Fibroids: Understanding Uterine Tumors

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Questions and Answers

What are the differential diagnoses for a patient with symptoms of lower abdominal heaviness, menorrhagia, and increased urinary frequency?

Potential differential diagnoses include uterine fibroids, endometriosis, adenomyosis, and pelvic inflammatory disease.

What imaging technique is most commonly used to confirm the diagnosis of fibroids?

Transvaginal ultrasound is usually employed to confirm the presence and size of fibroids.

What is the primary treatment option for symptomatic fibroids?

Hysterectomy is the primary treatment option for symptomatic fibroids in patients who have completed childbearing.

What could be the possible cause of severe abdominal pain in a 28-week pregnant woman?

Potential causes include placental abruption, uterine rupture, or round ligament pain. Signup and view all the answers

How would you confirm your diagnosis for abdominal pain during pregnancy?

Ultrasound is typically used to confirm the diagnosis and assess fetal well-being. Signup and view all the answers

What are four steps in the management of severe abdominal pain in a pregnant patient?

The management steps include stabilizing the patient, performing an ultrasound, monitoring fetal heart patterns, and providing pain relief. Signup and view all the answers

What are fibroids and what are they also known as?

Fibroids are benign tumors of uterine smooth muscle, also known as myomas or leiomyomas. Signup and view all the answers

What factors increase the risk of developing fibroids?

Increased risk factors include being black, nulliparous, having a family history of fibroids, obesity, and smoking. Signup and view all the answers

What are submucous fibroids, and how do they grow?

Submucous fibroids develop in the muscle underneath the inner lining of the uterus and grow into the uterine cavity. Signup and view all the answers

Describe the characteristics of cervical fibroids.

Cervical fibroids grow in the wall of the cervix and are challenging to remove without damaging surrounding tissues. Signup and view all the answers

What unique challenges do interligamentous fibroids present during removal?

Interligamentous fibroids grow sideways between the ligaments that support the uterus and can interfere with blood supply or adjacent organs during removal. Signup and view all the answers

What percentage of women with fibroids experience no symptoms?

It is estimated that 50% of women with fibroids do not experience any symptoms. Signup and view all the answers

Explain how large fibroids can affect bladder function.

Large fibroids may press against the bladder, causing problems such as urinary frequency or urgency. Signup and view all the answers

What type of pain may women with fibroids experience?

Women with fibroids may experience painful periods, dull aches in limbs, back pain, or constant abdominal pressure. Signup and view all the answers

How can fibroids cause anemia in women?

Fibroids can lead to heavy menstrual bleeding (menorrhagia), which may result in iron deficiency anemia. Signup and view all the answers

What is a parasitic fibroid?

A parasitic fibroid is a rare type of fibroid that attaches itself to another organ. Signup and view all the answers

What is a common complication post labor that may increase the risk of hemorrhage?

Postpartum hemorrhage. Signup and view all the answers

What ultrasound findings are important when diagnosing fibroids?

The size and location of fibroids, and to exclude hydronephrosis. Signup and view all the answers

Name two other diagnostic procedures that may be necessary if ultrasound results are unclear.

Hysteroscopy and laparoscopy. Signup and view all the answers

What dietary factors may help reduce the risk of developing fibroids?

Eating a lot of green vegetables and fruit while reducing red meat intake. Signup and view all the answers

What conservative management is suggested for asymptomatic fibroids?

Regular follow-up ultrasounds to monitor growth. Signup and view all the answers

How can anemia be managed in patients with fibroids?

By correcting it with oral iron supplements. Signup and view all the answers

What is the preferred medication for menorrhagia due to fibroids?

Tranexamic acid. Signup and view all the answers

Why might women nearing menopause be advised to wait for treatment of fibroids?

Because fibroids tend to shrink on their own after menopause. Signup and view all the answers

What are the potential causes of painful sex in individuals with fibroids?

Fibroids that press on the cervix or extend into the vagina can cause pain during penetrative sex and may lead to bleeding. Signup and view all the answers

How do fibroids affect urinary function?

Fibroids can lead to urinary issues like frequency, urgency, and even urinary retention, which may require urgent care. Signup and view all the answers

In what ways can fibroids impact pregnancy?

While many fibroids do not affect pregnancy, some can obstruct the fallopian tubes, making conception difficult or leading to miscarriage. Signup and view all the answers

What is red degeneration in relation to fibroids during pregnancy?

