Understanding Uterine Fibroids

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1 RCN Conference May 2014 Understanding Uterine Fibroids Dianne Crowe Advanced Gynaecology Nurse Specialist Northumbria Healthcare Trust

2 Objectives What are fibroids? What causes fibroids? What symptoms do fibroids cause? How are fibroids detected? What treatments are available?

3 What are fibroids? Up to 40% of all women have fibroids (30-50 years) Most common growth of the female reproductive tract 2-3 times more common in Afro-Caribbean women Fibroids arise from muscle cells in the wall of the uterus

4 Fibroids Range in size from as small as a pea to as large as a melon Range in number from 1 to >30 At least 50% of women with fibroids have no symptoms

5 Location of Fibroids The location determines what symptoms a women might experience.

6 Fibroids are white, hard, shiny and uniform in appearance. Symptoms of fibroids are related to their size and location.

7 What causes fibroids? Female hormones - oestrogen and progesterone After menopause, fibroids stop growing Pregnancy can make fibroids grow rapidly Fibroids shrink after delivery Familial tendency Possibly obesity

8 What symptoms do fibroids cause?

9 Pelvic Pressure or Discomfort Heavy, painful periods Fibroid Symptoms Lower Back Pain Urinary Symptoms Pain with Sexual Intercourse

10 Location dictates symptoms Fibroids in uterine cavity are the biggest problem for bleeding Fibroids that grow to the outside of the uterine cavity can get very large and press on the bladder or rectum Submucous Fibroids that develop just under the endometrium are very problematic

11 How are fibroids diagnosed?

12 NICE QS47 HMB (2013) Statement 2 Women with heavy menstrual bleeding in whom a structural or histological abnormality is suspected have a physical examination before referral for further investigations.

13

14 Pelvic MRI

15 Hysteroscopy is used to diagnose submucosal or intracavity fibroids

16 So. When is treatment necessary? What are the treatment options? What are the risks and benefits?

17 Treatment is necessary when fibroid Symptoms interfere with Activities of daily Living.

18 What are the Treatments?

19 Symptomatic Uterine Fibroids Medical Therapy Surgical Therapy Non-surgical treatment Hormones Non-hormonal Abdominal Myomectomy Hysterectomy Endometrial ablation Hysteroscopic myomectomy

20 NICE HMB Guidelines (2007) Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity. [D(GPP)]

21 Pharmaceutical therapy Hormonal Treatments for heavy periods Intrauterine Levonorgestrel-releasing system (Mirena-IUS) Combined oral contraceptives Oral progestogens Injected/depot progestogens Gonadotrophin-releasing hormone analogue for treatment of HMB associated with uterine fibroids (GnRH-a)

22 Pharmaceutical therapy Intrauterine Levonorgestrel-releasing systems (Mirena IUS) NICE (2007) first-line treatment for HMB

23 Gonadotrophin-releasing hormone analogue for treatment of HMB associated with uterine fibroids (GnRH-a) Evidence from seven RCTs shows that GnRH a causes fibroid shrinkage and a decrease in MBL. However, the effects do not continue after stopping treatment and adverse effects preclude long term use. NICE HMB (2007)

24 Pharmaceutical therapy Non-Hormonal Treatments for heavy periods Tranexamic Acid Nonsteroidal anti-inflammatory drugs (NSAIDs)

25 NICE QS47 HMB (2013) Statement 4 Women with heavy menstrual bleeding who are undergoing further investigations or awaiting definitive treatment are offered tranexamic acid or non-steroidal anti-inflammatory drugs at the initial assessment.

26 Medical Treatments There are no long term, effective medicines to treat fibroids Yet

27 Newly approved therapy ESMYA (Ulipristal Acetate) Selective progesterone receptor modulator Licensed for treatment of fibroids (March 2012) Symptom improvement in one week 98% improvement in heavy menstrual bleeding Less side effects than GnRH-a (hot flushes) 42% reduction in fibroid size Not for long-term use : 3-6 months and pre-operative indication

28 Summary: Under TRIAL Medical Therapy Product Outcome on fibroid size Outcome on heavy menstrual bleeding SPRM: Mifepristone(RU486) Decrease uterine volume by 40% Decrease (but small risk of endometrial hyperplasia) SPRM: Asoprisnil,Proellex Decrease by % Decrease SERM: ormeloxifene Unknown Decrease Oral progestogen:dienogest Unknown May decrease GnRHa: Ganirelix(subcutaneou s Injection) Aromatase Inhibitors:Anastrozole,Letrozol e Decrease by % Decrease Decrease Decrease Keys: SPRM: Selective progesterone receptor modulator SERM: Selective estrogen receptor modulator.

