6. DETAILED HISTORY & Examination
suspicion of fibroid is raised based on history of HMB, pelvic
mass / palpably enlarged uterus on pelvic and abdominal examination.
pressure symptoms may be present.
7. INVESTIGATIONS
Full Blood count – anemia
Liver and Renal Function tests – based on individual
patient history.
Transvaginal scan- should be preliminary radiological
investigation should be in combination with Abdominal Ultrasonography when
size is more than 12 weeks on abdominal examination.
MRI – Gadolinium enhanced.
greater precison , less interobserver variability
not cost-effective
Hysteroscopy – distinguish between polyps and sub-mucosal fibroids
Endometrial biopsy – in patients aged more than 45 years with hx of
prolonged HMB.
9. Expectant Management
50% fibroids are asymptomatic
No long-term detrimental effects in mere presence of fibroids
(estimated prevalence of leimyosarcoma in presumed fibroid is 0.14%)
Spontaneous regression of fibroids after menopause may be
Preferred in peri-menopausal age group.
10. MEDICAL MANAGEMENT
Objectives of medical management are relief of symptoms and reduction in
size of fibroids.
Non-Hormonal
NSAIDS- pain relief
not beneficial for reduction of heavy menstrual bleeding.
Tranexamic Acid – anti-fibrinolytic used in first line management of HMB
due to fibroid along with NSAIDS.
Hormonal
COCPS – with high dose of estrogen cause fibroid growth
low estrogen content –either no change or reduce size
LNG-IUS - effective for treatment of menorrhagia.
increased risk of expulsion or failed insertion when there is cavity
distortion.
11. GnRH-Analogues
causes amenorrhea and shrinkage in size of fibroids
used as adjunct to surgical treatment to reduce
intraoperative blood loss
shrinkage of fibroid size occurs markedly along with reduction
in vascularity
commenced in mid-luteal phase of ovarian cycle – amenorrhea is secondary to
suppression.
Optimal duration of pre-surgical treatment is 3 months , which will
also correct anemia.
Dosage – Zoladex (Goserelin) 3.6mg by monthly s/c depot injection.
Undesirable Effects :
Rapid rate of recurrence of fibroids after cessation of therapy
menopausal symptoms- vasomotor symptoms,
bone demineralization with prolonged use
13. Surgical Management
Myomectomy
Main indication for myomectomy is a woman with
symptomatic fibroids who wishes to conserve uterus.
Complications of procedure:
Intraoperative blood loss may need hysterectomy in 1-2%
patients.
Post-operative adhesion formation-risk increased with posterior &
multiple uterine incisions.
Risk of entering cavity
14. Hysteroscopic Resection:
Sub-mucosal fibroids are best removed hysteroscopically Type 0 &
Type1 fibroids 3-5cm size.
Resection of fibroid should be combined with endometrial ablation if
woman has completed childbearing.
Can be used to remove lesions upto 7cm size.
15. Uterine Artery Embolisation:
Per-cutaneous , image-guided procedure performed by interventional
radiologist.
Catheter is passed upto both uterine arteries via common femoral artery.
Poly-vinyl alchol is injected to occlude arteries.
Fibroids are supplied by end-arteries so circulation impairs immediately
undergo necrosis.
Treatment efficacy in reducing HMB is 85% & fibroid volume reduces by
Shorter hospital stay as compared to surgical method is an
advantage but patient symptoms are not definitely resolved.
16. Hysterectomy:
Decision should not be undertaken without considering other
treatment alternatives.
Definitive cure for women with heavy menstrual bleeding associated
with fibroids and who have completed family.
Abdominal route preferable for large fibroids , vaginal hysterectomy
can be done after GnRH analogues use.
Abdominal hysterectomy with conservation of ovaries is preferred
when fibroid is large in size.
Laproscopic hysterectomy can be done by morcellation of large
fibroids.
17. Things To Remember
Changes in fibroid during pregnancy
Types of fibroids
Management of cervical fibroid
Indications of hysterectomy in fibroid uterus
