haitham hamoda md frcog consultant gynaecologist, … · 2017-05-17 · •evaluate and classify...
TRANSCRIPT
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..