Fibroid (Leiomyoma)

Table of content

• 1. Definition

• 2. Incidence

• 3. FIGO Classification

• 4. Complications

• 5. Investigations

• 6. Treatment

• 7. Reference

Fibroid

Definition:

•Fibroids are smooth muscle tumours of the uterus, usually benign but they can have malignant transformations in >1% resulting in leiomyosarcoma

Incidence:

•20-40% of women in reproductive age
•5% to 10% of women presenting with infertility
•Present in 70% of uterus removed at hysterectomy
•Increased incidence in Afro-Caribbean women
•Decreased incidence with prolonged use of combined oral contraceptives
•Decreased incidence with increasing number of term pregnancies
•It has not been identified in pre-pubertal girls and usually shrinks at the time of menopause

Classification
They are classified as Sub-serosal, Intramural and Submucosal

FIGO Classification

Clinical features

• 50% of fibroids are asymptomatic
• Heavy Menstrual Bleeding
• Anaemia
• Dysmenorrhea
• Dragging and pressure symptoms in the pelvis
• Abdominal swelling
• Urinary frequency and retention
• Bowel problems
• Subfertility-Difficulty in conceiving, pregnancy loss, intrapartum bleeding e.g. during Caesarean section

Complications

• Hyaline degeneration (Painful)
• Red degeneration necrobiosis-occurs during pregnancy due to infarction at mid pregnancy
• Calcification (Womb stone)- usually in postmenopausal women
• Sarcomatous malignant change-0.2% risk, greater risk in women with multiple or rapidly growing fibroid at advanced age
• Infection/abscess-relatively rare
• Torsion of pedunculated fibroid

Investigations

• A large fibroid uterus can often be palpated as a firm pelvic mass.
• The ideal first-line investigation is pelvic ultrasound (transvaginal and transabdominal),
• MRI is useful when planning surgery or as a baseline prior to uterine artery embolisation (UAE)

Treatment

Individualise treatment based on size of fibroid/uterus, fertility desire, patient’s desire to preserve uterus, general medical health, age, Body mass index, previous surgery, previous fibroid treatment, risk and benefit of treatment

Types of treatment

• GnRH agonist
• Selective reversible progesterone modulator
• Levonorgestrel secreting intrauterine system
• Uterine artery embolisation
• Hysteroscopic myomectomy
• Laparoscopic myomectomy
• Abdominal myomectomy
• Hysterectomy
• Uterine artery embolisation
• Magnetic resonance imaging focused ultrasound ablation of uterine fibroid
• Bipolar radiofrequency ablation

Seeking contraception

• 1st step – COC, oral/injected/IUS progestogens, short course of GnRHa
• 2nd step – hysteroscopic myomectomy +/- ablation +/- Mirena IUS. Additional minimally invasive uterus-conserving treatment; UAE, MR focused ultrasonography, laparoscopic uterine artery occlusion and bipolar radiofrequency ablation
• 3rd step – hysterectomy +/- bilateral salpingo-ophrectomy.

Wishing to conceive:

• 1st step – tranexamic acid/NSAIDs
• 2nd step – hysteroscopic myomectomy, laparoscopic myomectomy. Additional minimally invasive uterus-conserving treatments as above
• 3rd step – abdominal myomectomy.

Medical treatment

• GnRH agonist-Causes postmenopausal symptoms and hot flushes. When used prior to myomectomy the plane of cleavage between fibroid and surrounding myomectomy can be masked and make surgery difficult
• Selective progesterone receptor modulator Ulipristal acetate (UPA) shown to be effective in controlling uterine bleeding related to myomas, to reducing myoma size, and to having a good safety profile in the short term.
• UPA is used in a dose of 5mg once daily for up to 3 months for either preoperative or intermittent treatment of moderate to severe symptoms of uterine fibroids in adult women of reproductive age.
  Re-treatment should commence only when menstruation has occurred
• Levonorgestrel secreting intrauterine system-Relatively contraindicated in distorted cavity. May be expelled during heavy menstruation
• Mefenamic and tranexamic acid can be safely prescribed

Uterine artery embolisation

• Women seeking future pregnancy should not generally be offered uterine artery embolization
• There are lower pregnancy rates, higher miscarriage rates, and more adverse pregnancy outcomes following uterine artery embolization than after myomectomy.
• Studies also suggest that uterine artery embolization is associated with loss of ovarian reserve, especially in older patients.

References

1. StratOG
2. Dewhurst’s Textbook of Obstetrics and Gynaecology