Uterine Pathologies

Question 1

What would be advised for a woman with a fibroid larger than a 14 week pregnancy, If she wanted to preserve fertility?

Answer 1

Local excision to remove the fibroid

Question 2

When is surgery indicated for fibroids?

Answer 2

Excessively enlarged uterine size
Pressure symptoms
Medical management not controlling symptoms
Submucosal fibroid and fertility reduced

Question 3

When is laparoscopic myomectomy indicated?

What are the benefits of this treatment?

Answer 3

Symptomatic women
Subserous fibroids
Wish to maintain fertility

Less pain
Shorter hospital stay
Reduced recovery time

Question 4

Management of women with asymptomatic fibroids?

Answer 4

No further investigations, unless there is rapid growth or reason to suspect malignancy
Annual follow up to access size and growth

Question 5

Management of women with menorrhagia associated with fibroids?
Fibroids <3cm and no distortion of the uterine cavity

Answer 5

in the following order:

levonorgestrel-releasing intrauterine system (LNG-IUS), provided long term use is anticipated

Tranexamic acid, or NSAIDs, or COCs

Norethisterone daily from days 5-26 (temporary) or long-acting progesterone (injectable)

Question 6

Management of women with menorrhagia associated with fibroids?
Fibroids >3cm and heavy menstrual bleeding

Answer 6

ulipristal acetate 5mg

Question 7

When to refer woman with fibroids?

Answer 7

Symptoms (for example, heavy menstrual bleeding) have not improved despite initial treatments.

• Use of NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within 3 menstrual cycles.

Complications, such as compressive symptoms from large fibroids (for example dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms).

Fertility or obstetric problems associated with fibroids

A clinical or radiological suspicion of malignancy.

Fibroids which are palpable abdominally, or intracavity fibroids and/or whose uterine length is measured at ultrasound, or hysteroscopy, >12 cm.

Question 8

Contraception for women with fibroids?

Answer 8

without distortion of the uterine cavity: all fine

With distortion: barrier, Combined hormonal pill/patch/ring
Progesterone only pill/implant/injection

Question 9

Medical treatment of fibroids

Answer 9

GnRH agonists - shrink, but return to size quickly after stopping. GnRH may be combined with HRT

Mifeprestone - anti progesterone, shrink

Ulipristal acetate - severe, pre-operative