Fibroid mapping. Haitham Hamoda MD FRCOG Consultant Gynaecologist, Subspecialist in Reproductive Medicine & Surgery King s College Hospital

Size: px

Start display at page:

Download "Fibroid mapping. Haitham Hamoda MD FRCOG Consultant Gynaecologist, Subspecialist in Reproductive Medicine & Surgery King s College Hospital"

Nicholas Horn
5 years ago
Views:

1 Fibroid mapping Haitham Hamoda MD FRCOG Consultant Gynaecologist, Subspecialist in Reproductive Medicine & Surgery King s College Hospital

2 Fibroids Common condition >70% of women by onset of menopause % cause symptoms that require intervention. More in Afrocaribbean (usually multiple fibroids). Stewart et al BJOG

3 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.

4 Fibroids

5 Fibroids

6 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.

7 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 BJOG

8 Fibroids Abnormal uterine bleeding. Infertility. Pressure symptoms.

9 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 Lumsden Miura et al SOGC Clinical Practice Guideline 2015.

10 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.

11 Systematic review by Pritts et al Submucous fibroids: lower pregnancy rates (70% lower; RR 0.32; 95%CI ) and surgical removal appeared to improve pregnancy rates (RR 2.03, 95%CI ). Intramural fibroids: May decrease fertility (RR 0.810; ), but benefit of surgical removal remains unclear. Subserous fibroids: similar fertility outcomes to women with no fibroids and surgical treatment did not alter outcome.

12 Management of Uterine Fibroids in Women with otherwise unexplained infertility gkh SOGC Clinical Practice Guideline 2015 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)

13 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)

14 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.

15 Clinical Assessment Size. Location: Submucous (subendometrial) Intramural Subserosal Combinations of these The number of fibroids.

16 Fibroids

18 FIGO: Fibroid subclassification system

19 Diagnosis Clinical assessment: Uterine size. Ultrasound 2D and 3D. 85% sensitivity 99% specificity. Sonohysterogram 2D and 3D. MRI. 92% sensitivity and 90% specificity. 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

20 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

21 2D ultrasound

22 3D ultrasound

23 MRI 100% sensitivity and 91% specificity. Limitations cost, accessibility. HSG Sensitivity (50%) and positive predictive value (29%) for intrauterine lesions low.

24 MRI

25 HSG

26 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

27 Normal endometrial cavity

29 Submucous fibroid: Saline sonography

30 Submucous fibroid: Saline sonography

32 Fibroids: Treatment Medical Surgical Uterine artery fibroid embolisation

33 Fibroids: Treatment Medical: Tranexamic acid / NSAID. Combined contraceptive pill. Mirena IUS. Oral progestogen e.g. Provera 10 mg day Depoprovera. SPRM (e.g. ulipristal).

34 Fibroids: Treatment Surgical: Hysterectomy Myomectomy - Preserve uterus Preserve fertility Removal of fibroids - Abdominal open / laparoscopic Hysteroscopic

36 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.

37 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)

44 Thank you..

Menstrual Disorders & Ambulatory Gynaecology

Menstrual Disorders & Ambulatory Gynaecology Mr. Nagui Lewis Aziz M B, CH B, FRCOG Consultant Gynaecologist The Royal Oldham Hospital 01/09/2018 Heavy menstrual bleeding (HMB ) is a common problem responsible