QuestionSBA
QuestionChoice
This woman has an obvious abnormality. Although this is likely to be fibroids, intrauterine contraception should only be used in women with fibroids after seeking specialist advice. She has adequate contraception in the form of the progestogen-only pill at present.
49838
b
Insert the Mirena coil and refer to gynaecology
QuestionChoice
This woman has an obvious abnormality and requires referral to gynaecology. In addition, intrauterine contraception should not be inserted where there is a palpable uterus unless under specialist advice.
49840
d
Insert the Mirena coil and advise the woman to return in one month for a repeat examination
QuestionChoice
This woman has an obvious abnormality and requires referral to gynaecology. Whilst an endometrial biopsy may form part of the investigations, it would not be appropriate to perform this in the family planning clinic. In addition, intrauterine contraception should not be inserted where there is a palpable uterus unless under specialist advice.
49839
c
Perform an endometrial biopsy before inserting the Mirena coil
QuestionChoice
This woman has heavy menstrual bleeding and a palpable uterus. The most likely diagnosis is uterine fibroids, however she requires imaging to confirm this. Intrauterine contraception should only be used in women with fibroids after seeking specialist advice.
49837
a
Refer to gynaecology without inserting the Mirena coil
QuestionChoice
While the likely diagnosis is fibroids, and GnRH analogues are a treatment strategy for the medical management of fibroids, the diagnosis is not confirmed. It would be inappropriate to commence this specialist treatment in a family planning setting.
49841
e
Prescribe the woman a gonadotropin-releasing hormone (GnRH) analogue and ask her to return for her Mirena coil insertion in six months
Concept
Chapter
# Summary
  
 
Fibroids are benign tumours of the myometrium of the uterus, common in women above 30, with peak incidence in perimenopausal years. Fibroids often present with menstrual dysfunction, such as menorrhagia and dysmenorrhoea, and can interfere with fertility if large enough. They are usually diagnosed following a transvaginal ultrasound scan. Management strategies depend on the symptoms and size of the fibroids, ranging from NSAIDs and contraceptive methods to surgical options including myomectomy, ablation, uterine artery embolisation, and hysterectomy.
  
 
# Definition
  
 
Fibroids, or uterine leiomyomas, are benign smooth muscle tumours originating from the myometrium of the uterus.
  
 
# Epidemiology
  
 
Uterine fibroids are the most prevalent benign uterine tumours in women and are the leading cause for hysterectomy. The incidence of fibroids increases with age until menopause. 

Symptomatic fibroids are less prevalent in women younger than 30 years of age, occurring in 20–50% of women older than 30 years. The peak incidence is observed in women in their 40s, with a crude incidence of 22.5 per 1000 woman-years.
  
 
# Aetiology
  
 
The exact cause of fibroids is unknown but they are thought to be influenced by genetic, hormonal, and environmental factors. Oestrogen and progesterone, the hormones that stimulate the development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more oestrogen and progesterone receptors than normal uterine muscle cells.
  
 
# Signs and Symptoms
  
 
Fibroids can often be asymptomatic, especially when they are small. However, when symptoms do occur, they usually present as:
  
 
  - Menstrual dysfunction, such as menorrhagia and dysmenorrhoea
  - Sub/Infertility, if the fibroid is large enough to distort the uterine cavity
  - Palpable mass on abdominal or pelvic examination if the fibroid is large
  - Abdominal pain, worse during menstruation
  - Urinary frequency if large enough and putting pressure on the bladder
  
 
# Differential Diagnosis
  
 
The main differentials for fibroids include other causes of menorrhagia and dysmenorrhoea. These include:
  
 
1.  **Endometrial polyps:** Present with irregular menstrual bleeding and spotting
2.  **Endometriosis:** Characterised by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility
  
 
# Investigations
  
 
  
**Bedside:**

* Bimanual examination: may feel enlarged uterus 
 
**Bloods**

* Consider FBC if worried about anaemia  
 
**Imaging:**
 
 * Trans-vaginal ultrasound: Used to assess the size and location of the fibroids
 * MRI: Used if ultrasound does not provide enough detail to assess the fibroid for surgery
 
**Invasive:**

* Biopsy: May be taken if there is any doubt over the diagnosis to differentiate the fibroid from other conditions such as endometrial cancer


 
# Management
  
Management of fibroids depends on the symptoms and size of the fibroids. It includes:
  
  - Non-surgical management for fibroids causing abnormal bleeding and under 3cm in size with no uterine distortion. This includes NSAIDs, anti-fibrinolytics (tranexamic acid), GnRH analogues, combined hormonal contraception, and Levonorgestrel-releasing intrauterine system (Mirena).
  - Surgical management for fibroids causing symptoms due to their mass effect. This includes myomectomy, ablation, uterine artery embolisation, and hysterectomy.

# Complications

* Recurrence 
* Haemorrhage and anaemia
* Degeneration, especially during pregnancy (red degeneration)
* Infertility (especially if large)
* Torsion
* Pressure effects (e.g. urinary retention, constipation)
* Delivery complications (e.g. breech presentation, bleeding) and pregnancy complications, including miscarriage 

 
# NICE Guidelines
  
 
[Click here for NICE CKS on fibroids](https://cks.nice.org.uk/topics/fibroids/)
  
# References

[Patient Info](https://patient.info/womens-health/periods-and-period-problems/fibroids)
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Gynaecology
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Quesmed Tutorial: Gynaecology 1
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10004
A 44-year-old woman attends the family planning clinic for insertion of a Mirena levonorgestrel-releasing intrauterine system; as she has read that this will help with her heavy periods. She currently takes the progestogen-only pill and is menstruating.

On routine bimanual examination before inserting the coil, the uterine fundus can be felt around the level of the umbilicus, and it is not possible to ascertain the position of the uterus.

What is the most appropriate next step?
a