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How do you reassure a worried patient with fibroids?

Dr Tanvir Jamil explores a common presentation in general practice

Dr Tanvir Jamil explores a common presentation in general practice

Case history

Jacki, a 40-year-old with two children has had a three year history of regular but very heavy periods. Her haemoglobin is 10.5g/l. She calls you after her scan and is clearly anxious. The sonographer has told her she has a tumour called a fibroid.

I've heard fibroids are the commonest type of tumour. Are there figures to back this up?

• Found in one in five women at post mortem

• Five in 1000 Caucasian women have fibroids in pregnancy

• 15x more often in body of uterus than cervix

• more common in nulliparae, low parity, over-40s, African-Caribbeans and Japanese.

What is the pathophysiology of fibroids?

Fibroids are most commonly associated with the myometrium and consist of smooth muscle bundles and connective tissue. Their size may vary from microscopic to huge and they have a characteristic whorled appearance.

As the tumours grow they can project from the uterus's peritoneal surface (subserous) or distort the uterine cavity (submucous). Subserous fibroids may become pedunculated and submucous fibroids polypoidal. They may be found in the cervix or broad ligament.

Fibroids can distort or displace the uterus, pushing it forwards, into retroversion or to one side. Fibroids are thought to be oestrogen-dependent as they do not occur prior to puberty and tend to shrink after the menopause. They may enlarge in pregnancy or on the combined oral contraceptive pill.

What signs and symptoms should I look out for?

These depend on the fibroid's size. A typical presentation is menorrhagia due to increased endometrial vascularity or uterine cavity distortion. The tumour may give rise to no symptoms until it fills the pelvis and becomes palpable abdominally. Frequent or occasional stress incontinence may arise due to pressure on the bladder. Backache is common but bowel symptoms are surprisingly rare. A fibroid polyp may cause acute colicky dysmenorrhoea and, if necrosis of the apex occurs, intermenstrual bleeding and discharge.

Fibroids are associated with infertility and may cause their effects by distorting the uterine cavity or blocking the fallopian tubes.

Occasionally, the patient may present with an abdominal lump or with pressure symptoms such as frequent micturation and/or swollen legs.

Fibroids can cause symmetrical enlargement of the uterus if single, or distort its shape if multiple. Small fibroids are found on vaginal examination as firm painless tumours which move with the cervix. Large fibroids arise out of the pelvis and can be felt abdominally. The tumour may be single and rounded or consist of a group of rounded 'bosses'.

Apart from a scan are other investigations worth doing?

Uterine fibroids are usually diagnosed clinically, but they may be difficult to differentiate from an ovarian mass. Fibroids and pregnancy may co-exist and in difficult cases pregnancy tests may need to be done. Unless the fibroid is very obvious, other causes will need investigation such as FBC, platelets, TSH, clotting screen for menorrhagia; prolactin, TSH, FSH and day 21 progesterone for infertility. Ultrasound scanning, especially transvaginal, can accurately identify the nature of a pelvic mass in over 80% of cases.

MRI is more accurate but is expensive and less widely available to GPs. If doubt remains about the nature of the pelvic mass the patient needs referral. Laproscopy or laprotomy are indicated to exclude an ovarian mass. Hysterosalpingography and hysteroscopy may be useful in the detection of submucous fibroids.

Jacki is worried her ‘lump' might be cancerous. What can I tell her?

Malignant change is rare in fibroids and tends to occur in larger tumours. There is rapid enlargement, ascites and pain with occasional postmenopausal or intermenstrual bleeding. Other non malignant changes are, however, more common:.

• Hyaline degeneration - common in large tumours and may lead to cystic change as the hyaline areas liquefy.

• Calcification (‘womb-stones') - often occurs in pedunculated fibroids in older women.

• Red generation – due to acute interference of blood supply (by kinking & thrombosis of blood vessels); more common in pregnancy. Tumour swells and softens. Fever, pain and vomiting occur. Characteristic tender spot on the uterus which moves with the uterus, distinguishing it from appendicitis or torsion of an ovarian cyst; self limiting condition treated with strong analgesics.

• Torsion – occurs in pedunculated fibroid; rare; acute pain, shock and vomiting. A medical emergency requiring laprotomy.

Torsion, red degeneration and impaction are more common in pregnancy, and a fibroid may be damaged and /or infected during labour.

What management options can I discuss with Jacki?

Small fibroids rarely require treatment, but need regular monitoring. Most women with symptomatic fibroids will need referral to a gynaecologist. Larger fibroids may be treated with danazol or a gonadotrophin-releasing hormone analogue (GnRH) to reduce their size, blood loss and complications prior to surgery. Surgery should be considered for heavy menstrual bleeding where large fibroids (>3 cm in diameter) are present and bleeding is having a severe impact on quality of life.

Surgical options include hysterectomy (when the patient has completed her family or is over 40); myomectomy (removal of the fibroid alone – in younger patients when future childbearing remains an option); and uterine artery embolisation. Following myomectomy there is relief of menorrhagia reported in 75% of cases, pregnancy in 50% and hysterectomy or further myomectmy in 25%.

Hysterectomy has a relatively low mortality rate (6/10,000) but high morbidity (43/100). Recent advances in 'minimally invasive surgery' have thrown up some alternatives to hysterectomy. Some fibroids can now be excised or ablated via the laproscope or the hysterscope. Large or multiple fibroids are however not usually suitable for these because of the risks of bleeding and increased technical difficulty. Lasers can be used directly to vaporise small fibroids or for dissection and excision of larger tumours.

Further patient information:
Patient UK

Womens' Health Solutions.co.uk

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