2. Uterine Fibroids
Benign tumours (leiomyomata) of uterine
smooth muscle
Common – 25% of women in a lifetime
Usually multiple
Various sizes
Genetic predisposition
more common in black races
More common in the obese
Less common in smokers
More common in nulliparas
Accounts for ~30% of hysterectomies
3. Fibroid Locations
Subserous
– Project from the uterus into the peritoneal cavity
– Sometimes pedunculated
– Least likely to cause symptoms
Submucous (~5% of all fibroids)
– Project into the uterine cavity
– Sometimes pedunculated
– Most likely to cause symptoms
Intramural
– Most common
– Usually multiple
6. Fibroid Symptoms
Mostly asymptomatic
Menorrhagia
– Heavy regular periods
– Iron deficiency anaemia
Pressure effects
– Urine frequency
– Pelvic tumour awareness
– Difficulty initiating micturition
Pain, Infertility & Irregular vaginal bleeding
– May be due to other pathology
7. Fibroids’ Natural History
Oestrogen-dependent tumours that grow
slowly:
– Whilst cycling premenopausal
– Probably whilst on COC
– When taking E2 HRT
Will regress with menopause
Response to progestin-only contraception is
uncertain
Malignant change rare <1:1000
8. Investigation of Fibroids
Ultrasound
– Frequently misdiagnosed with this modality
– “Multiple small fibroids” is usually irrelevant
– Heterogenous echolucency is normal in a parous uterus
– Adenomyosis can look the same
– Size and location important
– Can be a “contraction wave” in pregnancy
MRI better than CT Imaging
Laparoscopy and Hysteroscopy
Saline hysterography
– Useful for pedunculated submucous fibroids
11. Treatment Options for
Fibroids
Hysterectomy
– If the uterus is >10w size
– Or symptoms that are due to the fibroids
– Rapid growth
– Abdominal or vaginal
Myomectomy
– Best for single fibroid in a young woman
– ~50% come to hysterectomy within 5 years?
Hysteroscopic resection
Uterine artery embolisation (UAE)
Medical options
– GnRH analogue
– Mirena
12. NICE Recommendations for Uterine
Fibroids
For patients with heavy menstrual bleeding and
fibroids >3 cm size (and especially those with pelvic
pain or other symptoms) then…
– Hysterectomy, Uterine artery embolisation (UAE) and
myomectomy should all be offered
– Myomectomy recommended if fertility is desired
– Hysteroscopic resection of the entire fibroid with endometrial
resection is appropriate if the fibroid (s) are submucous
Pre treatment with GnRH analogue for 3 - 4m is
worthwhile before hysterectomy and myomectomy
– Reduces uterine size and makes surgery easier
– Better HB pre op and less bleeding
But GnRH analogues are contraindicated
before UAE
13. Fibroids and Infertility
In most women the association is result and
not cause
It is said that ≈3% of infertility is due to
fibroids
Most infertility specialists will recommend
removal of any fibroid with >50% of its
surface in the uterine cavity
The results from removal of a single
submucous fibroid can be dramatic
And there is evidence that removal of
intramural fibroids >5 cm diam will enhance
fertility with IVF
14. Fibroids and Pregnancy
In most women there is no effect
80% remain unchanged in size
Rarely rapid growth and red degeneration
Increased risk of bleeding and threatened
preterm delivery
– But most deliver at term
Fibroid in the lower segment can interfere
with vaginal birth
Myomectomy at the time of Caesarean is
not wise
– 30% require emergency hysterectomy