Uterine Fibroids

1. Uterine Fibroids Max Brinsmead PhD FRANZCOG January 2010

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

4. Intramural & Submucous Fibroids

5. Subserous Fibroid at Laparoscopy

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 • Heterogenousecholucency 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 pedunculatedsubmucous fibroids

9. Investigating a Submucous Fibroid

10. Investigating a Submucous Fibroid

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