Fibroids

Question 1

Fibroid makeup

Answer 1

Mixture of smooth muscle cells and fibroblasts, which form hard, round, worked tumors in the myometrium

Pathophysiology unknown

Question 2

What controls the growth of fibroids?

Answer 2

Oestrogen and progesterone

Question 3

Risk factors for fibroids

Answer 3

Race - black and Asian women
Heredity
Age
Earlier menarche (before age 11)
Nulliparity 
No use of contraception
Obesity
Dietary - alcohol

Question 4

Treatment of fibroids (surgical)

Answer 4

Hysterectomy
Myometrium
Uterine artery embolisation
Myosure/hysteroscopy

Question 5

Medical treatment of fibroids

Answer 5

Mefenatmic acid
TXA
Hormonal treatments
Ulipristal acetate
GNRH-A

Question 6

Risk of leiomysarcoma

Answer 6

2.94:1000 or 1 in 340

Question 7

Symptoms of fibroids

Answer 7

Menorrhagia
Frequent urination
Incomplete emptying of bladder
Pelvic pressure
Constipation
Backache or leg pain
Anaemia
AUB
Dyspaerunia

Question 8

Uterine artery embolisation procedure

Answer 8

IR vascular catheter into common femoral artery to uterine arteries where embolic agent is injected until blood flow to uterine arteries appears sluggish

Question 9

Role of preoperative GnRHa

Answer 9

3-4 month course
Reduces fibroid size and uterine volume - can potentially avoid midline
Improves preoperative haemoglobin levels
Reduces perioperative mood loss and transfusion requirements

Question 10

Effect on fertility

Answer 10

Removal of intricacies component of submucous fibroid improves fertilit
Subserosal fibroids do not affect fertility outcome
Intramural fibroids appear to decrease fertility, particularly those that distort the uterine cavity

Question 11

Ulipristal acetate

Answer 11

Selective. Progesterone receptor modulator that reversible blocs the progesterone receptor in the endometrium and myometrium
Net effect is inhibition of ovulation without significant effects on estradiol levels or glucocorticoid activity

Question 12

Submucous fibroid classification

Answer 12

0 - no intramural extension
1 - <50% intramural extension
2- >50% intramural extension

Question 13

Myosure/hysteroscopies myomectomy

Answer 13

HMB decreases by >80%
Increases fertility by 40-60%
Secondary treatment 2 year 10%, 5 year 30%
Complication rate 1-2%
Additional treatment: endometrial ablation +/- Mirena

Question 14

Abdominal myometomy

Answer 14

80% improvement in AUB
Uncertain if improves fertility over 41
Low conversion rate to hyst (<1%)
Comparable surgical morbidity risk to hysterectomy
Re-treatment rates: 20% over 2-5 years

Question 15

UAE risks

Answer 15

Sloughing tumor into uterine or abdo cavity
Pelvic sepsis
Anaphylaxis to contrast
Bleeding from puncture site
Precipitate menopause (2-8%)
Unable to exclude leiomyosarcoma presence

**can’t do on pedunculated fibroids

Question 16

How fibroids cause AUB

Answer 16

Abnormal uterine vasculatuure, impaired endometrial haemostasis
Dysregulation of angiogenic factors
Increased surface area
Altered uterine contractility

Question 17

Investigations for leiomyosarcoma

Answer 17

MRI

LDH

Question 18

CI to AUE

Answer 18

Asymptomatic fibroids
Preg
PID
Suspected or known uterine malignancy

Relative
Postmenopausal
Want to conceive
Fibroid location submucosal or subserosal with narrow stalk (sterile peritonitis)
Number/size of fibroids

Question 19

Outcomes with UAE

Answer 19

Pressure/bulk related sx ~60%
AUB 70-90%
Pain ~ 80%

Question 20

Indications for myomectomy in infertile women

Answer 20

-women undergoing ART with SM fibroids
Infertile women with symptomatic fibroids (no clear evidence, but symptoms may justify the intervention)
Couples with multiple failed cycles of ART with IM fibroids