Red degeneration refers to fibroids undergoing necrosis due to a lack of blood supply, causing abdominal pain and uterine contractions. Signup and view all the answers

What are the common treatment options for managing fibroids during pregnancy?

Treatment is typically conservative and includes analgesia, IVF, and tocolytics to manage symptoms. Signup and view all the answers

How can fibroids complicate delivery?

Fibroids can obstruct the birth canal, potentially necessitating a Caesarean section for safe delivery. Signup and view all the answers

Describe the relationship between estrogen and fibroids during pregnancy.

Fibroids tend to grow during pregnancy due to higher levels of estrogen circulating in the body. Signup and view all the answers

What symptoms might indicate the presence of fibroids affecting bowel function?

Symptoms may include bowel constipation and the development of hemorrhoids. Signup and view all the answers

What is the effect of long-term use of combined oral contraceptives (COCs) on menorrhagia?

COCs can result in a 50% decrease in menorrhagia. Signup and view all the answers

How do levonorgestrel-releasing IUDs compare to copper IUDs in terms of protecting from fibroids?

Levonorgestrel-releasing IUDs provide better protection from fibroids than copper IUDs. Signup and view all the answers

What is the mechanism by which GnRH analogues help in treating fibroids?

GnRH analogues reduce estrogen levels, leading to the shrinkage of fibroids. Signup and view all the answers

List two potential side effects of using GnRH analogues.

Hot flushes and vaginal dryness. Signup and view all the answers

What is add-back therapy, and which medication is the treatment of choice?

Add-back therapy involves administering hormones to counteract GnRH side effects; Tibolol is the treatment of choice. Signup and view all the answers

What surgical procedure removes fibroids while leaving the uterus intact?

Myomectomy. Signup and view all the answers

What is the role of iron therapy in the context of treating fibroids?

Iron therapy is used to treat anemia that may result from heavy menstrual bleeding due to fibroids. Signup and view all the answers

How do GnRH analogues impact menstrual periods after discontinuation?

Once GnRH analogues are stopped, fibroids may regrow, and periods typically return within a few weeks. Signup and view all the answers

Study Notes

Fibroids

Benign uterine smooth muscle tumors
Also called myomas or leiomyomas
Common in women of reproductive age
Composed of rounded smooth muscle and connective tissue whorls
Size can vary from a pea to a melon
Estimated 20-50% of women will have fibroids in their lifetime
Rare in women under 20
Most common in women in their 30s and 40s, particularly in Black women, nulliparous women, obese women, smokers, and women with a family history of fibroids.
Long-term oral contraceptive use (OCPs) and Depo-Provera are associated with a reduced risk
Tend to shrink after menopause

Pathophysiology

Hormone dependent, with receptors for estrogen and progesterone
Growth mediated by various growth factors, including epidermal growth factor, apoptosis-inhibiting protein, and reduced growth inhibitory (monocyte chemotactic protein-1)
Cytogenic aberration on chromosomes 3, 6, 7, and 12
0.1% chance of malignant transformation to sarcoma

Fibroid Types

Intramural: Most common type, growing within the uterine wall
Subserous: Grow from the outer layer of the uterine wall, sometimes on stalks (pedunculated fibroids). Can grow very large.
Submucous: Develop in the muscle beneath the inner lining of the uterus. Grow into the uterine cavity, sometimes with stalks that can protrude through the cervix.
Cervical: Grow in the wall of the cervix (neck of the uterus), difficult to remove without damaging surrounding tissue.
Interligamentous: Grow sideways between the ligaments supporting the uterus. Difficult to remove without potentially affecting blood supply or other organs.
Parasitic: Rarer type, attaching to another organ

Fibroid Symptoms

50% of women with fibroids are asymptomatic.
Symptomatology depends on fibroid size.
Large fibroids can press against the bladder, causing bladder problems.

Common Fibroid Symptoms

Heavy menstrual bleeding (menorrhagia): Can include flooding, prolonged periods, and passing clots.
Pain & pressure: Painful periods, dull thigh aches, back pain, and constant pressure in the abdominal area resembling bloating or fullness. Sudden severe pain in the pelvis or lower back can occur due to a twisted pedunculated fibroid, cutting off blood supply.
Pain during sex (dyspareunia): Cervix-impacting fibroids can make penetrative sex painful and cause bleeding during sex.
Bladder problems: Frequent urination, urgency, leaking or dribbling urine, urgent need to urinate with small volume, and difficulty or inability to urinate (urinary retention, requiring urgent care and a Foley catheter for bladder emptying).
Bowel problems: Constipation and hemorrhoids (piles).

