Fibroids (Leiomyomas) Guideline GL1095 Approval Approval Group Job Title, Chair of Committee Date Gynaecology Clinical Governance Chair, Gynaecology Clinical 15th November Governance 2019 Change History Version Date Author, job title Reason October 2017 Gbemisola David-West, Ayo Benign Gynaecology 1 Olumbori, Registrars O&G Requirement Dalia Sikafi O&G, Consultant 2.0 October 2019 B Chohan, O&G Consultant Reviewed, minor changes pg 8/9 re: degenerating fibroids Author: B Chohan Date: November 2019 Job Title: Consultant O&G Review Date: November 2021 Policy Lead: Group Director Urgent Care Version: V2.0 ratified 15/11/19 Location: Policy hub/Clinical/Gynaecology/GL1095 This document is valid only on date printed Page 1 of 15 Fibroids (Leiomyomas) GL1095 November 2019 Contents 1. Purpose .......................................................................................................................... 3 2. Scope ............................................................................................................................. 3 3. Roles and Responsibilities ............................................................................................. 3 4. Definitions ....................................................................................................................... 3 5. Document content .......................................................................................................... 3 5.1. Introduction .................................................................................................................. 3 5.2. Diagnosis: .................................................................................................................... 4 6. Consultation Undertaken ................................................................................................ 9 7. Dissemination/Circulation/Archiving ............................................................................. 10 8. Implementation ............................................................................................................. 10 9. Training ........................................................................................................................ 10 10. Monitoring of Compliance .......................................................................................... 10 11. Supporting Documentation and References: ............................................................. 10 12. Equality Impact Assessment ........................................ Error! Bookmark not defined. Flow chart 1: Medical Management Guideline of fibroids. ................................................... 13 Flow chart 2: Surgical Management Guideline of fibroids. .................................................. 14 Table 1: Medical management ............................................................................................ 15 Author: B Chohan Date: November 2019 Job Title: Consultant O&G Review Date: November 2021 Policy Lead: Group Director Urgent Care Version: V2.0 ratified 15/11/19 Location: Policy hub/Clinical/Gynaecology/GL1095 This document is valid only on date printed Page 2 of 15 Fibroids (Leiomyomas) GL1095 November 2019 1.0 Purpose 1.1. To aid all clinical staff in the management of fibroids in accordance to NICE recommendations. 1.2. The aim of this guideline is to provide evidence based up to date information on the treatment of uterine fibroids 2.0 Scope • Gynaecology Clinics • Gynaecology Clinic Staff 3.0 Roles and Responsibilities All medical staff who review patients with fibroids in the gynaecology clinic and on Sonning ward. 4.0 Definitions Leiomyomas or uterine fibroids are common benign uterine smooth muscle tumours. Their growth is hormone dependant, affected by both oestrogen and progesterone. 5.0 Document content 5.1. Introduction Uterine fibroids are the most common solid tumour of the female pelvis, occurring in up to 30% of women after 30 years of age with a higher incidence in women of Afro- Caribbean origin. The majority of fibroids are asymptomatic and will not require therapy. However, they may cause symptoms of menorrhagia, pressure, pain and reproductive problems. Fibroids can be single or multiple and can vary in size, location, and perfusion. Fibroids can be classified based on their location: subserosal (projecting outside the uterus), intramural (within the myometrium), and submucosal (projecting into the cavity of the uterus) 2. A newer, more detailed classification system has been devised and advocated by FIGO2 Author: B Chohan Date: November 2019 Job Title: Consultant O&G Review Date: November 2021 Policy Lead: Group Director Urgent Care Version: V2.0 ratified 15/11/19 Location: Policy hub/Clinical/Gynaecology/GL1095 This document is valid only on date printed Page 3 of 15 Fibroids (Leiomyomas) GL1095 November 2019 5.2. Diagnosis: In many women, fibroids may be asymptomatic and are diagnosed incidentally on clinical examination or imaging. Fibroids can cause significant morbidity including menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron deficiency anaemia, bulk symptoms (e.g. pelvic pressure/pain, obstructive symptoms), and fertility issues3. Symptomatic fibroids have a considerable impact on women’s quality of life as well as their productivity. 