Uterine fibroids (leiomyoma)

Uterine fibroids (leiomyoma)

Fibroids are usually benign, well-circumscribed, smooth muscle tumours of the uterus. Less than 1% of fibroids undergo malignant transformation (leiomyosarcoma). They are more common in certain populations (African–Caribbean women) and vary in size and number. They are typically found in the following locations ( Figure 87.21 ): /uni25CF Subserosal: may cause pressure-type symptoms; if pedun - - culated, they can be di ffi cult to distinguish from an ovarian - tumour. /uni25CF Intramural: may similarly cause pressure-type symptoms; can be associated with infertility and heavy periods if they lead to endometrial distortion. - /uni25CF Submucosal: associated with infertility , recurrent pregnan - cy loss and heavy periods; if pedunculated, they may occa - sionally extrude through the cervical os. - /uni25CF Rare: sites include the broad ligament and cervix. and/or irregular menstrual bleeding, anaemia, pressure-type symptoms or infertility , especially if the fibroid is distorting the uterine cavity . The pressure-type symptoms can include pel vic discomfort, urinary incontinence, frequency and retention, constipation and backache. When large fibroids are present, back pressure may cause or exacerbate varicosities. Although these symptoms are common, it is important to note that some women with fibr oids are asymptomatic. Rarely , women may present acutely with pain arising from torsion of a peduncu lated fibroid or red degeneration, especially in pregnancy . A diagnosis can usually be made on bimanual and/or abdominal examination, in the presence of an enlarged uterus with attached swellings. The principal di ff erential diagnosis is an ovarian tumour; in general, if an ovarian tumour is present, the uterus is felt separately on vaginal examination, although not if the structures are adherent to each other. A pelvic ultra sound scan is the first-line investigation with high sensitivity and specificity . An MRI can be performed if an ultrasound is declined by the patient or is inconclusive ( Figure 87.22 ). Treatment can be divided into: conservative if the w is asymptomatic; medical to reduce the quantity of menstrual bleeding; hormonal manipulation to control menstrual bleed ing or to shrink the fibr oids; or surgical (uterus-preserving or non-uterus-preserving methodologies) ( Table 87.7 ). The choice of treatment depends upon the woman’s age and fer tility intentions, the size and number of fibr oids as well as their location. Emergency surgical treatment is only required if there is substantial menstrual bleeding or uncontrollable pain; these are rare events.