Uterine fibroids

Question 1

Definition

Answer 1

Benign tumours in or around the uterus
AKA: uterine myomas or leiomyomas.

Question 2

Epidemiology

Answer 2

• 30-50 years
• Black
• Obesity
• Nulliparity: no children
• Early puberty
• FHx

Question 3

Pathophysiology

Answer 3

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.

Question 4

Locations which fibroids can grow

Answer 4

• 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.

Question 5

What is an pedunculated fibroid

Answer 5

Subserosal and submucosal uterine fibroids can grow on a stalk and extend away from the myometrium.

Question 6

Signs

Answer 6

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

Question 7

Symptoms

Answer 7

• Menorrhagia
• Dysmenorrhoea (submucosal and intramural)
• Dyspaerunia
• Intermenstrual bleeding
• Urinary frequency or retention (large subserosal fibroids)
• Bloating or constipation: (large subserosal fibroids)

Question 8

Diagnosis

Answer 8

FIRST LINE:
- FBC: fibroids can secrete erythropoietin which may cause polycythaemia
GOLD STANDARD: Transvaginal USS:
Consider:
- Hysterectomy
- Laproscopy

Question 9

Treatment

Answer 9

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

Question 10

When to refer to specialist

Answer 10

• Complications: dyspareunia, constipation or urinary symptoms
• Suspicion of malignancy
• Fertility complications e.g. subfertility
• FIbroids which are palpable abdominally

Question 11

Non-surgical methods secondary care

Answer 11

• 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

Question 12

Surgical methods

Answer 12

• 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

Question 13

Complications

Answer 13

Malignancy
Torsion
Subfertility
Pregnancy complications
‘Red degeneration’
Asherman’s syndrome