Fibroids

• Overview:

  • Benign tumours of the smooth muscle of the uterus
  • Also called uterine leiomyomas
  • Very common
  • More common in black women
  • Oestrogen sensitive
• Types:

  • Intramural - within the myometrium - as they grown they distort the uterus
  • Subserosal - just below the outer layer of the uterus - grow outwards and can become very large filling the abdominal cavity
  • Submucosal - just below the endometrium
  • Subserosal and submucosal fibroids can be pedunculated - on a stalk
• Presentation:

  • Often asymptomatic
  • Heavy menstrual bleeding is most common presenting symptom
  • Prolonged menstruation >8 days
  • Abdominal pain, worse during menstruation
  • Bloating or feeling full in the abdomen
  • Urinary or bowel symptoms due to pelvic pressures or fullness
  • Deep dyspareunia
  • Reduced fertility
• Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.
• If it not obvious on exam that a pelvic mass is due to fibroids, refer via 2WW for ovarian cancer
• Main investigation is a pelvic ultrasound - plus transvaginal if needed
• Medical options for less than 3cm fibroids with HMB:

  • 1st line = Mirena coil (must be no distension of the uterus)
  • Symptomatic management with NSAIDs and tranexamic acid
  • Combined oral contraceptive
  • Cyclical oral progestogens
• Surgical options for managing smaller fibroids with heavy menstrual bleeding are:

  • Endometrial ablation
  • Resection of submucosal fibroids during hysteroscopy
  • Hysterectomy
• For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are:

  • Symptomatic management with NSAIDs and tranexamic acid
  • Mirena coil – depending on the size and shape of the fibroids and uterus
  • Combined oral contraceptive
  • Cyclical oral progestogens
• Surgical options for larger fibroids are:

  • Uterine artery embolisation - stops fibroid blood supply
  • Myomectomy - surgically remove fibroid
  • Hysterectomy
• There are several potential complications of fibroids:

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

  • Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
  • More likely in larger fibroids (>5cm) during the second and third trimester of pregnancy
  • Fibroid rapidly enlarges during pregnancy, outgrowing its blood supply
  • Severe abdominal pain
  • Low-grade fever
  • Tachycardia
  • Vomiting
  • Management = supportive with rest, fluids and analgesia
• GnRH analogues (Zolidex)

  • Suppresses ovulation, inducing a temporary menopausal state.
  • Useful pre-operatively to reduce fibroid size and lower complications.
  • Can be used for 6 months only, due to the risk of osteoporosis