Health

Fibroid uterus- symptoms diagnosis and treatment

Uterine fibroids, also known as uterine myomas, uterine leiomyomas are the most common pelvic tumors in women with an incidence of 30 to 70% in reproductive age women, increasing with age. Fibroids are benign smooth muscle tumors that rarely undergo malignant transformation (0.5%).

Classification and types

Fibroids are classified according to their location in the uterus.

  • Submucosal fibroids- these develop from the myometrium just deep to the endometrial cavity. These can often protrude into the endometrial cavity or if pedunculated can even prolapse through the cervical os.
  • Intramural fibroids- located within the uterine wall, may distort the endometrial cavity.
  • Subserosal fibroids- develop below the serosal layer, can be pedunculated and accordingly extend between folds of the broad ligament.

Extrauterine fibroids- they are usually the result of the hematogenous spread of neoplastic smooth muscle cells from the uterus. Location most commonly include- genitourinary tract, gut mesentery and the cardiopulmonary system. Rare locations include spinal cord and blood vessels.

FIGO classification of fibroids

Clinical features and diagnosis

  • Most patients are asymptomatic. Most common symptom is abnormal uterine bleeding usually excessive menstrual bleeding or irregular bleeding.
  • Bulk symptoms- due to pressure on adjacent organs. When fibroid is adjacent to bladder neck and urethra, incontinence or acute urinary retention with overflow incontinence may occur. Compression on urethra may cause Hydronephrosis. Posterior fibroid may cause constipation, rectal pressure or trenesmus. Large fibroids may present with back pain and pain radiating down one or both legs
  • Chronic pain- including dysmenorrhea , dyspareunia and non-cyclical pelvic pain. Acute pain may be a consequence of twisting of a pedunculated fibroid or the degeneration of large fibroid.
  • Infertility/ subfertility– may occur due tosub mucous and intramural fibroid due to impaired implantation , tubal function or sperm transport. These fibroids may cause spontaneous abortion also.
  • Obstetric complications – miscarriage, preterm labour and delivery, malpresentation, cesarean delivery, postpartum hemorrhage and peripartum hysterectomy . Less common are Intrauterine growth retardation, abnormal placentation, 1 st trimester bleeding, preterm premature rupture of membranes, abruption and labor dystocia.

Diagnosis:

Sonography: This is the 1 st line and basic noninvasive test to diagnose fibroids

Transvaginal sonography is highly sensitive for accurate diagnosis and mapping Of fibroids.

MRI:  This is required in cases of cervical and broad ligament fibroids to confirm the diagnosis and for surgical planning before Myomectomy and Uterine artery embolization.

Sonohysterography: this is especially useful on cases of submucous fibroids.

         Management of fibroid uterus:

  • Management depends on patient’s age, fertility status, desire to retain uterusor avoid surgery.
  • Observation: small fibroids and asymptomatic fibroids can be managed conservatively. Physical examination and usg should be performed initially and repeated in 6 months to document the size and growth pattern of the fibroid. If growth is stable the patient may be followed clinically with annual pelvic examination and usg. Postmenopausal patients, current or history of previous long-term tamoxifen use, pelvic irradiation are some contraindications for conservative management.
  • Medical therapy:
  • Non-hormonal: includes tranexamic acid and non-steroidal anti-inflammatory agents(NSAID) to control menorrhagia and pain.
  • Hormonal therapy:

a)Combined oral contraceptives and progesterone releasing intrauterine device. Progesterone has a good effect on menorrhagia with little or no change in the size of fibroids.

b)Mifepristone- an antiprogestin, has been associated withdecrease in the size of leiomyoma with slow rate of regrowth after cessation of treatment.

c)Gnrh analogue- maximum reduction in tumour volume of approximately 50% has been observed with the use of leupride depot injection monthly over a 3 months course of treatment.

These agents are useful as a conservative therapy in perimenopausal women or as an adjunct to surgical treatment. Add back therapy with concomitant use of low dose hormone can be used to minimise the adverse effects of gnrh agonist . 3 to 6 months course of Gnrh agonist prior to scheduled surgery can reduce the tumor size and by inducing amenorrhea, Gnrhagonist therapy improves patient’s haemoglobin. However it is associated with obscuring of surgical plane between the fibroids and normal myometrium and makes Myomectomy more difficult.

  1. D) SPRM ( selective progesterone receptor modulator) like ullipristal was used earlier but it is removed from the market die to its side effects
  • Surgical therapy

Myomectomy: Surgical excision of fibroid is the only option when future pregnancy is desired. Myomectomy can be done abdominally or laparoscopically. Submucous Myomectomy can be done by combined laparoscopy and hysteroscopy approach.

Laparoscopic Myomectomy is preferred over open approach due to many advantages. Major complication of Myomectomy is hemorrhage that can be reduced by using vasopressin, bupivacaine + epinephrine , tranexamic acid, bilateral uterine artery ligation.

Patient wishing to conceive advised a delay of 3-6 months . The most common obstetric complications include uterine rupture, abnormal placentation (placenta accreta) , preterm delivery etc.

Hysterectomy: can be performed abdominally , vaginally and laproscopically. The method of approach is dictated by-size of the uterus and fibroids, location of fibroids, mobility and ability to safely access vasculature, patient comorbidities, ability to tolerate pneumoperitoneum and trendelenburg position and surgeon’s expertise .

Laproscopic hysterectomy is preferred due to these advantages-

  • No big scars
  • Rapid recovery
  • Less postoperative pain
  • Short hospital stay
  • Better visualisation of surgical field
  • Concomitant evaluation of abdominal cavity for any pathologies
  • Removal of fallopian tubes is mandatory in all cases because according to recent guidelines tubes are responsible for malignancy after hysterectomy and removal of tubes is technically difficult by vaginal route.

Uterine artery embolisation: 

It decreases blood supply to the uterus and ultimately causes ischemic necrosis of leiomyoma. The procedure is performed by the interventional radiologist and involves catheterisation of the femoral orradial artery to gain access to uterine arteries.

The effect of UAE on future pregnancy remains understudied and ACOG advises that it must be used with caution in women desiring future pregnancy.

Magnetic resonance imaging guided focused ultrasound surgery ( MRI – FUS) :

This procedure is performed with MRI thermal mapping  and fibroid tissue is heated and destroyed using targeted ultrasound energy passing through the anterior abdominal wall. It is currently approved for premenopausal women who don’t desire future fertility. It is not appropriate for pedunculatedmyoma and those adjacent to the bowel and bladder.

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