What are fibroids?
- fibroids are benign tumours of the smooth muscle of the uterus
- also called uterine leiomyomas
- they are oestrogen senistive meaning they grow in response to oestrogen
Describe the epidemiology of fibroids
- very common affecting 40-60% of women in later reproductive years
- more common in black women
What are the types of fibroids?
- Intramural
- subserosal
- submucosal
- pedunculated
Where are intramural fibroids located?
- within the myometrium (muscle of uterus)
- as they grow they change shape and distort the uterus
Where are subserosal fibroids located?
- just below the outer layer of the uterus
- these grow outwards and can become very large, filling the abdominal cavity
Where are submucosal fibroids located?
-just below the lining of the uterus (endometrium)
Where are pedunculated fibroids located?
-on the stalk
What symptoms can fibroids cause?
- often asymptomatic
- menorrhagia is most frequent symptom
- prolonged menstruation > 7 days
- abdo pain, worse during menstruation
- bloating or feeling full in the abdomen
- urinary or bowel symptoms due to pelvic pressure or fullness
- deep dyspareunia (pain during intercourse)
- reduced fertility
- abdo and bimanual exam may reveal a palpable pelvic mass or an enlarged firm non-tender uterus
What are the investigations for fibroids?
- hysteroscopy is the initial investigation for submucosal presenting with menorrhagia
- pelvic US investigation of choice for larger fibroids
- MRI scanning may be considered before surgery where more info is needed
What does the management of fibroids depend on?
-symptoms and the size of the fibroids
What would be the management for fibroids less than 3cm?
same as menorrhagia:
- Mirena coil (first line) must have no distortion of uterus
- Combined OCP
- symptomatic management with tranexamic acid and NSAIDs
- Cyclical oral progestogens
What are surgical options for small fibroids?
- endometrial ablation
- resection of submucosal fibroids during hysteroscopy
- hysterectomy
What would be the management for fibroids more than than 3cm?
- need referal to gyaenocology
- symptomatic management with tranexamic acid and NSAIDs
- mirena coil - depending on size and shape
- combined OCP
- Cyclical oral progestogens
What are surgical options for large fibroids?
- uterine artery embolisation
- myomectomy
- hysterectomy
What may be used before surgery to reduce the size of fibroids?
GnRH agonists such as goserelin (zoladex) or leuprorelin (Prostap)
What does myomectomy involve?
- Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy
- only known treatment that potentially improves fertility in patients with fibroids
What does hysterectomy involve?
Hysterectomy involves removing the uterus and fibroids.
What are the complications of fibroids?
- Heavy menstrual bleeding, often with iron deficiency anaemia
- Reduced fertility
- Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
- Constipation
- Urinary outflow obstruction and UTIs
- Red degeneration of the fibroid
- Torsion of the fibroid, usually affecting pedunculated fibroids
- Malignant change to a leiomyosarcoma is very rare (<1%)
What does red degeneration of the fibroid involve?
-Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
-more likely to occur in larger fibroids
presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting
-Management is supportive, with rest, fluids and analgesia.
