Uterine fibroids, UF

Notes

## Basic introduction

  • UF are benign uterine growths (tumors) of the smooth muscle origin.
  • They are form of leiomyoma
  • They are the most common pelvic tumors
  • UF can be sub-serous, interstitials or submucous.
  • UF tend to grow during the reproductive years and reduce in size after menopause. This is due to the fact that they are responsive to levels of estrogens.
  • Occasionally, UF may degenerate into cystic and fatty masses due to poor perfusion (as their sizes outgrow the demand).
  • Fibroids are 3 times more common in African-American women than in white Americans.

## Statistics

  • UF occur most commonly at the age of ≥30yrs
  • The global prevalence of UF is 70% of women by age 45 (including small and asymptomatic UF) with 25-50% of women expressing symptomatic UF.
  • UF are more common in obese women.
  • The annual recurrence rate of myomectomy is 2-3%.

## Types of UF

  • Intramural when in the wall of the uterus.
  • Submucosal when under the lining of the uterus.
  • Subserosal when under the outer surface of the uterus.
  • Pedunculated when they grow on a stalk
Symptoms
  • Pelvic pain and pressure.
  • Mass in the lower abdomen that is firm, nodular, non-tender and it moves with the cervix.
  • Dysmenorrhea
  • Menorrhagia

## Complications of UF

  • Anemia (iron-deficiency)
  • Constipation
  • Hyaline degeneration
  • Torsion of pedunculated fibroid
  • Hydronephrosis (due to ureteral obstruction)
  • Infertility
  • Recurrent miscarriage
  • Fetal malpresentation
  • Premature labour
  • Postpartum haemorrhage
  • Increased urinary frequency and/or urgency
Diagnosis
  • Clinical review
  • Ultrasound
  • MRI (the most accurate but expensive)
  • Hysterosalpingography in infertile or sub fertile cases
  • Intravenous Urogram (IVU) in selected cases
  • FBC (including HB for probable anemia)
  • Urinalysis
  • Endometrial sampling and histology
  • Blood grouping
  • Urea & electrolyte
  • Pregnancy test (for differential diagnosis)
Differential
  • Pregnancy
  • Dysfunctional uterine bleeding.
  • Ovarian cancer
  • Endometrial polyp
  • Adenomyosis
  • Endometrial hyperplasia
  • Endometrial carcinoma
  • Uterine sarcoma
  • Endometriosis
  • Chronic pelvic inflammatory disease
Prevention
  • None is known
Reference

1. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

2. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

3. Olufowobi O, Sharif K, Papaionnou S, et al; Are the anticipated benefits of myomectomy achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital.; J Obstet Gynaecol. 2004 Jun;24 (4):434-40.

4. Parker WH; Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril. 2007 Apr;87(4):725-36.

Management

## Patients’ monitor

  • Asymptomatic UF should not be treated; the patient should be monitored regularly
  • Generally, UF regress with the menopause and symptoms resolve

## Pharmacotherapy of UF

  • GnRH agonists: Their initial administration stimulates release of gonadotropins, LH and FSH, from the anterior pituitary gland. This is followed by their suppression. This reduces fibroid size and bleeding. GnRH agonists are the drugs of choice for management of UF are goserelin and leuprolide:

_Rx Goserelin 3.6mg depot S.C into the anterior abdominal wall every 28 days. OR

    _ Rx Leuprolide1 mg SC as a single dose

  • Progestins: These drugs reduce bleeding but they do not reduce the size of UF as effectively as GnRH agonists.

_Depot medroxyprogesterone acetate 150 mg IM every 3 months OR Tabs medroxyprogesterone 5-10mg OD for 10-14 day within the menstrual cycle  OR Tabs medroxyprogesterone 5-10mg OD continuously.

  • Other drugs include: Raloxifene (a selective estrogen receptor modulator), Danazol (an androgenic agonist), Tranexamic acid (an antifibrinolytic drug that reduces uterine bleeding) and combined hormonal contraceptives (but not as effective as GnRH agonists and progestins mentioned above).

## Surgical interventions

  • Myomectomy (fibroidectomy): This is the surgical removal of UF alone; preserving the uterus hence retaining the reproductive potential. It can restore fertility that has been lost due to UF.
  • Hysterectomy (the surgical removal of the uterus and often the cervix, ovaries, fallopian tubes and other surrounding structures) for definitive therapy of UF.
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