What is the risk of sarcomatous change in fibroids?
0.2% or 2/1000 women having surgery for fibroids have sarcoma on histology.
Management of fibroids
Medical (non-hormonal):
- TXA
- NSAIDS / mefanamic acid
Medical (hormonal):
- COCP
- POP
- Depo
- Mirena
- GnRH agonist (max 6 months)
Minimally invasive:
- MRgFUS
- Uterine artery embolisation
- Bipolar radio frequency ablation (hysteroscopic or laparoscopic)
- Laparoscopic or US doppler guided occlusion of uterine artery
Surgical (uterine preserving):
- Myosure/hysteroscopic resection
- Laparoscopic resection
- Myomectomy
Surgical (non-uterine preserving):
- Hysterectomy
NB. most of the “minimally invasive” category are still being assessed for their effects on fertility, and should not be considered first-line for women wishing to preserve fertility as we don’t yet know if they improve or reduce fertility rates
Pros and cons of uterine preserving management?
pros:
- Maintain fertility
- Usually less invasive with faster recovery
- Effective for managing symptoms of fibroids
Cons:
- 20-30% patients will require further treatment within 2 years due to recurrence of fibroids
Is there evidence to support myomectomy prior to fertility treatment?
- Removal of the intracavity portion of fibroid improves fertility (RR 1.72)
- Subserosal fibroids have no effect on fertility
- Intramural fibroids affect fertility, particularly if they distort the cavity - but no evidence that their removal improves live brith rates, and potential operative risk of requiring hysterectomy
What are the classification systems for submucosal fibroids?
ESGE and FIGO
0 - pedunculated
1 - < 50% in myometrium
2 - >50% in myometrium
How does Ullipristal acetate work?
NB. NO longer used due to concerns for liver failure in prolonged use!
- It is a selective progesterone receptor modulator (SPRM)
- reversibly blocks progesterone receptor in endometrium and myometrium, and inhibits ovulation whilst having little effect on steroid synthesis and circulating oestrogen levels
- It reduces the size of fibroids and improves bleeding - effects comparable to GnRH analogues, but better tolerated and less associated with problematic hot flashes
- It can be taken prior to surgery or on its own
- Dose 5mg OD for up to 3 months ; maximum 4 cycles (the most cycles assessed during studies)
What are the quoted outcomes for hysteroscopic resection of fibroids?
- 80% reduction in bleeding
- 40-60% improvement in fertility
- 1-2% risk of perforation
- 1% risk of severe hyponatremia (suspect if >1L glycine or >2L normal saline deficit)
- infection, bleeding etc
- 10% require retreatment within 2 years, 30% require retreatment within 5 years
Outcomes after myomectomy?
- 80% reduction in bleeding
- Effective reduction in uterine size and pressure symptoms
- If over 41 years, effect on fertility is not proven
- <1% risk hysterectomy
- 20-30% require pretreatment within 2-5 years
- Risks and recovery comparable to hysterectomy
How is UAE done?
What are the contraindications?
- Radiologically guided procedure
- Local anaesthetic and sedation
- Access via femoral artery to catheterise uterine artery
- Occlusive particles (polyvinyl) injected to uterine artery, causing occlusion and necrosis of fibroids
Contraindications:
- pelvic infection
- Pelvic malignancy
Relative:
- Pedunculated fibroids - can slough off and cause necrosis and infection within peritoneal cavity or uterine cavity
- SM fibroids (as above)
- Post-menopausal
- Recent GnRH analogue use
- previous UAE
What are the risks and benefits of UAE?
Benefits:
- 80-90% women report reduction in bleeding
- reduction in size
- uterus preserving, but effect on fertility unclear
- Minimally invasive
- Day case with quick recovery
Risks:
Early
- pain
- Allergy or ADR to contrast
- haematoma or bleeding at entry site
- Other organ embolisation (most commonly vagina causing pain and sexual dysfunction, or ovary causing menopause)
- Pulmonary embolism
- Post embolisation syndrome (low grade fever, pain, fatigue N&V - peaks 48hr post procedure)
- Pelvic abscess or endometritis +/- sepsis
- Expulsion of necrotic fibroid or prolonged foul smelling discharge
- 5% require hysterectomy within first month due to treatment complications or failure
Late:
- 2-8% risk of precipitate menopause due to premature ovarian failure
- 35% require hysterectomy at 10 years for treatment failure
What are the key findings of the EMMY trial?
