Uterine fibroids Flashcards
Definition
Benign tumours in or around the uterus
AKA: uterine myomas or leiomyomas.
Epidemiology
- 30-50 years
- Black
- Obesity
- Nulliparity: no children
- Early puberty
- FHx
Pathophysiology
They are a mixture of fibroblasts and smooth muscle cells which form hard, round, “whorled” tumours in the myometrium (muscular layer of the uterus).
- Fibroid growth is linked to increased oestrogen and progesterone , therefore less common after menopause.
Locations which fibroids can grow
- Subserosal: between the outer muscular later of the myometrium and overlying serosa.
= Commonly ASx, v.large can press on adjacent structures, e.g. bladder - Intramural (MC): between muscular layers of the myometrium
= Sx: Menorrhagia or dysmenorrhoea. - Submucosal: Between the inner muscular layer of the myometrium and underlying mucosa
= Sx: Menorrhagia, dysmenorrhoea or subfertility; may occur with even small submucosal fibroids.
What is an pedunculated fibroid
Subserosal and submucosal uterine fibroids can grow on a stalk and extend away from the myometrium.
Signs
Pelvic examination:
- firm, enlarged, and irreguarly shaped non-tender uterus (CHARACTERISTIC)
Abdominal examination: a central irregular mass may be found in cases of large fibroids
Symptoms
- Menorrhagia
- Dysmenorrhoea (submucosal and intramural)
- Dyspaerunia
- Intermenstrual bleeding
- Urinary frequency or retention (large subserosal fibroids)
- Bloating or constipation: (large subserosal fibroids)
Diagnosis
FIRST LINE:
- FBC: fibroids can secrete erythropoietin which may cause polycythaemia
GOLD STANDARD: Transvaginal USS:
Consider:
- Hysterectomy
- Laproscopy
Treatment
Asx = no Tx
<3cm = Primary care:
- FIRST LINE: Intrauterine system (IUS): levonorgestrel-releasing coil (e.g. Minera) Cannot be used if there is a distortion of the uterine cavity
- Second line: Tranexamic acid or NSAID
- OR Hormone treatment COCP/Progestogen
When to refer to specialist
- Complications: dyspareunia, constipation or urinary symptoms
- Suspicion of malignancy
- Fertility complications e.g. subfertility
- Fibroids which are palpable abdominally
Non-surgical methods secondary care
- GnRH analogues: e.g. leuprorelin acetate, these agonists prevent FSH/LH release causing a drop in oestrogen/progesterone leading to shrinking of fibroids; short term
- Uterine artery embolization (UAE): injecting small particles into the uterine artery to block supply to the fibroids to relieve symptoms and reduce their size
Surgical methods
- Myomectomy: surgical removal of a fibroid;
- GOLD STANDARD: Hysterectomy: the removal of the uterus = recommended for large fibroids and severe bleeding;
- Hysteroscopic resection or endometrial ablation: usually for patients with submucosal fibroids
Complications
Malignancy
Torsion
Subfertility
Pregnancy complications
Degenerative changes:
- ‘Red degeneration’: necrosis and haemorrhage
- Hyaline degeneration: ASx softening and liquefaction
- Cystic degeneration: ASx central necrosis of the fibroid leaving cystic spaces, can become calcified
Asherman’s syndrome