Fibroids

Question 1

What are fibroids?

Answer 1

• benign tumours of the smooth muscle of the uterus
• they are oestrogen sensitive (grow in response to oestrogen)

also called uterine leiomyomas

Question 2

Who is affected by fibroids?

Answer 2

• they are very common and affect 40-60% women in later reproductive years
• they are more common in black women

Question 3

What are the 4 different types of fibroid?

Answer 3

intramural:

• grows within the myometrium (muscle of the uterus)
• can change the shape / distort the uterus

subserosal:

• just below the outer layer of the uterus
• these can become very large and fill the abdominal cavity

submucosal:

• just below the endometrium (lining of the uterus)

pedunculated:

• grows on a stalk

Question 4

What is the most common presenting feature of fibroids?

Answer 4

• they are often asymptomatic
• the most frequent presenting symptom is menorrhagia (heavy menstrual bleeding)

Question 5

What are the other symptoms associated with fibroids?

Answer 5

• prolonged periods (> 7 days)
• deep dyspareunia
• abdominal pain (worse during menstruation)
• bloating / feeling full
• urinary / bowel symptoms (due to pelvic pressure / fullness)
• reduced fertility

Question 6

What examination findings may be present?

Answer 6

abdominal examination:

• may reveal a palpable pelvic mass

bimanual examination:

• may reveal an enlarged firm non-tender uterus

Question 7

What are the initial investigations for fibroids?

Answer 7

• hysteroscopy is the initial investigation for submucosal fibroids presenting with menorrhagia
• pelvic USS is the initial investigation for larger fibroids

Question 8

What type of scan may be performed in fibroids and why?

Answer 8

MRI

• can be performed prior to surgery
• provides more information about the size, shape + blood supply of the fibroids

Question 9

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

Answer 9

• Mirena coil is first line (fibroids must be < 3cm with no distortion of the uterus)
• symptomatic management with NSAIDs + tranexamic acid
• COCP
• cyclical oral progestogens

this is the same as the management for menorrhagia (heavy menstrual bleeding)

Question 10

What are the surgical options for smaller fibroids?

Answer 10

• endometrial ablation
• resection of submucosal fibroids during hysteroscopy
• hysterectomy

Question 11

What is involved in the management of fibroids > 3cm?

Answer 11

• medical management is the same as for smaller fibroids

surgical options:

• uterine artery embolisation
• myomectomy
• hysterectomy

mirena coil may not be appropriate if uterus is distorted / fibroids are too large

Question 12

What medication may be given prior to fibroid surgery and why?

Answer 12

GnRH agonists:

• e.g. goserelin / leuprorelin
• they are given to shrink the fibroids prior to surgery
• they should only be used short-term

• they work by inducing a medical menopause
• this reduces the amount of oestrogen maintaining the fibroid

Question 13

What is involved in uterine artery embolisation?

Answer 13

• a catheter is inserted into the femoral artery
• it is passed through to the uterine artery under XR guidance
• particles are injected to cause a blockage in the arterial supply to the fibroid
• this deprives it of oxygen + causes it to shrink

Question 14

What is involved in myomectomy?

What is the benefit to this procedure?

Answer 14

• the fibroid is surgically removed via laparoscopic surgery or laparotomy
• it is the only treatment known to potentially improve fertility

Question 15

What is involved in endometrial ablation?

Answer 15

• this involves destruction of the endometrium
• usually involves balloon thermal ablation
• a balloon is inserted into the endometrial cavity and filled with high-temperature fluid to burn the lining of the uterus

Question 16

What are the complications associated with fibroids?

Answer 16

• heavy menstrual bleeding (+ IDA)
• reduced fertility
• pregnancy complications (obstructive delivery, miscarriage, premature labour)
• constipation
• urinary outflow obstruction
• red degeneration
• torsion (in pedunculated fibroids)
• malignant change to leiomyosarcoma (very rare)

Question 17

What is red degeneration of the fibroid?

Answer 17

ischaemia, infarction and necrosis of the fibroid due to a disrupted blood supply

Question 18

What is red degeneration often mistaken for?

Answer 18

• it is often mistaken for malignancy
• malignant tumours generally DO NOT arise from benign ones

Question 19

What makes red degeneration more likely?

Answer 19

• more common to occur in large fibroids > 5cm

AND

• during the 2nd / 3rd trimester of pregnancy

Question 20

Why does red degeneration tend to occur in pregnancy?

Answer 20

• the fibroid rapidly enlarges
• this causes it to outgrow its blood supply and become ischaemic
• the uterus changes in shape / expands during pregnancy which may result in kinking of the blood vessels

Question 21

How does red degeneration present?

Answer 21

• severe abdominal pain
• low-grade fever
• tachycardia
• N&V

Question 22

What is the management for red degeneration?

Answer 22

supportive management with rest, analgesia & fluids