- 5% UAE patients required hysterectomy in first month due to complications or failure
- 35% UAE patients required hysterectomy within 10 years
- 65% were saved a hysterectomy
- High rate of reintervention in the UAE group negated any cost benefit of Use over hysterectomy
Would you recommend UAE or myomectomy for someone wanting to preserve fertility? And why?
Myomectomy.
- Significantly higher live birth rates
- Lower risk of recurrent miscarriage
- UAE 2-8% risk precipitate menopause (AFC and AMH significantly reduced at 3 months; in age <40 it usually recovers, but frequently doesn’t if > 40 yo)
- Risk of devacularising myometrium and endometrium affecting implantation
- Other obstetric and perinatal outcomes comparable between both groups
What are the risks/complications of fibroids?
obstetric - infertility, miscarriage, abdominal pain (red degeneration of fibroids midtrimester), preterm labour, malpresentation, caesarean delivery, postpartum haemorrhage
Hyaline degeneration is relatively common and presents as painful enlarged fibroids due to hyaline/cystic degeneration pathological process. Red degeneration (necrobiosis) occurs typically during pregnancy due to infarction at mid-pregnancy. Calcification (‘womb stone’) - usually in postmenopausal women, occurs as the end point of degeneration. Sarcomatous (malignant) change. Generally presents as a 0.2% risk. There is a greater risk in women with multiple or rapidly growing fibroids, postmenopausal status, retinoblastoma gene, increasing size despite UAE
Infection (abscess) - relatively rare.
Torsion of pedunculated fibroids.
What is the prevalence of fibroids?
70-80% by 50 yo
Increases with increasing age towards the menopause.
What are the risk factors for fibroids?
Black African - Caribbean ethnicities at highest risk - 2-3 fold increased risk
Increasing age (till menopause)
premenopausal status
family hx
time since last birth
consumption of soy bean products and food additives
What are protective factors against fibroids?
multi parity,
smoking if low BMI,
COCP or depo use.
Histology of fibroids.
comprise uterine smooth muscle cells and fibroblasts. They contain a large amount of extracellular matrix (including collagen, proteoglycan, fibronectin) and are surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers.
What are the key consideration when deciding management for fibroids?
- Wanting to maintain fertility
- Wanting to maintain uterus
- Size: uterus >20wk, multiple fibroid >5cm - will likely require hysterectomy for successful treatment
- Previous surgeries / BMI / medical co-morbidities
- Previous treatments for fibroids ??effective
- Risk of further surgery requirement - <1% open myomectomy converts to TAH, up to 5% UAE needs early surgical intervention for complications, with 35% surgical intervention for failure at 10 years
What is the role of GnRH agonists in fibroid management?
- Can be used up to 6 months as a second line hormonal medical management - not a long term option
- Can be used for 3-4 months preopertaively to improve surgical outcomes
What are the benefits of GnRH pretreatment prior to surgery for fibroids?
- Increase Hb pre-operatively
- Reduce uterine size - can mean pfannenstiel rather than midline, or laparoscopic procedure
- Reduce operative blood loss
What increases the risk/suspicion for sarcomatous change?
- There is a greater risk in women with multiple or rapidly growing fibroids, postmenopausal status, retinoblastoma gene, increasing size despite UAE
What is the FIGO Leiomyoma Subclassification System?
Submucous SM (0-2) vs Other O (4-8) 0 - Pedunculated intracavity 1 - <50% intramural 2 - >/=50% intramural 3 - Contacts endometrium, 100% intramura 4 - Intramural 5 - Subserous >/= 50% intramura 6 - Subserous < 50% intramural 7 - Subserous pedunculated 8 - Other (specify, e.g. cervical)
Which fibroids are associated with reduced fertility and increased miscarriage rate?
Submucosal ARE Intramural MAY be Subserosal are NOT
What are three indications for myomectomy in infertile women?
- Infertile women and those undergoing ART who have SM fibroids 2. Infertile women with symptomatic fibroids 3. Couple presenting with multiple failed cycles of ART where the female partner has IM fibroids
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Endometrial hyperplasia22
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Fibroids36
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VWD and clotting disorders3
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Hirsuitism12
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PCOS42
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Hyperprolactinaemia7
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Endometriosis and adenomyosis98
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Ovarian torsion10
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Ovarian cysts in premenopausal women25
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Ovarian cysts in postmenopausal women25
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RANZCOG questions on ovarian cysts25
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Contraception79
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PMS25
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Endometrial polyps10
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Menstrual Disorders (HMB, AUB)39
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Benign vulval pathology42
