Modern Management of Fibroids

Modern Management of Fibroids
ModernManagementofFibroids
MrNarendraPisal
ThePortlandHospital
Modern management of fibroids | www.london-fibroids.com
Fibroids
Verycommon
20-40%ofallwomen
Upto80%ofblackwomenby50y
MostfibroidsareasymptomaFc
50%willhavesignificantsymptoms
SymptomsdependonlocaFon,size,changes&pregnancystatus
Modern management of fibroids | www.london-fibroids.com
AbnormalUterineBleeding
Submucousfibroidsmorelikelytocausebleeding
Menorrhagia+IMB
Modern management of fibroids | www.london-fibroids.com
Pain
VascularocclusionÆnecrosis,infecFon
ReddegeneraFonÆacutepain
Heaviness,fullnessinthepelvicarea
Massandpressuresymptoms
Dyspareunia
Modern management of fibroids | www.london-fibroids.com
PressureEffects
Pressureonureters,bladderorrectum
UrinarysymptomsandretenFon
Hydroureterandhydronephrosis
ConsFpaFon
Legedema
Modern management of fibroids | www.london-fibroids.com
InferFlity
Fibroidscanleadtosub-ferFlity
SubmucousfibroidsoWeninterferewithimplantaFon
Cornualfibroidscanobstructfallopiantubes
MulFplefibroidsandanenlargeduterinecavityalsobeafactor
ThereisgoodevidencethatmyomectomywillimproveferFlity
LaparoscopicMyomectomyandHysteroscopicsurgeryareassociatedwithbestoutcome
Modern management of fibroids | www.london-fibroids.com
PregnancyandFibroids
FibroidscanaffectchancesofgeXngpregnant
Submucousfibroidscancauseearlypregnancylossandprematurelabour
Fibroidstendtoincreaseinsizeduringpregnancyleadingto:
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Increaseddiscomfort
ReddegeneraFonofpregnancy
MalposiFonormalpresentaFon
IncreasedneedforCaesareanSecFon(whichcanbedifficultandcomplex)
Post-partumHaemorrhage
Modern management of fibroids | www.london-fibroids.com
Fibroids:Whentorefer
DiagnosisbasedonexaminaFon+scan
SymptomaFcFibroids
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Largefibroids
Heavyperiodscausinganaemia
Intermenstrualbleeding
Pressuresymptoms
Pre-pregnancycounseling
Difficultyinconceiving
Suddenincreaseinsize
Modern management of fibroids | www.london-fibroids.com
Fibroids:InvesFgaFons
ExaminaFon+USSscan
FBCFerriFn
Hysteroscopy
MRImaybeneededpriortoLapMyomectomy
Fibroidmapping(Pre-op)withUSS
Modern management of fibroids | www.london-fibroids.com
Treatment
SupporFveTreatment
HysteroscopicSurgery
Myomectomy
•  LaparoscopicMyomectomy
•  OpenMyomectomy
Hysterectomy
UterineArteryEmbolisaFon
MRIGuidedFocusedUltrasound
MedicalTreatment(GnRHa/UllipristalAcetate)
Modern management of fibroids | www.london-fibroids.com
SupporFveTreatment
Regulatemenses
•  OCPs
Stabilizeendometrium
•  CyclicalProgesterone
Stopmenses
•  GnRHanalogues/UllipristalAcetate
TranexamicAcid
CorrecFonofanaemia
Mirenaifcavitynormal
Modern management of fibroids | www.london-fibroids.com
TranscervicalResecFonofSubmucousFibroid
Advantages
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MosteffecFvetreatment
Daysurgeryprocedure
Quickrecovery
Reducedbleeding
ImprovedferFlity
Improvedpregnancyoutcome
Disadvantages
•  Notallfibroidssuitable
•  SomefibroidscanonlybeparFally
resectedneedingsecondstage
procedure
Modern management of fibroids | www.london-fibroids.com
Laparoscopic myomectomy
Modern management of fibroids | www.london-fibroids.com
LaparoscopicMyomectomy
Advantages
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MinimalAccess
Enhancedrecovery
CosmeFcscars
MinimalpostoperaFveadhesions
Excellentpregnancyrates
Disadvantages
•  Notallfibroidsremoved
•  RiskofmorcellaFon
•  NeedforcaesareansecFon
Modern management of fibroids | www.london-fibroids.com
Excellentresults
Modern management of fibroids | www.london-fibroids.com
OpenMyomectomy
Modern management of fibroids | www.london-fibroids.com
UterineArteryEmbolisaFon
Advantages
•  Non-invasiveprocedure
•  90%getsomereliefofpressureand
bleedingsymptoms
•  VolumereducFonby40-60%
•  Excellentchoiceforwomenin40stypically
aWercompleFonoffamily
Disadvantages
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Notsuitableforlargefibroids(>24w)
Painfulprocedure
Discomfort/waterydischarge\InfecFon
Prematuremenopause
Recurrence
Modern management of fibroids | www.london-fibroids.com
MRIguidedfocusedUltrasound
StMary’sHospital
NotsupportedbyNICEyetforgeneraluse
Forasinglefibroidupto10cm
20%reducFoninvolume
Limitedrole
Modern management of fibroids | www.london-fibroids.com
GNRHAgonists(Prostap/Zoladex)
ReducFoninvolumeupto50%over3months
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Tostopbleedingtoimprovepreopfitness
ForpreopreducFoninsizetomakesurgeryeasier
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NowadaysreplacedbyUllipristalAcetate
Modern management of fibroids | www.london-fibroids.com
UllipristalAcetate(Esmya)–TabletsforFibroids?
SelecFveProgesteroneReceptorModulator
ActslocallyonfibroidsthroughinhibiFonofcellproliferaFonandapoptosis
Directeffectonendometriumwithreducedbleeding
Alsoactsonpituitary/hypothalamustoinhibitovulaFon(butoestrogenlevelsmaintained)
Modern management of fibroids | www.london-fibroids.com
UllipristalAcetate(Esmya)–TabletsforFibroids?
Advantages
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OraladministraFon(5mgODx3m)
Reducedvolumeoffibroids(67%)
Stopsbleedingquickly(amenorrhoeain75%)
EffecFvepreoperaFvely
Licensedforrepeatcourses(2periodsbetweenconsecuFvecoursesof3m)
EffectcomparablewithGnRHawithlesssideeffects
Improvedqualityoflife,reducedpain
Establishedsafetyrecord
Disadvantages
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Cost
Temporaryeffect(butlastsuptosixmonths)
Minorsideeffects(Nausea/headache/FaFgue/Acne/Hotflushesin15%)
Modern management of fibroids | www.london-fibroids.com
PlaceforHysterectomy
LaparoscopicHysterectomyoWenpossible
SomeFmesopenincisionneeded
Canbetotalorsubtotal
PermanentsoluFon
Womenovertheageof40withcompletedfamily
Modern management of fibroids | www.london-fibroids.com
Summary
•  Verycommon
•  OWenasymptomaFc
•  OWencanbemanagedbysupporFvetreatment
•  SurgicalintervenFonrequiredin20%ofwomen
•  Ifsurgeryrequired;hysteroscopicorlaparoscopicsurgerypreferred
•  Ullipristalhaschangedthemanagementoffibroidsoverthelastfewyears
Modern management of fibroids | www.london-fibroids.com
ThankYou
London Gynaecology Limited
The Portland Hospital
212, Great Portland Street
London W1W 5QN
Secretary:
Viviana Amoretti
M: 07971 200 832
T : 020 8367 8999
F : 020 8082 5667
contact@london-gynaecology.com
www.london-gynaecology.com
www.london-fibroids.com
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