Fibroids

Question 1

What are fibroids?

Answer 1

Benign tumours of the smooth muscle of the uterus.

Also known as uterine leiomyomas

Question 2

What is the incidence of fibroids?

Answer 2

Affect 40-60% in later reproductive years

More common in black women compared to other ethnic groups

Question 3

What are fibroids sensitive to?

Answer 3

Oestrogen

Question 4

Name 4 types of fibroid.

Answer 4

1. Intramural
2. Subserosal
3. Submucosal
4. Pedunculated

Question 5

What is an intramural fibroid?

Answer 5

Lies within the myometrium (the muscle of the uterus).

As they grow, they change the shape and distort the uterus.

Question 6

What is a subserosal fibroid?

Answer 6

Grows just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.

Question 7

What is a submucosal fibroid?

Answer 7

Lies just below the lining of the uterus (the endometrium).

Question 8

What is a pedunculated fibroid?

Answer 8

Fibroid on a stalk.

Question 9

How might fibroids present?

Answer 9

1. Heavy menstrual bleeding (most frequent presenting symptom)
2. Prolonged menstruation (7+ days)
3. Abdominal pain, worse during menstruation
4. Bloating or feeling full in abdomen
5. Urinary or bowel symptom due to pelvic pressure/ fullness
6. Deep dyspareunia
7. Reduced fertility

Question 10

What might abdominal and bimanual examination show in a patient with fibroids?

Answer 10

Palpable pelvic mass or enlarged firm non-tender uterus.

Question 11

When is hysteroscopy used for fibroid investigation?

Answer 11

For initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.

Question 12

When is pelvic ultrasound the investigation of choice?

Answer 12

For larger fibroids.

Question 13

When might MRI scanning be needed when investigating fibroids?

Answer 13

May be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Question 14

What is the medical management of fibroids less than 3cm?

Answer 14

Medical management same as with heavy menstrual bleeding:

1. Mirena coil (1st line)
2. Symptomatic management with NSAIDs and transexamic acid
3. COCP
4. Cyclical oral progestogens

Question 15

In what situations is the mirena coil used for fibroid management?

Answer 15

If they are <3cm with no distortion of the uterus.

Question 16

Name three surgical options for managing smaller fibroids with heavy menstrual bleeding.

Answer 16

1. Endometrial ablation
2. Resection of submucosal fibroids during hysteroscopy
3. Hysterectomy

Question 17

Name three surgical options for managing larger fibroids.

Answer 17

1. Uterine artery embolisation
2. Myomectomy
3. Hysterectomy

Question 18

What can be used to reduce the size of fibroids before surgery?

Answer 18

GnRH agonists e.g. goserelin (Zoladex) or leuprorelin (Prostap).

Question 19

How do GnRH reduce the size of fibroids?

Answer 19

Inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid.

Usually only used in the short term.

Question 20

What is a myomectomy?

Answer 20

Surgical removal of fibroid via laparoscopic surgery or laparotomy.

Question 21

What is the only treatment known to potentially improve fertility in patients with fibroids?

Answer 21

Myomectomy

Question 22

What are potential complications of fibroids?c

Answer 22

1. Heavy menstrual bleeding, often with iron deficiency anaemia
2. Reduced fertility
3. Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
4. Constipation
5. Urinary outflow obstruction and urinary tract infections
6. Red degeneration of the fibroid
7. Torsion of the fibroid, usually affecting pedunculated fibroids
8. Malignant change to a leiomyosarcoma is very rare (<1%)

Question 23

What is red degeneration of a fibroid?

Answer 23

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

Question 24

In what fibroids is red degeneration most likely to occur and when?

Answer 24

Larger fibroids (>5cm) during second and third trimester of pregnancy.

Question 25

Why does red degeneration occur?

Answer 25

Fibroid rapidly enlarges during pregnancy, outgrowing its bloody supply and becoming ischaemic. May also occur due to kinking in blood vessels as the uterus changes shape and expands during pregnancy.

Question 26

How does red degeneration of a fibroid present?

Answer 26

1. Severe abdominal pain 2. Low grade fever 3. Tachycardia 4. Sometimes vomiting

Question 27

How is red degeneration managed?

Answer 27

Supportively, with rest, fluids and analgesia.