Fibroids and Menorrhagia Flashcards
Definition of fibroids
Uterine fibroids (Leiomyomata) are benign tumours which are caused by proliferation of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium (muscle of the womb)
* They can be single, or multiple and their size can vary from a few mm to 30cm or larger
Peak age of incidence of fibroids
Typically develop in women of reproductive age, as their growth and maintenance is thought to be oestrogen and progesterone dependant
* Peak incidence is in their 40s, with a crude incidence of 22.5 per 1000 women-years
* Incidence is likely to be underreported and are often asymptomatic
Descrie the location of fibroids
May develop anywhere in the myometrium:
* Subserosal- Develop near the outer serosal surface of the uterus and extend outside the uterus into the peritoneal cavity (commonly asymptomatic or minimally symptomatic- when large enough they may cause symptoms due to pressure on adjacent surfaces- may be urinary pressure symptoms
* Intramural- Develop within the myometrium without extending into uterine or peritoneal cavities- may cause menorrhagia and dysmenorrhoea by interfering with constriction of blood vessels during menstruation
* Submucosal- Develop near the inner mucosal surface of the uterus and extend into the uterine cavity- even small ones can cause heavy menstrual bleeding, dysmenorrhoea or reduced fertility
* Rarely a pedunculated fibroid on the uterine surface may detach and establish a blood supply from an adjacent organ
Risk factors for developing fibroids
Increasing age (during reproductive years until menopause), early menarche (risk is increased if menarche occurred before age of 11), Nulliparity, Older age at first pregnancy (Fibroids may enlarge during the 1st trimester of pregnancy and shrink thereafter), obesity, HTN, T2DM, ethnicity (risk is higher in black and Asian women), FHx.
Do contraceptives increase the risk of fibroids
There is no evidence that combined hormonal contraceptive (CHCs) increase the risk of fibroids, The progesterone-only injectable and oral pills reduce the risk of fibroids. More pregnancies= lower risk.
Non-obstetric complications of fibroids
- Iron deficiency anaemia- Heavy or abnormal uterine bleeding may occur due to distortion of the endometrial lining by fibroids- leads to endometrial vascular dysfunction
- Compression of adjacent organs by large fibroids, leading to: Recurrent UTI (if pressure was on the bladder), Urinary retention, hydronephrosis
- Subfertility or infertility (rare)- submucosal or deep intramural fibroids may distort the uterine cavity, interfering with implantation and live birth rates
- Torsion of a pedunculated fibroid (rare)
- Hemoperitoneum (rare)- may result from spontaneous rupture of fibroids or an overlying blood vessel
Obstetric complications of fibroids
- Miscarriage
- Fibroid vascular infarction (‘red degeneration’)- may cause acute pain due to degenerative changes when rapid growth of a fibroid, promoted by high levels of sex hormones, causes it to outgrow its blood supply.
- Higher rates of C-section instrumental delivery
- Foetal malpresentation
- Pre-term delivery
‘RED DEGENERATION’ refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply, and commonly occurs in the second and third trimester of pregnancy- can cause severe pain
Should not remove fibroids at C-section due to the risk of heavy bleeding
Presentation of a uterine fibroid
Fibroids are most commonly asymptomatic and may be identified incidentally during a routine pregnancy assessment or gynaecology assessment for a different condition (such as failure to conceive).
Symptoms relate to the site rather than size
Typical symptoms include:
* Heavy menstrual bleeding and/or dysmenorrhoea (IMB- suggests submucosal or polypod)
* Pelvic pain, pressure, or discomfort- dyspareunia
* Abdominal discomfort or bloating, back pain
* Urinary symptoms- frequency, urgency, urinary incontinence/retention, increased risk of developing urinary tract infections (particularly if a large fibroid is causing pressure on the bladder)
* Bowel symptoms- bloating, constipation, painful defecation
* Subfertility or infertility (caused by distortion of the cavity- intramural, or prevention of implantation- submucosal fibroids)
O/E: Typically a firm, enlarged, and irregularly shaped non-tender uterus on pelvic examination. A central irregular abdominal mass- may be moved slightly from side-to-side (knobbly)
Investigations for fibroids
- Important to ask about previous fertility issues and hopes for future fertility + history of cervical screening and results
- Conduct an abdominal and bimanual pelvic examination to assess for the presence of any masses
- Arrange a routine pelvic ultrasound scan (transabdominal and transvaginal if needed)- need to determine the number, size and location of fibroids
- FBC if there is suspicion of anaemia
Differentials for fibroids
- Malignant cause- ovarian, endometrial cancer, rarely leiomyosarcoma (presents with rapid r unexpected growth after menopause), GI or Urinary tract malignancy
- Benign cause- Endometrial polyp or hyperplasia, adenomyosis or endometriosis, urinary retention, pregnancy including ectopic
When should a woman be referred to a specialist with uterine fibroids
- Urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids).
