1. Uterine Fibroids for Undergraduates
Max Brinsmead MB BS PhD
September 2012

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 Submucous (~5% of all fibroids) Intramural
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
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 Pressure effects
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. 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

10. 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

11. 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

12. Any Questions or Comments?
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