Symptoms of fibroids
Major asymptomatic - 40%
Abnormal uterine bleeding
Heavy flow (menstruation) - submucosal fibroids due to increased surface area
IMP - submucosal pedunculated (blood supply in stalk leak after avascular necrosis)
Pressure symptoms
Urinary frequency, retention, recurrent uti,
Change in bowel habits
Abdominal discomfort
Dysmenorrhea - submucosal pedunculated.Sometimes like labour pain.
Reproductive effects
Subfertility - rare
Miscarriage
Preterm delivery
IUGR
Effect during labour
PPH
Red degeneration - increase growth, blood supply cant keep up,can get smaller
Risk of Malignancy
Incidence: Very rare < 1%Signs:Rapidly enlarging
Pain
Durign surgery - necrotic areas, adhesions
4 cm in US sound then suspect and then biospy etc?
Cachecic symptoms
Diagnosis
History??
Clinical Examination features in Fibroids
- Ab Ex - mass arising from the pelvis (cant get below the mass and other signs arising from the pelvis)
- Firm mass
- Irregular knobby mass
- Mobile
- Non tender but not in pregnancy red generation
PV- mass move with the cervix
Investigations
- USS (most important primary well defined hypoechoic mass, usually multiple)
- CT/MRI (only to assess further like pressure)
- Saline infusion sonography(submucosal pedunculated)
- Hysteroscopy (submucosal)
- FBC - Low HB, Increase platelet (assess consequence)
Assessing complications?
tender in malignancy? submucosal?
Uterine mass vs ovarian mass?
MANAGEMENT OF FIBROIDS
1. Expectant - if small and asymptomatic (reassure and come because risk of malignancy is < 1%)
2. Medical - to reduce bleeding - tranexamic acid, OCP, MIRENA (IUCD but not cu, have pellet of progesterone - proper generic name?) - GnRh analogues - inhibits hormones and this cause iatrogenic menapause - to reduce size pre operatively, close to menapause .... reduce size by 50% after 6 months of Tx but regrows to same size once discotinued ...and costlier. So disads?
Given injections. Not usually given more than 6 months. Used 1 preoperatively 2 near menapause
Have some other drugs too
3. Surgical
> Minimally invasive (hysteroscopy) - hysteroscopic resection of fibroid (submucosal) - hysteroscopic ablation of endometrium if bleeding is main problem
> Hysterectomy - abdominal, vaginal, laparascopy ...if family complete. (depending on size and other factors)
> Myomectomy
- open or laparoscopically - if having fertilty wishes - in young patients - risk of haemorrage is high (but still rare) so take consent of hysterectomy, cross match 4-5 units of blood (normally Cxm 1 unit) , give GnRH preoperatively or inject vasopressin during sx to reduce bleeding. > Uterine artery embolisation - Us guided occlusion of feeding vesssels - C/I fertility wishes pr suspicious of malignacy is contraindicated There are other management options coming up - new management - ten teachers read.