Fibroids and Pregnancy

Most fibroids do not hinder pregnancy.
Some fibroids in specific locations can make conception difficult or increase the risk of miscarriage.
Fibroids can press on or block the fallopian tube entrance, preventing egg transport to the uterus.
Submucous fibroids growing into the uterine cavity are linked to recurrent miscarriage.

Fibroids During Pregnancy

Fibroids grow due to increased estrogen levels.
"Red degeneration" occurs, where a fibroid becomes cut off from blood supply and undergoes necrosis (death). This can cause intense abdominal pain and uterine contractions, possibly leading to premature rupture of membranes (PROM) and early labor.
Conservative treatment with analgesia, IVF, and tocolytics is used.
Fibroids can obstruct the birth canal, potentially requiring a Cesarean section.
Postpartum hemorrhage risk is increased.

Management of Fibroid Changes

Primarily conservative until delivery, addressing complications such as:
- Red degeneration (most common in pregnancy)
- Calcification (common in menopause)
- Twisting (torsion)
- Necrosis
- Sarcoma formation
- Hyaline degeneration
- Infection

Fibroid Diagnosis

History and physical examination.
Ultrasound scan: Provides detailed information on fibroid size and location. Also used to rule out hydronephrosis and differentiate ovarian masses from fibroids.
Hysteroscopy: Visualizes the uterine cavity using a small telescope inserted through the vagina. Can be used for biopsy under local or general anesthesia.
Laparoscopy: Allows visualization of the uterus from the outer surface, enabling tissue sampling.

Differential Diagnoses

Any abdominal or pelvic masses in women of reproductive age.
Pregnant uterus.
Ovarian tumors
Uterine sarcoma

Living with Fibroids and Prevention

No known cause of fibroids, therefore no definitive prevention guidelines.
Potential risk reduction strategies include weight loss to minimize estrogen levels and dietary changes (reduced red meat, increased green vegetables and fruits).

Treatment

Symptomatic fibroids require conservative management and regular ultrasound follow-ups to monitor growth.
Treatment choices depend on symptom severity, fibroid size and location, patient age, and future childbearing desires.
Women approaching menopause, where fibroids naturally shrink, may experience symptom improvement without treatment.

Conservative and Medical Treatment

Correction of anemia: Oral iron supplementation.
Tranexamic acid: Preferred over NSAIDs for menorrhagia management.
Combined Oral Contraceptives (COCs): Long-term use reduces menorrhagia by 50%.
Progesterone:
- Medroxyprogesterone (long-term) protects against fibroids.
- Levonorgestrel-releasing IUD offers superior protection compared to copper IUDs.
- Danazol and androgenic anti-progesterones (gestrogens) reduce fibroid size and blood loss.
- Mefepristone (anti-progesterone) decreases fibroid size with minimal bone density impact.

GnRH Analogues

Reduce estrogen levels, causing fibroids to shrink.
Six months of treatment can reduce fibroid size by up to 50%, stopping menstrual bleeding and pelvic pain.
Used in patients who are unfit for surgery or have failed medical therapy.
Administered prior to hysterectomy or myomectomy to minimize blood loss, reduce fibroid size, and enhance the possibility of a transverse abdominal incision.
Iron therapy is used to address anemia.

GnRH Analogue Side Effects

Menopause-like symptoms such as hot flashes, vaginal dryness, and bone loss (osteoporosis).
Fibroids grow back after drug discontinuation, and periods return within weeks. However, some women may no longer ovulate after treatment.
Temporary treatment option for women approaching menopause.

Add-Back Therapy

Used with long-term GnRH therapy to reduce fibroid size, bone loss, and vasomotor symptoms.
- Tibolone: Preferred choice for add-back therapy.
- Low-dose estrogen: 0.75 mg or 0.3 mg conjugated estrogen, with cyclical norethisterone 0.7 mg or continuous norethisterone 10 mg for a 2-year period.

Surgical Procedures

Myomectomy: Individual fibroid removal, leaving the uterus intact. Can be performed through laparotomy, laparoscopy, or hysteroscopy.
- Laparotomy: Used for intramural and subserous fibroids.
- Laparoscopic myomectomy: Minimal invasive option.
- Hysteroscopic myomectomy: Suitable for submucous fibroids.

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This quiz explores the essential aspects of fibroids, including their definition, prevalence, and characteristics. It also delves into the pathophysiology, risk factors, and the various types of fibroids. Join us to test your knowledge on these common uterine tumors.