29 Surgical Treatments

30 Hysterectomy - an operation to remove the uterus Hysterectomy

31 How Common is Hysterectomy? 55,000 performed each year in UK 2nd most common surgical procedure 1 in 5 women at some point in their life. Majority performed between years.

32 Hysterectomy Fibroids Cannot Grow Back Symptoms Go Away No More Periods Advantages No Change In Hormones No Need for Contraception High Patient Satisfaction

33 Hysterectomy Loss of Uterus Unable to Become Pregnant Potential Disadvantages Need for Future Surgery Risk for Incontinence or Pelvic Relaxation

34 NICE HMB (2007) Hysterectomy should not be used as a first line treatment soley for HMB Women who have heavy bleeding and other treatments have failed, do not wish to remain fertile, or have large fibroids may request a hysterectomy

35 Myomectomy an operation to remove fibroids Myomectomy Abdominal Hysteroscopic Laparoscopic

36 Myomectomy Uterus Preserved Able to Become Pregnant Advantages Symptoms Usually Improve

37 Myomectomy New Fibroid Growth Symptoms May Not Go Away Potential Disadvantages C-Section to Delivery Babies Need for Future Surgery Major Surgery

38 Non-hysterectomy surgery Normal size uterus or small fibroids <3cm Endometrial ablation may be offered as an initial treatment for HMB after full discussion with the woman of the risks and benefits and of other treatment options. [A] Hysterectomy should not be used as a first line treatment solely for HMB. [D(GPP)] NICE HMB (2007)

39 One Stop Ambulatory Clinics: Clinical assessment with USS/Bloods/Biopsy. Definitive treatment with hysteroscopy +/-: Mirena IUS. Endometrial Ablation. Hysteroscopic Myomectomy. Outcome: Discharged to GP with either a management plan or with treatment completed. Add to waiting list for inpatient surgery such as hysterectomy.

40 Novasure endometrial ablation The NovaSure system is intended to ablate the endometrial lining of the uterus in pre-menopausal women with heavy bleeding due to benign causes for whom childbearing is complete.

41 Intracavitary Fibroids

42 MyoSure Procedure Animation. The MyoSure tissue removal system is a procedure that can eliminate fibroids without having to remove the uterus. This animation video demonstrates how the MyoSure procedure works. Hologic and MyoSure are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries.

43 Myosure Patient Selection: Indications & Benefits Indications: The MyoSure Hysteroscopic Tissue Removal System is intended for hysteroscopic intrauterine procedures by trained clinicians to resect and remove tissue including submucous myomas and endometrial polyps. Patient Benefits: Performed without incisions and with little or no anaesthesia Minimal recovery time Increased safety due to saline usage Efficient removal Short procedure time 10 min or less

44 Hysteroscopic Myomectomy Hysteroscopic Myomectomy - an operation to remove fibroids from inside the uterus

45 Hysteroscopic Resection of a Submucous Fibroid Hysteroscopy showing a pedunculated submucous fibroid (myoma) and the complete removal of the fibroid using the resectoscope

46 Non-surgical alternatives NICE QS47 HMB (2013) Statement 6 Women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.

47 MRgFUS (Magnetic Resonance Guided Focus Ultrasound) uses MRI Only suitable for small fibroids (3-10cm) where the high intensity ultrasound energy does not pass through the bowel or bladder on it s way to reach the fibroids NOT recommended for women who still want children The whole process takes up to 3-4 hours In the UK, this treatment method os not available on the NHS (costs )

48 Uterine Artery Embolisation (UEA) Indication: For heavy bleeding and large fibroids (NICE HMB 2007)

49

50 Uterine Artery Embolisation (UEA) Efficacy Bleeding 87-95% Pelvic pain/dysmenorrhea 85-97% Bulk-related symptoms 80-94% Reduction in fibroid volume 3 months 40-65%

51 Uterine Artery Embolisation (UAE) Complications Fibroid expulsion Vaginal discharge Endometritis/Infection Ovarian failure Contrast, medication allergies

52 Summary 50% women with fibroids have no symptoms Asymptomatic fibroids require no treatment Fibroids typically improve after the menopause Medical, surgical and non-surgical treatments are available for symptomatic women

53

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