Fibroids (leiomyomas)       Most common pelvic tumour in women, hormonally responsive Benign, arise from smooth muscle of myometrium

Occur in women of reproductive age Typically present with pelvic pain or DUB May impact fertility and result in adverse pregnancy outcomes Types: o intramural-growing in the wall of the uterus o submucosal- growing in the endometrium (can bleed) o subserosal-growing on the outside of the wall of the uterus o cervical- in the cervix

Risk Factors: o Early menarche (<10 years old) o Nulliparity o ?obesity o consumption of excessive red meat o increased alcohol intake (especially beer) o ?heredity o hypertension o uterine infection Protective factors: o Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation o ?early age at first birth o Long acting progestin-only contraceptives (eg, depot medroxyprogesterone) protect against development of leiomyomas o consumption of green vegetables and fruit o smoking (unknown mechanism) Clinical presentation:  Abnormal uterine bleeding o menorrhagia/ prolonged menses (especially submucosal fibroids) o intermenstrual and post menopausal bleeding are NOT characteristic of fibroids  Pelvic pressure and pain o Urinary Sx: frequency, incomplete bladder emptying and obstruction (rarely) o Bowel Sx: constipation

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o SVC compression: thromboembolic events o Low back pain Reproductive dysfunction o distortion of uterine cavity with submucosal and intramural fibroids o difficulty conceiving, risk of miscarriage o increased risk of pregnancy Cx: placenta abruption, IUGR, preterm labour and birth Dysmenorrhoea o often in association with menorrhagia/ passing of clots o more likely to be associated with adenomyoma if it is the primary presenting sx Dyspareunia o deep (if anterior/fundal fibroids) Acute pain o consider degeneration or torsion o Associated sx: fever, uterine tenderness, peritoneal signs, raised WCC Transcervical prolapse (rare) Ectopic hormone production (rare) o Polycythemia from autonomous production of EPO o Hypercalcemia from autonomous production of PTHrP o Hyperprolactinemia Many asymptomatic Symptoms are related to number, size and location of fibroids

Examination:  Bimanual pelvic ex: enlarged, mobile uterus with an irregular contour  The size of the myomatous uterus is described in menstrual weeks, as with the gravid uterus  Speculum Ex: a prolapsed submucosal fibroid may be visible at the external cervical os. These should be removed and are distinguished from a large endocervical or endometrial polyp by the firm consistency of the tissue and by pathologic evaluation Investigations:  USS: Transvaginal ultrasound has high sensitivity (95 to 100 percent) for detecting myomas in uteri less than 10 weeks' size. Localization of fibroids in larger uteri or when there are many tumors is limited.  Diagnostic hysteroscopy (not as good at predicting size)

 MRI (best, but expensive): can distinguish among leiomyomas, adenomyosis, and adenomyomas  Hysterosalpingography: typically used when also want to evaluate tubal patency in ?infertility Ddx of enlarged uterus: o Uterine adenomyosis or adenomyoma o Leiomyoma variant o Pregnancy o Hematometra o Uterine sarcoma o Uterine carcinosarcoma o Endometrial carcinoma o Metastatic disease (typically from another reproductive tract primary) Natural Hx:  Fibroids may grow throughout reproductive years (although at different rates)  Often grow in pregnancy  Fibroids usually shrink at menopause  Changes in fibroids over time: o Hyaline degeneration (necrosis with loss of muscle cell structure) o Cystic degeneration (after hyaline, breakdown + cyst formation, may rupture into adjacent cavities) o Fatty degeneration (partial necrosis resulting in fatty substances +/-calcification) o Red degeneration (thrombosis>ischaemia>necrosis, usually in pregnancy. Very painful!) o Malignant transformation (rare~ 0.2%) Managment:  Surveillance w/ annual USS  Symptomatic tx (eg. analgesia, OCP for bleeding etc.)  Gonadotropin-releasing hormone (GnRH) agonists o most effective medical therapy for uterine myomas o work by initially increasing the release of gonadotropins, followed by desensitization and downregulation to a hypogonadotropic, hypogonadal state that clinically resembles menopause. o Most develop amenorrhea, improvement in anemia, and a significant reduction (35 to 60 percent) in uterine size within three months of initiating tx

o SE: menopausal sx o often used pre-operatively 3-6mo prior to surgery  Surgery/percutaneous procedures: o Arterial embolisation Under local anaesthetic, a fine tube is passed through an artery in the arm or leg into the main artery supplying the fibroid with blood  Monitored by Xray  Fine, sand-like particles are then injected into the artery to block the blood supply to the fibroid  The fibroid slowly dies and symptoms generally settle over a few months o Myomectomy Hysteroscopy  fibroids are removed through the cervix using a hysteroscope.  Laparoscopy  Open surgery  for larger fibroids  weakens the wall of the uterus and makes Caesarean sections for future pregnancies more likely o Hysterectomy

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