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Fibroids

Definition
Benign tumours of the uterus primarily composed of smooth muscle & fibroids connective tissue
leiomyomata (monoclonal).
- Benign monoclonal growth of myometrium
o Contains collagen
o Surrounded by pseudo-capsule

Epidemiology
Occurs in 20 50% of women >30y.o.
o YOUNGER PATIENTS (Polyps = older patients)
Most common solid tumour of the female pelvis
In ~85% of cases, fibroids occur in multiples

Risk factors/Aetiology
BMI
Advanced maternal age
Black ethnicity
Exposure to sex hormones (e.g. contraceptive, HRT)
Nulliparity
Hypertension
High intake of beef/red meat
Smoking

Pathophysiology
Arise from the myometrial layer of the uterine corpus (intramural)
o Protrudes outward = subserosal
o Protrudes inward = submucous
Symptoms associated with distortion of endometrial lining more common in submucous
Growth accelerates during pregnancy (due to elevated hormones)
Involutes at menopause (decrease in size)
Hormone sensitive
o More hormone = grow faster
Increases in size with pregnancy
o Decreases in size after menoapuse

Classification (by where they appear)


1. Intra-uterine
o Subserosal pedunculated severity depends on location
o Intramural (most common)
o Submucosal/submural (least common) ?can affect backwards
2. Extra-uterine
o Cervical within the cervix
o Broad ligament located between 2 layers of the ligament
o Parasitic (likely pedunculated subserosal leiomyoma that twists off and latches on to
adjacent structures, with neo-vascularisation)
3. Diffuse uterine leiomyomatosis
Subserosal and intramural cause bleeding

Degeneration
- Fibroids may undergo atrophy, internal haemorrhage, fibrosis and calcification.
o This is bad it will be painful!
Types of degeneration:
1. Red degeneration**
Sudden cut of blood supply
Presents with acute abdo pain + localised tenderness over uterus
Risk factors
o Pregnancy
o PCOS
o Hormone supplement (e.g. OCP, HRT)
Due to haemorrhagic infarction

2. Hyaline degeneration (~60%)


Focal or generalised hyalinisation outgrown the blood supply
Outgrow blood supply cystic degeneration

3. Cystic degeneration (~5%)


Fibroid outgrows vascular supply necrosis oedema calcification

4. Myxoid degeneration
Filled with gelatinous material
Appear as complex cystic masses
Can mimic malignant leiomyosarcoma

Signs & symptoms


Commonly asymptomatic
Irregular firm, central pelvic mass
O&G

Abnormal uterine bleed/Abnormal PV bleed (due to distortion of endometrial lining most


common with submucous fibroids)
Heavy periods (menorrhagia)
Intermenstrual bleeding
Infertility
Dyspareunia (if on cervix)
Space-occupying

Recurrent 2nd trimester loss (submucosal)


Obstructed labour
Deep dysmenorrhoea (obstruction of menstrual flow)
Pressure:

Bloating
Pelvic pressure
Urinary frequency/urgency
Urinary & faecal incontinence
Pedunculated submucous fibroids can dilate cervix prolapse into vagina risk of infection
Pain:

Acute or chronic pain 2 degeneration


Menorrhagia
Dysmenorrhoea
Bleed:

Abnormal PV bleed

Bimanual examination
Cobble-stone uterus irregular, hard, palpable mass on the uterus

Diagnosis
Test Findings
Bimanual examination Round firm irregular vagina
BUZZWORD: Cobblestone uterus
Abdominal U/S 1st line Heterogenous hypoechoic masses +/- cystic areas
- Rule out ovarian mass
Calcification (cystic degeneration)
Hysteroscopy Direct visualisation of space-occupying lesions

Laparoscopy + histology Visualisation of irregular protrusion from uterine surface

MRI gold standard For evaluation of atypical cases of pelvic/abdo masses


- Differentiate types of fibroids + exclude other causes

Gross pathology: firm, round, well-circumscribed nodules located either:


o Subserosal (under the uterine serosa)
o Intramural (within myometrium)
o Submucosal (just below the endometrium)
Micropathology: spindle-shaped cells with no mitotic activity or remarkable nuclear atypia

Management (look at growth rate)


Conservative: if fibroids are asymptomatic and not causing any complications, simply monitor for any
changes
Medical (pre-operative adjunct)

Nafarelin (Synarel) (GnRH antagonist) to reduce size of fibroids


o Stops ovulating and shrink fibroids
o High SE: Non-reversible androgenising
Mirena if small fibroids. Not for big fibroids as Mirena wont be retained
Surgical
1st line: hysteroscopic myomectomy/endometrial resection (hysteroscopic or manually)

The only surgical procedure that preserves fertility uterus preserving


Complications
o Risk of future fibroids
o Haemorrhage
o May require hysterectomy
Give GnRH (goserelin) to reduce size of fibroid before surgery
Alternative: UAE (uterine artery embolization)
Gold standard: Hysterectomy

Complications

Recurrent uterine fibroid growth


Woman
o Affects fertility (intra and submucosal types)
o Increased rates of miscarriage
o (Subserosal tends to be okay?)
o Inter-menstrual bleeding
o Pain
Pain on intercourse
o Mass effect if tumour too bigspace occupying
o Urinary and bowel obstruction
Baby
o May affect babys growth
Labour & delivery complications
o PPH
o Malpresentation
o Small fibroids can cause preterm laboru
o Fibroids can block birth canal
Acute torsion
Significant haemorrhage
Anaemia
Degenerative changes