Menstruation and Menstrual Disorders - Fibroids

Question 1

What are Fibroids?

Answer 1

Oestrogen-Sensitive Benign tumours of the smooth muscle of the uterus - a.k.a. uterine leiomyomas.

Question 2

Epidemiology of Fibroids.

Answer 2

1. 40-60% of Women in later Reproductive Years.

2. Commoner in Black Women.

Question 3

Types of Fibroids (4).

Answer 3

1. Intramural - Within Myometrium (growth distorts uterus).
2. Subserosal - Below Outer Layer of Uterus (growth distorts abdomen).
3. Submucsal - Below Endometrium.
4. Pedunculated (Stalk).

Question 4

Clinical Features of Fibroids (7).

Answer 4

1. Asymptomatic.
2. Menorrhagia (Commonest).
3. Prolonged Menstruation.
4. Abdominal Pain (worse during Menstruation).
5. Bloating/Feeling Full in Abdomen/Urinary or Bowel Symptoms.
6. DEEP Dysparenia.
7. Reduced Fertility.

Question 5

What blood findings may be seen in Fibroids?

Answer 5

1. Iron-Deficiency Anaemia.

2. Polycythaemia.

Question 6

Investigations of Fibroids (3).

Answer 6

1. Initial Investigation for Menorrhagia : Hysteroscopy.
2. Larger Fibroids : Pelvic US.
3. MRI Scan : Before Surgery to get details about size, shape and blood supply of fibroids.

Question 7

Clinical Examination of Fibroids (2).

Answer 7

1. Abdomen : Palpable Pelvic Mass.

2. Bimanual : Enlarged Firm Non-Tender Uterus.

Question 8

Management of Fibroids.

Answer 8

1. Asymptomatic - Conservative.
2. Medical.
3. Surgical.

Question 9

Medical Management of Small (Less than 3cm) Fibroids (4).

Answer 9

• same as Menorrhagia :
  1. 1st Line : Mirena Coil (if no uterus distortion).
  2. Symptomatic : NSAIDs and Tranexamic Acid.
  3. COCP.
  4. Cyclical Oral Progestogens.

Question 10

Surgical Management of Small (Less than 3cm) Fibroids (3).

Answer 10

1. Endometrial Ablation.
2. Resection of Submucosal Fibroids during Hysteroscopy.
3. Hysterectomy.

Question 11

Medical Management of Large (More than 3cm) Fibroids.

Answer 11

Same as for Small Fibroids but with Referral to Gynaecology.

Question 12

Surgical Management of Large Fibroids (More than 3cm) (3).

Answer 12

1. Uterine Artery Embolisation.
2. Myomectomy.
3. Hysterectomy.

Question 13

What medications can be used to reduce the size of Fibroids before surgery?

Answer 13

GnRH Agonists induce a menopause-like state ad reduce the amount of Oestrogen that maintains the fibroid.

Question 14

What is Uterine Artery Embolisation?

Answer 14

A surgical option used by interventional radiologists - insert catheter into an artery (usually femoral) to the uterine artery under X-ray guidance to inject particles that cause blockage in arterial supply to fibroid.

Question 15

What is a Myomectomy?

Answer 15

Laparoscopic or Laparatomic surgical removal of the fibroid.

Question 16

Important Consideration of Myomectomy.

Answer 16

Only treatment known to potentially improve fertility in patients with Fibroids.

Question 17

What is Balloon Thermal Ablation?

Answer 17

Second Generation Non-Hysteroscopic Technique : insert a specially designed balloon into the endometrial cavity and filling it with a high-temperature fluid that burns the endometrial lining of the uterus.

Question 18

What is a Hysterectomy?

Answer 18

Laparotomic/Laparoscopic/Vaginal Removal of the Uterus and Fibroids.

Question 19

Complications of Fibroids.

Answer 19

1. Menorrhagia (& IDA).
2. Reduced Fertility.
3. Pregnancy Complications (Miscarriages, Premature Labour, Obstructive Delivery).
4. Constipation.
5. Urinary Outflow Obstruction and UTIs.
6. Red-Degeneration.
7. Torsion of Pedunculated Fibroids.
8. Malignant Change - Leiomyosarcoma.

Question 20

What is Red Degeneration of a Fibroid?

Answer 20

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

Question 21

How does Red Degeneration of a Fibroid present?

Answer 21

1. Severe abdominal pain.
2. Low Grade Fever.
3. Tachycardia.
4. Vomiting.

Question 22

Risk Factors of Red Degeneration of a Fibroid.

Answer 22

Larger Fibroids (5+cm) during Pregnancy’s 2nd/3rd Trimester : fibroid rapidly enlarges to outgrow its blood supply or kinking in blood vessels as the uterus changes shape.

Question 23

Management of Red Degeneration of a Fibroid.

Answer 23

Supportive with Rest, Fluids and Analgesia (4-7 day resolution).