5.3. Assessment: 5.3.1 History If fibroids are suspected, take a full medical and gynaecological history. This should include her cervical screening history, risk factors (including family history of fibroids), history of fertility problems and whether their family is complete. Ask about symptoms such as heavy bleeding, pelvic pain, abdominal distension, pressure symptoms and urinary or bowel symptoms 5.3.2 Clinical assessment Conduct an abdominal and bimanual pelvic examination to assess for the presence of a mass. On physical examination, an enlarged, mobile uterus (correlating to a weight of approximately 300 g or 12 weeks of pregnancy) with irregular contour is consistent with fibroids. 5.3.3 Investigations FBC To assess for iron deficiency anaemia Author: B Chohan Date: November 2019 Job Title: Consultant O&G Review Date: November 2021 Policy Lead: Group Director Urgent Care Version: V2.0 ratified 15/11/19 Location: Policy hub/Clinical/Gynaecology/GL1095 This document is valid only on date printed Page 4 of 15 Fibroids (Leiomyomas) GL1095 November 2019 Ultrasound Scan (trans-abdominal and trans-vaginal) Ultrasound is the most widely used modality because of its availability, ease of use, and cost-effectiveness. It is particularly helpful to assess fibroid growth and the adnexae if these cannot be palpated separately with confidence4. MRI An MRI of the pelvis may provide further information regarding location and size of fibroids. It is a prerequisite before consideration of uterine artery embolisation. It is also recommended prior to performing a myomectomy procedure. Any rapid growth in the size of the fibroids needs urgent investigation to exclude sarcomatous change. Abnormal uterine bleeding i.e. intermenstrual, heavy >45 years, postcoital or post menopausal bleeding necessitates further investigation to exclude pathology. 5.4. Management (Flow chart 1 and 2): Management of fibroids depends mainly on patient’s symptoms. Appropriate treatment should be planned with the woman, based on symptoms, fertility wishes, age and fibroid characteristics – site, size and location. 5.5. Expectant management Expectant management is acceptable in those who are asymptomatic. Consider annual follow up to monitor size and growth (NICE recommendation). 5.6. Medical Management for Symptomatic Patients: 5.6.1 Medical management (fibroid <3 cm) If the fibroids are less than 3 cm and the uterine cavity is not distorted, consider treatments in the following order: (NICE recommendation) Levonorgestrel-releasing intrauterine system (LNG-IUS) for at least 12 months LNG-IUS has been widely accepted as an effective treatment for heavy menstrual bleeding. Observational studies have shown a reduction in uterine volume, bleeding, and an increase in haematocrit5. Progesterone also induces endometrial atrophy. Another advantage is that it provides contraception. A randomised controlled trial showed that the LNG-IUS was more effective than the COCP in reducing menstrual loss and improving haemoglobin levels6. The LNG-IUS can be inserted by the GP/family planning clinic or booked into minor ops clinic at the RBH Hospital. Please ensure patients are given the information leaflet. Author: B Chohan Date: November 2019 Job Title: Consultant O&G Review Date: November 2021 Policy Lead: Group Director Urgent Care Version: V2.0 ratified 15/11/19 Location: Policy hub/Clinical/Gynaecology/GL1095 This document is valid only on date printed Page 5 of 15 Fibroids (Leiomyomas) GL1095 November 2019 Tranexamic acid (antifibrinolytic agent) Approved for treatment of heavy menstrual bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs are used to reduce menstrual blood loss and dysmenorrhoea. They are prostaglandin antagonists which prevent the uterus contracting, leading to pain. Combined oral contraceptive pill (COCP) Approved for treatment of heavy menstrual bleeding. Mechanism of action is endometrial atrophy. Associated with decreased risk of fibroids and reduced symptoms from other gynaecological conditions. Norethisterone/ Long-acting progesterone-only injectables This form of treatment is thought to induce endometrial atrophy thus licensing it for the treatment of heavy menustrual bleeding.