QuestionSBA
QuestionChoice
This is an option for patients for a short period of time, to induce a 'pseudo-menopause' and shrink the size of the fibroids. This is not appropriate in somebody who would like to become pregnant.
10017344
d
GnRH analogues
QuestionChoice
There is some evidence that removing fibroids in cases of subfertility may increase the chance of pregnancy. Further, it is clear that the patient is suffering with symptoms from the fibroids. Intervention should be offered.
10017341
a
Myomectomy
QuestionChoice
This is likely to alleviate some of the symptoms, but perhaps not her menorrhagia. Further, this does not address the element of subfertility that may be caused by the fibroids.
10017342
b
Symptomatic relief with NSAIDs
QuestionChoice
This is clearly contraindicated as pregnancy is desired.
10017345
e
Hysterectomy
QuestionChoice
This is an option for patients who have no contraindications to hormonal contraceptives, and who do not want to become pregnant.
10017343
c
Hormonal contraceptives to control menorrhagia
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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Fibroids
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Quesmed Tutorial: Gynaecology 1
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Myomectomy is a surgical procedure to remove fibroids from the uterus, preserving the uterine structure and function, and is often recommended for women who wish to maintain fertility or experience significant symptoms such as heavy bleeding or pain.
A 33-year-old woman is referred to gynaecology on the 2-week-wait cancer pathway after her GP felt a pelvic mass on bimanual examination, which was performed as she was experiencing severe menorrhagia and lower abdominal pain. A transvaginal ultrasound scan shows a fibroid measuring 4cm in the uterus. The patient states that she has been trying (unsuccessfuly) to conceive for 2 years and would like children.

What is the most appropriate management to suggest?
a