Uterine fibroids (Complete)

Question 1

Define fibroids

Answer 1

Benign smooth muscle tumors of myometrium of uterus

Question 2

What are the main risk factors for uterine fibroids?

Answer 2

Non-modifiable:

Afro-carribean ethnicity

Increasing age (until menopause)

Question 3

What is the peak incidence of uterine fibroids

Answer 3

40s

N.B. 30-50% of woman have fibroids over age 30

Question 4

What is the pathophysiology of uterine fibroids

Answer 4

Unknown however:

Oestrogen and progesterone promote fibroid growth

Fibroids have more oestrogen and progesterone recpetors than normal uterine muscle cells

Question 5

What are the main signs/symptoms of uterine fibroids?

Answer 5

Menorrhagia (Heavy bleeding)

Lower abdominal pain: (Dysmenorrhoea)
* Cramping
* Occurs during menstruation

Bloating

Infertility (if fibroid large enough to distort uterine cavity)

Increased urinary frequency (Occurs with larger fibroids)

N.B. Can be assymptomatic in many cases

Question 6

What findings on examination are suggestive of uterine fibroids?

Answer 6

Palpable mass on abdominal examination

Question 7

What are the main differentials to consider alongside uterine fibroids?

Answer 7

Endometriosis

Endometrial polyps

Ovarian cancer (due to bloating)

Question 8

How can uterine fibroids be distinguished from endometriosis

Answer 8

Pain:
Fibroids: Pain typically not related to menstrual cycle and constant due to fibroid mass effects
Endometriosis: Pain typically cyclical

Bleeding patterns:
Fibroids: Heavy or prelonged menstrual bleeding, irregular periods
Endometriosis: Possible spotting between periods

Question 9

What investigations should be considered for patients with uterine fibroids?

Answer 9

Bedside:
Basic obs: Check haemodynamically stable

Bloods:
FBC: If worried about anaemia
Iron studies: If worried about anaemia
Ca-125: Rule out ovarian cancer

Imaging:

Transvaginal ultrasound

MRI: If ultrasound does not provide clear enough picture to guide surgery

Biopsy: To rule out potential endometrial cancer

Question 10

What is the management for patients with uterine fibroids who are assymptomatic?

Answer 10

No treatment required, just occasional monitoring of fibroid size and growth

Question 11

What is the general management for symptomatic fibroids?

Answer 11

Medicine:

Menorrhagia: Levonorgestrel-releasing intrauterine system (Mirena)

GnRH agonists: Shrink or remove fibroid

Surgical: To resolve symptoms caused by mass effect

Myomectomy
Ablation
Uterine artery embolisation
Hysterectomy.

Question 12

When is surgical management for uterine fibroids indicated?

Answer 12

May be indicated if fibroids are:

Large

Rapidly growing

Non-responsive to medical treatment

Question 13

What surgical options are available for patients with uterine fibroids (4).

Answer 13

Myomectomy

Hysterectomy

Uterine artery embolisation

Ablation

Question 14

When is Mirena contraindicted for management of menorrhagia?

Answer 14

If patient has uterine distortion

Question 15

What alternative options are available to manage menorrhagia in women with uterine fibroids? (5)

Answer 15

• NSAIDs e.g. mefenamic acid
• Tranexamic acid (anti-fibrotic)
• Combined oral contraceptive pill
• Oral progestogen
• Injectable progestogen

Question 16

Why is it reccomended for GnRH agonsists to be used only for short-term management?

Answer 16

Has side effects such as:

Loss of bone mineral density

Can cause menopausal symptoms

Question 17

When would GnRH agonists be effective?

Answer 17

Effective before possible surgical management to reducen the size of fibroids and alleviate heavy bleeding which could complicate surgery if anaemic

Question 18

Name an example of a GnRH agonist

Answer 18

Goserelin

Question 19

What are some complications of uterine fibroids? (3)

Answer 19

Iron-deficiency anaemia

Subfertility

Red degeneration (aka vascular infarction of fibroid)

Question 20

Red degeneration typically occurs in which patients with uterine fibroids?

Answer 20

Pregnant woman

Question 21

What are the main features of red degeneration? (4)

Answer 21

Severe lower abdominal pain

Low-grade fever

Tacchycardia

Vomitting