Fibroid mapping

Haitham Hamoda MD FRCOG

Consultant Gynaecologist, Subspecialist in

Reproductive Medicine & Surgery

King’s College Hospital

Fibroids

• Common condition >70% of women by

onset of menopause.

• 25-50% cause symptoms that require

intervention.

• More in Afrocaribbean (usually multiple

fibroids). Stewart et al. 2017 BJOG

Fibroids

• Benign neoplasms that arise from

uterine smooth muscle (myometrium) in

women of reproductive age.

• Composed of disordered myofibroblasts

buried in abundant quantities of

extracellular matrix.

Fibroids

Fibroids

Fibroids

• The initiating events for fibroid genesis

remain speculative.

• Growth is dependant on the ovarian

steroids oestrogen and progesterone.

• Therefore most fibroids shrink after

• menopause.

Fibroids: Risk factors

Increased risk:

• Black women: 2-3 fold

increase.

• Age (40-50 are 10 times

more likely to have

fibroids than 21-30).

• Family Hx.

• Time since last birth (>5

years 2-3 fold increase).

• Soybean milk.

• Obesity.

Lower risk:

• Parity.

• Oral contraceptive pill.

• Depo (DMPA).

• Smoking.

Stewart et al. 2017 BJOG

Fibroids

• Abnormal uterine bleeding.

• Infertility.

• Pressure symptoms.

Abnormal uterine bleeding

• Heavy menstrual bleeding is the

indication in 30% of myomectomies.

• Mechanism is unknown.

?Increased endometrial surface area

?vascular dysregulation

?interference with endometrial

hemostasis. Buttram et al. 1981. Lumsden 1998. Miura et al. 2006. SOGC

Clinical Practice Guideline 2015.

Fibroids and infertility

• Studies have demonstrated an association between

fibroids and subfertility.

• 5-10% of women with infertility have fibroids. (1-2%

after excluding other causes). Donnez 2002

• Explanation poorly understood.

• ? related to distortion of the endometrial cavity with

submucous fibroids.

• Other possible mechanisms include inflammation

and alteration of endometrial blood supply resulting

in a hostile endometrial environment affecting sperm

motility and embryo implantation.

Systematic review by Pritts et al.

2009

• Submucous fibroids: lower pregnancy rates

(70% lower; RR 0.32; 95%CI 0.13-0.70) and

surgical removal appeared to improve

pregnancy rates (RR 2.03, 95%CI 1.08- 3.83).

• Intramural fibroids: May decrease fertility

(RR 0.810; 0.70-0.94), but benefit of surgical

removal remains unclear.

• Subserous fibroids: similar fertility outcomes

to women with no fibroids and surgical

treatment did not alter outcome.

• Evaluate and classify fibroids, particularly

those impinging on the endometrial cavity,

using TV U/S, hysteroscopy,

hysterosonography or MRI. (III-A).

• In women with otherwise unexplained

infertility, submucosal fibroids should be

removed in order to improve conception and

pregnancy rates. (II-2A)

Management of Uterine Fibroids in Women

with otherwise unexplained infertility gkh

SOGC Clinical Practice Guideline 2015

SOGC Clinical Practice Guideline

2015

• Effect of intramural fibroids remains unclear.

• If intramural fibroids do have an impact on

fertility, it appears to be small and to be even

less significant when the endometrium is not

involved.’ (II-3)

• Subserosal fibroids do not appear to have an

impact on fertility.

• Removal of subserosal fibroids is not

recommended. (III-D)

Pressure symptoms / Pelvic pain

• Pelvic pressure:

-Bladder symptoms (urinary frequency /

urgency) may be present with larger fibroids.

Should be investigated prior to surgery.

-Bowel dysfunction.

• Pelvic pain rare with fibroids. May signify

degeneration, torsion, or associated adenomyosis

and/or endometriosis.

• Postmenopausal woman with new onset pain /

bleeding in new or existing fibroids, leiomyosarcoma

should be considered.

Clinical Assessment

• Size.

• Location:

Submucous (subendometrial)

Intramural

Subserosal

Combinations of these

• The number of fibroids.

Fibroids

FIGO: Fibroid subclassification

system

Diagnosis

• Clinical assessment: Uterine size.

• Ultrasound 2D and 3D.

85% sensitivity 99% specificity.

• Sonohysterogram 2D and 3D.

92% sensitivity and 90% specificity.

• MRI.

• Hysteroscopy.

Smith et al. 1984, Fukuda et al. 1993, Dueholm et al, 2001, Jurkovic, 2002,

Leone and Lanzani 2003, Van Dongen et al., 2007, El-Sherbiny et al. 2011.

Ultrasound

• Ultrasound has been shown to be an

adequate and cost-effective means of

evaluating:

size, number, and location of fibroids.

• May identify fibroids of up to 4 to 5 mm in

diameter.

• Interobserver variation greater than with MRI.

Dueholm et al. 2002.

2D ultrasound

3D ultrasound

MRI

• 100% sensitivity and 91% specificity.

• Limitations cost, accessibility.

HSG

• Sensitivity (50%) and positive

predictive value (29%) for intrauterine

lesions low.

MRI

HSG

Saline sonography

• Superior to TV U/S alone and equal to

hysteroscopy in the evaluation of

endometrial impingement.

• Highly sensitive and specific for

submucosal fibroids.

-Risk of infection (approximately 1%)

-Discomfort.

Dueholm et al. 2001

Normal endometrial cavity

Submucous fibroid:

Saline sonography

Submucous fibroid:

Saline sonography

Fibroids: Treatment

• Medical

• Surgical

• Uterine artery fibroid embolisation

Fibroids: Treatment

Medical:

• Tranexamic acid / NSAID.

• Combined contraceptive pill.

• Mirena IUS.

• Oral progestogen e.g. Provera 10

mg day 5-26.

• Depoprovera.

• SPRM (e.g. ulipristal).

Fibroids: Treatment

• Surgical:

Hysterectomy

Myomectomy - Preserve uterus

Preserve fertility

• Removal of fibroids -

Abdominal open / laparoscopic

Hysteroscopic

NICE Recommendations for Uterine

Fibroids

• Heavy menstrual bleeding and fibroids >3 cm size

(especially with pelvic pain or other symptoms)

options:

– Hysterectomy, Uterine artery embolisation (UAE)

and myomectomy should all be offered.

– Myomectomy recommended if fertility is desired.

– Hysteroscopic resection is appropriate if the

fibroid(s) are submucous.

• GnRH analogue for 3-4 months before hysterectomy

and myomectomy:

– Reduces uterine size and makes surgery easier.

– Better HB pre op and less bleeding.

SOGC Clinical Practice Guideline

2015: myomectomy vs embolisation

• Lower pregnancy rates, higher miscarriage

rates, more adverse pregnancy outcomes

following uterine artery embolisation than after

myomectomy. (II-3)

• Cumulative pregnancy rates for laparoscopy vs

minilaparotomy are similar, but laparoscopic

approach associated with quicker recovery,

less postoperative pain, and less febrile

morbidity. (II-2)

Thank you..