Adenomyosis and Leiomyomas

Question 1

What is another term for leiomyomas?

Answer 1

Fibroids

Question 2

What are fibroids?

Answer 2

Benign smooth muscle tumours originating from myometrium of uterus.

Question 3

Aetiology of fibroids?

Answer 3

Exact cause is unknown

Although oestrogen and progesterone appear to promote fibroid growth

Fibroids contain more oestrogen and progesterone receptors than normal uterine muscle cells.

Question 4

Symptoms of fibroids?

Answer 4

• Majority is asymptomatic
• Pressure symptoms +/- abdominal distension (includes urinary frequency or chronic retention).
• Heavy menstrual bleeding
• Subfertility
• Acute pelvic pain (rare)

Question 5

Signs of fibroids?

Answer 5

A solid mass or enlarged uterus may be palpable on abdominal or bimanual examination

Uterus usually non-tender

Question 6

Investigations for fibroids?

Answer 6

Imaging:
- Pelvic US
- MRI (rarely used unless sarcoma is suspected)

Question 7

Medical management of fibroids?

Answer 7

Tranexamic acid (antifibrinolytic)

Mefanamic acid (NSAID)

Hormonal contraceptives (i.e. Mirena coil)

GnRH analogues

Selective progesterone receptor modulators

Question 8

Surgical management of fibroids?

Answer 8

Hysteroscopy and transcervical resection of fibroid (TCRF)

Myomectomy (removal of fibroid)

Uterine artery embolisation

Hysterectomy

Question 9

When is myomectomy (removal of fibroid) offered to patients?

Answer 9

When the fibroid exceeds 3cm in size. Removal of the fibroid through surgery may be offered.

Question 10

What medication can be provided to patients weeks before a myomectomy?

Answer 10

GnRH analogues such as goserelin

Question 11

Why are GnRH analogues such as goserelin given at the interval before myomectomy?

Answer 11

Can be given prior to surgery to manage bleeding in anaemic women as a result of fibroids.

Can also be used to shrink the size of the fibroid, aiding with surgery.

Question 12

What is first line treatment for women with fibroids smaller than 3cm and not causing uterine cavity distortion?

Answer 12

Levonorgestrel-releasing intrauterine system (IUS) is used for first line management in women with fibroids smaller than 3cm not causing uterine distortion.

This only applies if patient is not looking to conceive.

Question 13

What can happen to fibroids in the second and third trimester of pregnancy?

Answer 13

Fibroids are oestrogen sensitive (grow in the presence of oestrogen), therefore in the second and third trimesters of pregnancy, fibroids can rapidly enlarge and outgrow its blood supply.

Can lead to ischaemia and necrosis of the fibroid, this can be known as “red degeneration”.

Question 14

What is adenomyosis?

Answer 14

The presence of functional endometrial tissue within the myometrium of the uterus.

Question 15

Aetiology of adenomyosis?

Answer 15

Thought to occur when endometrium communicates with myometrium follwoing uterine damage. May occur in association with:
- Pregnancy and childbirth
- C-section
- Uterine surgery (e.g. endometrial curettage)
- Surgical management of miscarriage or termination of pregnancy

Question 16

Symptoms of adenomyosis?

Answer 16

Menorrhagia (abnormal heavy menstrual bleeding)

Dysmenorrhoea (painful menstruation, usually involving cramps)

Deep dyspareunia (painful sex)

Irregular bleeding

Question 17

Signs of adenomysosis?

Answer 17

Symmetrically enlarged tender uterus

Question 18

Investigations of adenomyosis?

Answer 18

Definitive diagnosis - biopsy after hysterectomy

Imaging can assist diagnosis - transvaginal US, MRI

Question 19

Management of adenomyosis?

Answer 19

Hysterectomy is only curative therapy

Conservative approaches for symptom management include:
- Combined oral contraceptives
- Progestogens (oral or intrauterine system e.g. Mirena)
- GnRH analogues
- Aromatase inhibitors