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  1. 1. Uterine Fibroids Max Brinsmead PhD FRANZCOG January 2010
  2. 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. 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
  4. 4. Intramural & SubmucousFibroids
  5. 5. Subserous Fibroid atLaparoscopy
  6. 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. 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. 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
  9. 9. Investigating a Submucous Fibroid
  10. 10. Investigating a Submucous Fibroid
  11. 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. 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. 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. 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