Fibroids

Question 1

Define Fibroids.

Answer 1

Benign tumours (leiomyomas) arising from myometrium.

• Types:
  
  • Submucosal (within cavity)
  • Intramural
  • Subserosal (can undergo secondary changes)

Question 2

What are the risk factors for Fibroids?

Answer 2

• BONE
  
  • Black women + FHx
  • Obesity
  • Nulliparity
  • Expecting/pregnant

Question 3

What are the protective factors for Fibroids?

Answer 3

• Smoking
• (Grand) multiparity
• COCP

Question 4

What changes do fibroids go through?

Answer 4

• Hormone-dependent - contain lots of oestrogen and progesterone receptors
  
  • Enlarge in pregnancy (due to oestrogen) and shrink in menopause
• Degeneration
  
  • Hyaline degeneration
  • Calcification– post menopausal
  • Red degeneration – coagulative necrosis in pregnancy, cystic change

Question 5

What are the signs and symptoms of fibroids?

Answer 5

• Asymptomatic
• Dysfunction uterine bleeding
• Miscarriage
• Sub-fertility
• Abdominal swelling
• Pressure symptoms on bowel or bladder
• O/E: palpable pelvic masses, uterine enlargement

Question 6

What are the appropriate investigations for suspected fibroids?

Answer 6

• 1st line: TVUSS - if >4mm when not expected, do a hysteroscopy
• 2nd line: OPD hysterocopy
• 3rd line: Laparoscopy ± biopsy
• Bloods - FBC (anaemia), TFTs (hypo), clotting screen

Question 7

What is the management of fibroids <3cm?

Answer 7

• Hormonal contraception
• Bleeding: Tranexamic acid, 1g TDS
• Pain: Mefenamic acid
• Surgical (if severe symptoms):
  
  • Endometrial ablation (will need continued contraception)
  • Hysterectomy

Question 8

What is the management of fibroids >3cm?

Answer 8

• 1st line:
  
  • Tranexamic acid, 1g TDS
  • Mefenamic acid / NSAIDs
  • Hormonal contraception
• Surgical
  
  • Injectable GnRH Agonist (short-term, usually used prior to surgery)
  • Ulipristal Acetate (short-term, selective progesterone receptor modulator)
  • Hysteroscopic (TCRF)
  • Myomectomy - best for improving fertility
  • Hysterectomy
  • Endometrial ablation - removes fertility; must use contraception
• Radiological
  
  • Uterine artery embolisation

Question 9

Why is injectable GnRH agonists and ulipristal acetate used before surgery?

Answer 9

• Shrinks fibroids
• Reduce bleeding
• GnRH agonists induces a menopausal state (shuts down ovarian oestradiol production)

Question 10

What are the complications of fibroids?

Answer 10

• Pregnancy
  
  • Red degeneration
  • Miscarriage
  • Malpresentation/transverse lie
  • PTL
  • PPH
• Prognosis:
  
  • 10-year recurrence rate after myomectomy is 20%
  • Fibroids regress and calcify after menopause
• Leiomyosarcoma (<1 per 100,000):
  
  • Very rare cancer; smooth muscle cancer of the uterus
  • Associated with Gardner’s syndrome (sub-type of FAP with extra-colonic polyps)

Question 11

What are the signs and symptoms of red degeneration of fibroids?

Answer 11

• Low fever
• Pain
• Vomiting

Question 12

What is the management of red degeneration of fibroids?

Answer 12

• Conservative - resolves in 4-7 days