- Using a 2 week wait pathway if she has a pelvic mass associated with any other features of cancer
- To an appropriate specialist if the woman has: an uncertain diagnosis, severe heavy menstrual bleeding or compressive symptoms which cannot be managed in primary care, confirmed fibroids measuring 3cm or more in diameter, suspected associated fertility or obstetric issues
How should asymptomatic women be managed
- Manage conservatively (no treatment or follow-up needed), but SafetyNet
- In some women HRT may increase the size of fibroids and possibly cause symptoms- if HRT is started for menopause, should assess for fibroid Sx at each review
How should symptoatic women with fibroids be managed
May need to manage menorrhagia
Drug treatments:
* NSAIDs, Tranexamic acid (anti-fibrinolytic) and hormonal contraception
* Gonadotrophin-releasing hormone analogues (GnRH analogues) which may be used pre-operatively to treat fibroids which are causing an enlarged or distorted uterus, or in women approaching the menopause- triptorelin
* Induces a menopausal state via overactivation- poorly tolerated due to sx such as hot flushes
Interventional radiology:
* Uterine artery embolization- symptomatic fibroids as an alternative to surgery
* Not suitable if planning family
* Embolization induces infarction and degeneration of fibroids leading to a reduction in fibroid volume of around 50%
* Patients usually require admission to deal with pain
* Complications- fever, infection, fibroid expulsion potential ovarian failure
* 1/3rd of patients require medical, radiological or Ssurgical treatment within 5 years
Surgical treatment:
* Depends on patient preference
* Minimally invasive hysteroscopic surgery can be used to remove submucous fibroids and fibroid polyps
* Myomectomy (fibroidectomy) is preferred if preservation of fertility is required- can be done laparoscopically- small riskof uncontrolled bleeding which will require hysterectomy
* Both hysterectomy and myomectomy can be preceeded by GnRH agonist treatment for 3 months to debulk the fibroid (as well as the vascularity), will also improve symptoms
Definition of menorrhagia (HMB)
Menorrhagia is excessive (heavy) menstrual blood loss that occurs regularly (every 24 to 35 days) which interferes with a woman’s physical, emotional, social and material quality of life, which can occur alone or in combination with other symptoms.
* Classified as 80mL or more and/or a duration of more than 7 days- direct measurement of menstrual blood loss is accurate, but complex to perform in clinical practice (average blood loss during menses is 30-40 mL- 90% of women have blood loss less than 80 mL)
* Also defined as the need to change menstrual products every one or two hours, passage of clots greater than 2.5cm or ‘very heavy’ periods as reported by women
Prevalence of HMB
One of the most common reasons for referral to a gynaecologist
* The prevalence of menorrhagia increases with age, peaking in women aged 30-49 years
* 5% of women aged 30-49 years in the UK seek medical advice for HMB
* 25% of women suffer at least one episode of dysfunctional uterine bleeding during their reproductive age
Causes of HMB
In around 50% of cases, no cause is identified- classified as dysfunctional uterine bleeding
Uterine and ovarian pathologies:
* Uterine fibroids (dysmenorrhoea, pelvic pain) in 10% and 40% with severe menorrhagia (blood loss of 200mL per cycle or more)
* Endometriosis and adenomyosis (dysmenorrhea, dyspareunia, pelvic pain, subfertility)
* PID (vaginal discharge, pelvic pain, intermenstrual and postcoital bleeding, fever),
* Endometrial polyps, endometrial hyperplasia/carcinoma (postcoital and intermenstrual bleeding)
* PCOS
Systemic disorders:
* Coagulation disorders, Hypothyroidism, T2DM, Hyperprolactinaemia, liver or renal disease
Iatrogenic causes:
* intrauterine contraceptive devices
Investigations for HMB
- If the woman has a history of menorrhagia without other related symptoms, consider starting pharmacological treatment without carrying out any physical examination
- If the woman has a history of menorrhagia with other related symptoms, offer a physical examination:
- Check for underlying disease (goitre, bruises or petechiae, acne, hirsutism etc.)
- Abdominal examination- for large fibroids or other masses
- Speculum- for cervical changes, visualisation of polyps/carcinoma, discharge swabs
- Bimanual pelvic examination- except in young girls who are not sexually active (exclude ascites, fibroids, gynae cancer, should be done if considering LNG-IUS)
- FBC in all women- rule out IDA
- Hysteroscopy or USS to assess for cause of menorrhagia (look for polyps, submucosal fibroid etc)
- NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings
- Vaginal or cervical swab, TFTs, Coagulation screen
