Uterine_Fibroids_Flashcards
What are uterine fibroids?
Uterine fibroids are benign smooth muscle tumors of the uterus, occurring in approximately 20% of white and 50% of black women during their reproductive years.
What are the common associations and when do fibroids typically develop?
Fibroids are more common in Afro-Caribbean women and rarely develop before puberty. They typically arise in response to estrogen.
What are the common symptoms of uterine fibroids?
Symptoms can include being asymptomatic, menorrhagia, iron-deficiency anemia, lower abdominal cramping pains during menstruation, bloating, urinary frequency, and subfertility.
How are uterine fibroids diagnosed?
Uterine fibroids are typically diagnosed using transvaginal ultrasound.
What are the management options for asymptomatic uterine fibroids?
Asymptomatic fibroids usually require no treatment, other than periodic review to monitor size and growth.
How is menorrhagia secondary to fibroids managed?
Management options include levonorgestrel intrauterine system (LNG-IUS), NSAIDs, tranexamic acid, combined oral contraceptive pill, oral and injectable progestogens.
What are the treatment options to shrink or remove fibroids?
Treatment options include medical interventions like GnRH agonists, previously ulipristal acetate, and surgical options like myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.
What are the complications associated with uterine fibroids?
Complications can include subfertility, iron-deficiency anemia, and red degeneration, especially during pregnancy.
What is Fibroid degeneration, how does it present and how is it managed
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
summarise fibroids
Uterine fibroids
Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Associations
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Features
may be asymptomatic
menorrhagia
may result in iron-deficiency anaemia
bulk-related symptoms
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
Diagnosis
transvaginal ultrasound
Management
Asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids
levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
Treatment to shrink/remove fibroids
medical
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity
surgical
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Prognosis and complications
Fibroids generally regress after the menopause.
Some of the complications such as subfertility and iron-deficiency anaemia have been mentioned previously.
Other complications
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
A 36-year-old with menorrhagia is investigated and found to have a 1.5 cm uterine fibroid which is not distorting the uterine cavity. She has three children and wants ongoing contraception, but is using only condoms at the moment. What is the most appropriate initial treatment for her menorrhagia?
Intrauterine system
GnRH agonist
Tranexamic acid
Refer for consideration of a myomectomy
Combined oral contraceptive pill
Intrauterine system
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
Important for meLess important
As the fibroid is less than 3 cm medical treatment can be tried. NICE Clinical Knowledge Summaries recommend an intrauterine system initially, which will also provide contraception.
A 33-year-old female attends your gynaecology clinic. This is a follow up appointment following diagnosis of a symptomatic 4cm intramural fibroid. This problem has been troubling her for a number of months and as such she is being considered for surgery. As she has not yet completed her family, it has been decided that the most appropriate surgical approach would be an open myomectomy. Which of the following is a common complication following this operation?
Cyst formation
Bladder injury
Uterine perforation
Surgical menopause
Adhesions
Adhesions
Adhesions are the most common complication of this operation. Bladder injury and uterine perforation are complications but they are less common. Cyst formation and surgical menopause are not complications.
Please see the following NICE guidelines for further information:
http:cks.nice.org.uk/fibroids#!scenariorecommendation:3
A 30-year-old is experiencing menorrhagia and dysmenorrhoea. This is causing her to miss work and is resulting in significant distress. She does not have any children and does not feel ready to start a family, but would like to in the future.
She has an ultrasound of the pelvis to investigate further. This demonstrates a 2cm intramural fibroid and is otherwise within normal limits.
What is the most appropriate treatment for her symptoms?
Combined oral contraceptive pill (COCP)
Hysterectomy
Hysteroscopic resection of fibroid
Myomectomy
No treatment
Combined oral contraceptive pill (COCP)
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
Combined oral contraceptive pill (COCP) would be the most appropriate answer here. Fibroids under 3cm can be treated with medical management. Other options for medical management include other forms of contraception (e.g. the intrauterine system and oral progesterone) alongside other hormonal methods. In some cases, gonadotropin-releasing hormone agonists, such as goserelin can be used.
Hysterectomy would be inappropriate as this patient would like to try for children in the future. This may be a definitive treatment in patients that do not wish to retain their fertility and have been unsuccessful with other treatments.
Hysteroscopic resection of fibroid would not be recommended here as the fibroid is <3cm in size and does not distort the uterine cavity. This treatment may be recommended for submucosal fibroids in women wishing to retain their fertility.
Myomectomy would not be recommended here before medical therapies (COCP, tranexamic acid, levonorgestrel intrauterine system) have been trialled. It may be an appropriate treatment for larger fibroids.
No treatment would be inappropriate here as the patient is symptomatic.
buzz words
menorrhagia
open myomectomy
cocp
dysmenorrhoea.
intramural, subserosal, submucosal
A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain. The pain came on gradually and has been getting progressively worse for 3 days. She is nauseated and has vomited twice this morning. She has a temperature of 38.4ºC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute. The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler. On speculum examination the cervix is closed and there is no blood. She has a history of menorrhagia due to uterine fibroids. This is her first pregnancy. What is the most likely diagnosis?
Multiple pregnancy
Fibroid degeneration
Inevitable miscarriage
Nausea and vomiting of pregnancy
Heterotropic pregnancy
Fibroid degeneration
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
A multiple pregnancy is possible but should have been detected by this stage and would not explain the raised temperature or abdominal pain. A closed cervical os means this is not an inevitable miscarriage. Heterotropic pregnancy describes a very rare situation in which there are simultaneous ectopic and uterine pregnancies. It is usually treated by surgical removal of the ectopic pregnancy.
