Uterine Uterine FibroidsFibroids

Max Brinsmead PhD FRANZCOGMax Brinsmead PhD FRANZCOGJanuary 2010January 2010

Uterine FibroidsUterine Fibroids

Benign tumours (leiomyomata) of Benign tumours (leiomyomata) of uterine smooth muscleuterine smooth muscle

Common – 25% of women in a lifetimeCommon – 25% of women in a lifetime Usually multipleUsually multiple Various sizesVarious sizes Genetic predispositionGenetic predisposition

more common in black racesmore common in black races More common in the obeseMore common in the obese Less common in smokersLess common in smokers More common in nulliparasMore common in nulliparas Accounts for Accounts for ~30% of hysterectomies~30% of hysterectomies

Fibroid LocationsFibroid Locations

SubserousSubserous– Project from the uterus into the peritoneal cavityProject from the uterus into the peritoneal cavity– Sometimes pedunculatedSometimes pedunculated– Least likely to cause symptomsLeast likely to cause symptoms

SubmucousSubmucous ( (~5% of all fibroids)~5% of all fibroids)– Project into the uterine cavityProject into the uterine cavity– Sometimes pedunculatedSometimes pedunculated– Most likely to cause symptomsMost likely to cause symptoms

IntramuralIntramural– Most commonMost common– Usually multipleUsually multiple

Intramural & Submucous Intramural & Submucous FibroidsFibroids

Subserous Fibroid at Subserous Fibroid at LaparoscopyLaparoscopy

Fibroid SymptomsFibroid Symptoms

Mostly asymptomaticMostly asymptomatic MenorrhagiaMenorrhagia

– Heavy regular periodsHeavy regular periods– Iron deficiency anaemiaIron deficiency anaemia

Pressure effectsPressure effects– Urine frequencyUrine frequency– Pelvic tumour awarenessPelvic tumour awareness– Difficulty initiating micturitionDifficulty initiating micturition

Pain, Infertility & Irregular vaginal Pain, Infertility & Irregular vaginal bleedingbleeding– May be due to other pathologyMay be due to other pathology

Fibroids’ Natural Fibroids’ Natural HistoryHistory

Oestrogen-dependent tumours that Oestrogen-dependent tumours that grow slowly:grow slowly:– Whilst cycling premenopausalWhilst cycling premenopausal– Probably whilst on COCProbably whilst on COC– When taking E2 HRTWhen taking E2 HRT

Will regress with menopauseWill regress with menopause Response to progestin-only Response to progestin-only

contraception is uncertaincontraception is uncertain Malignant change rare <1:1000Malignant change rare <1:1000

Investigation of Investigation of FibroidsFibroids

UltrasoundUltrasound– Frequently misdiagnosed with this modalityFrequently misdiagnosed with this modality– ““Multiple small fibroids” is usually irrelevantMultiple small fibroids” is usually irrelevant– Heterogenous echolucency is normal in a parous Heterogenous echolucency is normal in a parous

uterusuterus– Adenomyosis can look the sameAdenomyosis can look the same– Size and location importantSize and location important– Can be a “contraction wave” in pregnancyCan be a “contraction wave” in pregnancy

MRI better than CT ImagingMRI better than CT Imaging Laparoscopy and HysteroscopyLaparoscopy and Hysteroscopy Saline hysterographySaline hysterography

– Useful for pedunculated submucous fibroidsUseful for pedunculated submucous fibroids

Investigating a Submucous Investigating a Submucous FibroidFibroid

Investigating a Submucous Investigating a Submucous FibroidFibroid

Treatment Options for Treatment Options for FibroidsFibroids

HysterectomyHysterectomy– If the uterus is >10w sizeIf the uterus is >10w size– Or symptoms that are due to the fibroidsOr symptoms that are due to the fibroids– Rapid growthRapid growth– Abdominal or vaginalAbdominal or vaginal

MyomectomyMyomectomy– Best for single fibroid in a young womanBest for single fibroid in a young woman– ~50% come to hysterectomy within 5 years?~50% come to hysterectomy within 5 years?

Hysteroscopic resectionHysteroscopic resection Uterine artery embolisation (UAE)Uterine artery embolisation (UAE) Medical optionsMedical options

– GnRH analogueGnRH analogue– MirenaMirena

NICE Recommendations for Uterine NICE Recommendations for Uterine FibroidsFibroids

For patients with heavy menstrual bleeding and For patients with heavy menstrual bleeding and fibroids >3 cm size (and especially those with fibroids >3 cm size (and especially those with pelvic pain or other symptoms) then…pelvic pain or other symptoms) then…– Hysterectomy, Uterine artery embolisation (UAE) and Hysterectomy, Uterine artery embolisation (UAE) and

myomectomy should all be offeredmyomectomy should all be offered– Myomectomy recommended if fertility is desiredMyomectomy recommended if fertility is desired– Hysteroscopic resection of the entire fibroid with Hysteroscopic resection of the entire fibroid with

endometrial resection is appropriate if the fibroid (s) are endometrial resection is appropriate if the fibroid (s) are submucoussubmucous

Pre treatment with GnRH analogue for 3 - 4m is Pre treatment with GnRH analogue for 3 - 4m is worthwhile before hysterectomy and worthwhile before hysterectomy and myomectomymyomectomy– Reduces uterine size and makes surgery easierReduces uterine size and makes surgery easier– Better HB pre op and less bleedingBetter HB pre op and less bleeding

But GnRH analogues are contraindicated But GnRH analogues are contraindicated before UAE before UAE

Fibroids and InfertilityFibroids and Infertility In most women the association is result In most women the association is result

and not causeand not cause It is said that ≈3% of infertility is due to It is said that ≈3% of infertility is due to

fibroidsfibroids Most infertility specialists will Most infertility specialists will

recommend removal of any fibroid with recommend removal of any fibroid with >50% of its surface in the uterine cavity>50% of its surface in the uterine cavity

The results from removal of a single The results from removal of a single submucous fibroid can be dramatic submucous fibroid can be dramatic

And there is evidence that removal of And there is evidence that removal of intramural fibroids >5 cm diam will intramural fibroids >5 cm diam will enhance fertility with IVFenhance fertility with IVF

Fibroids and Fibroids and PregnancyPregnancy

In most women there is no effectIn most women there is no effect 80% remain unchanged in size80% remain unchanged in size Rarely rapid growth and red Rarely rapid growth and red

degenerationdegeneration Increased risk of bleeding and Increased risk of bleeding and

threatened preterm deliverythreatened preterm delivery– But most deliver at termBut most deliver at term

Fibroid in the lower segment can Fibroid in the lower segment can interfere with vaginal birthinterfere with vaginal birth

Myomectomy at the time of Caesarean Myomectomy at the time of Caesarean is not wiseis not wise– 30% require emergency hysterectomy30% require emergency hysterectomy