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Fibroids in General Practice: A PLAB 2 Roadmap from Diagnosis to Referral

Updated: Jun 26


🩺 In General Practice (GP Setting)


🔍 Initial Assessment

  • Full history and pelvic exam

  • Blood tests: especially FBC (for anemia)

  • Request pelvic ultrasound scan (transvaginal preferred)


💊 Medical Management

1. Pain Relief:

  • NSAIDs (e.g., ibuprofen, mefenamic acid) – reduce menstrual pain and cramping

2. Bleeding Control:

  • Tranexamic acid – reduces blood loss during menstruation

  • Combined oral contraceptive pill (COCP) or Progestins – regulate cycles and reduce bleeding

3. LNG-IUS (Mirena®):

  • Effective in reducing heavy menstrual bleeding

  • Suitable if fibroids are <3 cm and do not distort the uterine cavity

  • Small intramural fibroids may be acceptable if they do not indent the cavity

  • Not suitable for:

    • Submucosal fibroids

    • Large intramural fibroids causing cavity distortion

    • Cases where proper placement is doubtful

4. Anemia Management:

  • Iron supplementation (oral or IV if severe)

5. Monitoring & Follow-up:

  • Reassess in 3–6 months

  • Provide safety netting:

    “Please return if you experience severe pain, heavy bleeding (soaking pads hourly), worsening urinary or bowel symptoms, unusual discharge, or if you're planning pregnancy or become pregnant.”


📤 When to Refer to a Specialist (Gynaecologist)


🕓 Routine Referral (via NHS e-RS)

  • Fibroids >3 cm

  • Persistent heavy bleeding despite treatment

  • Anemia not resolving

  • Distortion of the uterine cavity

  • Fertility concerns

  • Patient preference for surgical or advanced options


🔺 Urgent Referral

  • Postmenopausal woman with new or growing fibroid

  • Rapid fibroid growth

  • Suspicious ultrasound features (e.g., irregular margins, necrosis)

  • Severe pressure symptoms (e.g., urinary retention)



🏥 Specialist Treatment Options

(and Their Impact on Fertility)


🔍 Further Imaging

  • Detailed pelvic ultrasound or MRI

    • Helps map fibroid size, number, and relationship to uterine cavity

    • Essential for fertility planning and surgical decision-making


💊 Advanced Medical Therapies

  • GnRH Agonists (e.g., Leuprolide)

    • Temporarily shrink fibroids and improve anemia before surgery

    • Short-term fertility benefit if used pre-IVF or myomectomy

  • SPRMs (e.g., Ulipristal acetate)

    • Can reduce size and bleeding

    • Restricted use due to rare risk of liver damage

    • Not used to enhance fertility


✂️ Surgical Options

  • Myomectomy

    • Removes fibroids while preserving the uterus

    • Ideal for women trying to conceive

    • May be done laparoscopically, abdominally, or hysteroscopically

    • Improves fertility, especially if submucosal or large intramural fibroids are removed

  • Hysterectomy

    • Complete removal of the uterus

    • Definitive treatment

    • Not suitable for those who wish to conceive

  • Hysteroscopic Resection

    • For submucosal fibroids within the uterine cavity

    • Minimally invasive

    • Can significantly improve fertility and reduce miscarriage risk



🌐 Non-Surgical Interventions


Uterine Artery Embolization (UAE)

UAE involves injecting tiny particles into the uterine arteries to block blood flow to the fibroids, causing them to shrink. While it’s uterus-sparing, it is not recommended for women who wish to preserve fertility, due to the following risks:

🧠 Mechanism of Action:

  • Targets the fibroids by cutting off their blood supply

  • Intends to spare the uterus—but precision is not perfect

⚠️ Why It Can Affect Fertility:

  1. 🧬 Endometrial Damage

    • The endometrium (uterine lining) also receives blood from the uterine arteries

    • Ischemia can cause:

      • Thinning or scarring of the lining

      • Impaired implantation

      • Increased risk of miscarriage

  2. 🥚 Ovarian Impairment

    • The ovaries share collateral blood flow with the uterus

    • UAE may affect ovarian function, especially in:

      • Women over 40

      • Women with anatomical vascular variants

    • May lead to:

      • Reduced ovarian reserve

      • Early menopause

      • Disrupted ovulation

  3. 🤰 Pregnancy Complications (if conception occurs):

    • Higher risk of:

      • Placenta previa

      • Placental abruption

      • Fetal growth restriction

      • Preterm delivery

      • Uterine rupture (rare)

📌 Summary:

Although UAE aims to preserve the uterus, its potential impact on the endometrium and ovaries makes it unsuitable for women trying to conceive. Fertility outcomes after UAE are less predictable, and safer options like myomectomy are preferred in reproductive-age women.


MRI-Guided Focused Ultrasound (MRgFUS)

  • Non-invasive, uses ultrasound energy to destroy fibroid tissue under MRI guidance

  • Preserves the uterus

  • Fertility outcomes still under research

  • Offered only in specialist centres


Summary Table: GP vs Specialist Management

Aspect

GP Management

Specialist Management

Assessment

History, exam, FBC, pelvic ultrasound

MRI, advanced imaging

Medical Treatment

NSAIDs, Tranexamic acid, COCP, Progestins, LNG-IUS

GnRH agonists, SPRMs

Fertility-Safe Option

LNG-IUS (if <3 cm, no cavity distortion)

Myomectomy, hysteroscopic resection

Definitive Treatment

—

Hysterectomy

Minimally Invasive

—

UAE (fertility risk), MRgFUS (research stage)

Referral Type

Routine (>3 cm or failed medical mgmt), Urgent (if red flags)

—


📚 References

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