (or retention) if pressing on bladder
Hydronephrosis if pressing on ureters
Impaired fertility if tubal ostia (opening of Fallopian tubes) blocked or submucosal prevent implantation

Question 17

Menstrual Sx caused by fibroids?

Answer 17

Heavy menstrual bleeding in 30% (although timing of menses unchanged)
Intermenstrual loss may occur if fibroid submucosal or polypoid

Question 18

What pain Sx are caused by fibroids?

Answer 18

Dysmenorrhoea
Seldom cause pain unless; torsion (twisting), red degeneration (haemorrhagic infarction of fibroid) or rarely, sarcomatous (malignancy) change occurs

Question 19

What is felt on examination?

Answer 19

A solid mass may be palpable on pelvic or abdo exam
Will arise from pelvis and be continuous with uterus
Multiple small fibroids can cause irregular ‘knobbly’ enlargement of uterus

Question 20

Complications of fibroids?

Answer 20

1. Enlargement
2. Degenerations
3. Malignancy

Question 21

Enlargement of fibroids?

Answer 21

Very slow
Often stop growing an calcify after menopause
Oestrogen in HRT can stimulate further growth
Can enlarge in mid-pregnancy
Pedunculated fibroids can undergo torsion, causing pain

Question 22

When does ‘degeneration’ occur?

Answer 22

Inadequate blood supply

Question 23

Types of degeneration?

Answer 23

Red degeneration
Hyaline degeneration
Cystic degeneration

Question 24

What happens in red degeneration?

Answer 24

Pain and uterine tenderness

Haemorrhage and necrosis occur

Question 25

What happens in hyaline and cystic degeneration?

Answer 25

Fibroid is soft and partly liquefied

Question 26

What percent of fibroids are malignant (leiomyosarcomata)?

Answer 26

0.1%

Question 27

How to diagnose malignancy?

Answer 27

Histology

Question 28

When should malignancy be expected?

Answer 28

Fibroid growth in postmenopausal women Rapidly enlarging fibroids Sudden onset of pain

Question 29

Problems that can occur in pregnancy?

Answer 29

``` Premature labour Malpresentations (abnormal presentation in labour) Transverse lie Obstructed labour Postpartum haemorrhage Red degeneration common and cause pain ```

Question 30

Should fibroids be removed in a c-section

Answer 30

No as bleeding can be heavy

Question 31

What should be done when HRT is causing fibroid growth?

Answer 31

Tx as for premenopausal women | Remove HRT

Question 32

What Ix should be done to establish diagnosis?

Answer 32

1. US; determine number, size, and position 2. MRI (if diagnosis unclear or greater accuracy required when determining mode of Tx) 3. Hysteroscopy, saline transvaginal US or hysterosalpingogram (HSG) is used to assess distortion of uterine cavity, particularly if fertility is an issue

Question 33

When is Tx required?

Answer 33

When causing Sx

Question 34

What guides type of Tx chosen?

Answer 34

Desire for fertility | Preservation of uterus

Question 35

Medical Tx of fibroids?

Answer 35

1. Tranexamic acid 2. NSAIDs 3. Progesterones (1-3 often ineffective when causing menorrhagia but worth trying 1st line) 4. Progesterone IUS (but cannot be used when uterine cavity distorted) 5. GnRH agnosists 6. Selective progesterones receptor modulators (SPRMs)

Question 36

How do GnRH agonists treat fibroids?

Answer 36

Cause temporary amenorrhoea and fibroid shrinkage by inducing a temporary menopausal state Side effects and and BMD restrict use to only 6 months, so usually used near to menopause or just before surgery to make easier and safer Once GnRH stopped, fibroids will return to initial size Not appropriate for women trying to conceive

Question 37

Surgical Tx of fibroids?

Answer 37

Hysteroscopic surgery (up to 3cm) Myomectomy Radical: hysteroscopy

Question 38

Problems with myomectomy?

Answer 38

Heavy blood loss (risk of blood transfusions, or hysterectomy to save life) Small fibroids can be missed New ones can develop so recurrence of problems Scar tissue or adhesions Pregnancy or childbirth complications (e.g. scar rupture during labour)

Question 39

When is myomectomy performed?

Answer 39

Medical Tx failed, but preservation of reproductive function required

Question 40

What is hysteroscopic surgery?

Answer 40

Done with tools inserted into the uterus via the vagina. Cut and resect areas affected until fibroids removed

Question 41

Further Tx (not medical or surgical) for fibroids?

Answer 41

Embolisation | Ablation