Fibroids Flashcards
What are the proper name of fibroids?
Leiomyomata
What are fibroids?
Benign tumours of the myometrium
What percentage of women have fibroids by age 50?
By age 50, nearly 70% of white women and >80% of black women have at least one fibroid
RFx for fibroids?
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
Factors that make you less likely to have fibroids?
Parous women
Taken OCP
Taken injectable preogesterones
What sizes can fibroids range between?
A few millimetres to huge tumours filling the abdomen
Types of fibroid?
Intramural
Subserosal
Submucosal
(Submucosal can also form intercavity polyps)
What types of tissue make up a fibroid?
Smooth muscle and fibrous tissue
What does a transverse section of a fibroid look like?
A ‘whorled’ appearance of smooth muscle and fibrous tissues
What does fibroid growth depend on?
Oestrogen and progesterone
What is likely to happen to fibroids during pregnancy?
Grow, shrink or show no change
What happens to fibroids after the menopause and why?
Regression due to reduction in circulating sex hormones
What percentage of fibroids are asymptomatic and how are these discovered?
50%, discovered only at physical or US examinatiob
What are Sx related to?
Site rather than size of fibroid
What type of fibroid are most likely to cause Sx?
Intercavity and submucosal
What Sx can fibroids cause?
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
Menstrual Sx caused by fibroids?
Heavy menstrual bleeding in 30% (although timing of menses unchanged)
Intermenstrual loss may occur if fibroid submucosal or polypoid
What pain Sx are caused by fibroids?
Dysmenorrhoea
Seldom cause pain unless; torsion (twisting), red degeneration (haemorrhagic infarction of fibroid) or rarely, sarcomatous (malignancy) change occurs
What is felt on examination?
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
Complications of fibroids?
- Enlargement
- Degenerations
- Malignancy
Enlargement of fibroids?
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
When does ‘degeneration’ occur?
Inadequate blood supply
Types of degeneration?
Red degeneration
Hyaline degeneration
Cystic degeneration
What happens in red degeneration?
Pain and uterine tenderness
Haemorrhage and necrosis occur
What happens in hyaline and cystic degeneration?
Fibroid is soft and partly liquefied
What percent of fibroids are malignant (leiomyosarcomata)?
0.1%
How to diagnose malignancy?
Histology
When should malignancy be expected?
Fibroid growth in postmenopausal women
Rapidly enlarging fibroids
Sudden onset of pain
Problems that can occur in pregnancy?
Premature labour Malpresentations (abnormal presentation in labour) Transverse lie Obstructed labour Postpartum haemorrhage Red degeneration common and cause pain
Should fibroids be removed in a c-section
No as bleeding can be heavy
What should be done when HRT is causing fibroid growth?
Tx as for premenopausal women
Remove HRT
What Ix should be done to establish diagnosis?
- US; determine number, size, and position
- MRI (if diagnosis unclear or greater accuracy required when determining mode of Tx)
- Hysteroscopy, saline transvaginal US or hysterosalpingogram (HSG) is used to assess distortion of uterine cavity, particularly if fertility is an issue
When is Tx required?
When causing Sx
What guides type of Tx chosen?
Desire for fertility
Preservation of uterus
Medical Tx of fibroids?
- Tranexamic acid
- NSAIDs
- Progesterones
(1-3 often ineffective when causing menorrhagia but worth trying 1st line) - Progesterone IUS (but cannot be used when uterine cavity distorted)
- GnRH agnosists
- Selective progesterones receptor modulators (SPRMs)
How do GnRH agonists treat fibroids?
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
Surgical Tx of fibroids?
Hysteroscopic surgery (up to 3cm)
Myomectomy
Radical: hysteroscopy
Problems with myomectomy?
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)
When is myomectomy performed?
Medical Tx failed, but preservation of reproductive function required
What is hysteroscopic surgery?
Done with tools inserted into the uterus via the vagina. Cut and resect areas affected until fibroids removed
Further Tx (not medical or surgical) for fibroids?
Embolisation
Ablation
