QuestionSBA
QuestionChoice
This may help in confirming the aetiology of the anaemia, although the clinical information provides enough information to reasonably assume the anaemia was caused either by menorrhagia or from malignancy. The patient has presented with an abdominal mass which must be investigated first
33009
b
Blood film
QuestionChoice
This patient most likely has uterine fibroids which has resulted in her menorrhagia, subfertility, and anaemia. She has a smooth benign-feeling suprapubic mass; however this still needs to be formally assessed sonographically to be characterised and assessed for malignancy
33008
a
Transvaginal ultrasound scan
QuestionChoice
This may help in confirming the aetiology of the anaemia, although the clinical information provides enough information to reasonably assume the anaemia was caused either by menorrhagia or from malignancy. The patient has presented with an abdominal mass which must be investigated first
33011
d
Low vaginal swab for chlamydia and gonorrhoea
QuestionChoice
These would be reasonable suggestions to investigate subfertility/infertility if the patient did not present with an abdominal mass and ultrasound scans were unremarkable
33010
c
Mid luteal phase progesterone
QuestionChoice
MRI Pelvis provides excellent anatomic delineation of gynaecological structures. It is the most _accurate_ modality for detecting, localising, and characterising uterine fibroids. It is, however, not generally required for diagnosis and would not be the _first_ investigation of choice
33012
e
MRI Pelvis
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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Fibroids
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Gynaecology
Video
Concept
971
Fibroids
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hFCH5A8
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Quesmed Tutorial: Gynaecology 1
Video
Concept
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Fibroids
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Fibroids
Transvaginal ultrasound scan
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A transvaginal ultrasound scan is a diagnostic imaging technique used to visualize uterine fibroids, providing detailed images of their size, number, and location within the uterus, aiding in diagnosis and treatment planning.
A 32-year-old woman presents with 12 months of infertility despite regular unprotected intercourse. She reports regular periods, though increasingly heavy in recent years. She had normal childhood development and menarche at age 11, with up-to-date negative cervical smears for HPV, and has no past medical history. She is in a monogamous relationship with a negative sexually transmitted infection screen 6 months ago.


On examination, she has a firm, palpable painless 10cm smooth mass in the suprapubic region. Abdomen is otherwise soft non-tender with no shifting dullness or fluid thrill.


Routine bloods reveal microcytic iron deficiency anaemia but are otherwise unremarkable.


Urine dip and beta HCG are negative.


What is the most appropriate next investigation?
a