1. Uterine Fibroids
Max Brinsmead PhD FRANZCOG
January 2010

2. Uterine Fibroids
 Benign tumours (leiomyomata) of uterine
smooth muscle
 Common – 25% of women in a lifetime
 Usually multiple
 Various sizes
 Genetic predisposition
 more common in black races
 More common in the obese
 Less common in smokers
 More common in nulliparas
 Accounts for ~30% of hysterectomies

3. Fibroid Locations
 Subserous
– Project from the uterus into the peritoneal cavity
– Sometimes pedunculated
– Least likely to cause symptoms
 Submucous (~5% of all fibroids)
– Project into the uterine cavity
– Sometimes pedunculated
– Most likely to cause symptoms
 Intramural
– Most common
– Usually multiple

4. Intramural & Submucous
Fibroids

5. Subserous Fibroid at
Laparoscopy

6. Fibroid Symptoms
 Mostly asymptomatic
 Menorrhagia
– Heavy regular periods
– Iron deficiency anaemia
 Pressure effects
– Urine frequency
– Pelvic tumour awareness
– Difficulty initiating micturition
 Pain, Infertility & Irregular vaginal bleeding
– May be due to other pathology

7. Fibroids’ Natural History
 Oestrogen-dependent tumours that grow
slowly:
– Whilst cycling premenopausal
– Probably whilst on COC
– When taking E2 HRT
 Will regress with menopause
 Response to progestin-only contraception is
uncertain
 Malignant change rare <1:1000

8. Investigation of Fibroids
 Ultrasound
– Frequently misdiagnosed with this modality
– “Multiple small fibroids” is usually irrelevant
– Heterogenous echolucency is normal in a parous uterus
– Adenomyosis can look the same
– Size and location important
– Can be a “contraction wave” in pregnancy
 MRI better than CT Imaging
 Laparoscopy and Hysteroscopy
 Saline hysterography
– Useful for pedunculated submucous fibroids

9. Investigating a Submucous Fibroid

10. Investigating a Submucous Fibroid

11. Treatment Options for
Fibroids
 Hysterectomy
– If the uterus is >10w size
– Or symptoms that are due to the fibroids
– Rapid growth
– Abdominal or vaginal
 Myomectomy
– Best for single fibroid in a young woman
– ~50% come to hysterectomy within 5 years?
 Hysteroscopic resection
 Uterine artery embolisation (UAE)
 Medical options
– GnRH analogue
– Mirena

12. NICE Recommendations for Uterine
Fibroids
 For patients with heavy menstrual bleeding and
fibroids >3 cm size (and especially those with pelvic
pain or other symptoms) then…
– Hysterectomy, Uterine artery embolisation (UAE) and
myomectomy should all be offered
– Myomectomy recommended if fertility is desired
– Hysteroscopic resection of the entire fibroid with endometrial
resection is appropriate if the fibroid (s) are submucous
 Pre treatment with GnRH analogue for 3 - 4m is
worthwhile before hysterectomy and myomectomy
– Reduces uterine size and makes surgery easier
– Better HB pre op and less bleeding
 But GnRH analogues are contraindicated
before UAE

13. Fibroids and Infertility
 In most women the association is result and
not cause
 It is said that ≈3% of infertility is due to
fibroids
 Most infertility specialists will recommend
removal of any fibroid with >50% of its
surface in the uterine cavity
 The results from removal of a single
submucous fibroid can be dramatic
 And there is evidence that removal of
intramural fibroids >5 cm diam will enhance
fertility with IVF

14. Fibroids and Pregnancy
 In most women there is no effect
 80% remain unchanged in size
 Rarely rapid growth and red degeneration
 Increased risk of bleeding and threatened
preterm delivery
– But most deliver at term
 Fibroid in the lower segment can interfere
with vaginal birth
 Myomectomy at the time of Caesarean is
not wise
– 30% require emergency hysterectomy