Management of fibroids

Fibroids are common and have presence in up to 80% of women. They are monoclonal benign tumours arising from smooth muscle cells in the myometrium.

They can be single or multiple, small (under a centimetre) to massive (over 10cm). The exact aetiology is unknown. They are hormonally responsive. Symptoms are usually experienced by women in the reproductive years. AfroCaribbean women seem to have the highest ethnic prevalence but women from all ethnicities are affected.

Treatment depends on the symptoms experienced. Many women are asymptomatic and the fibroids are an incidental finding on imaging for another reason. Such women can be reassured that they do not need treatment. Ultrasound is usually sufficient for imaging, but if the fibroid is large or rapidly growing, an MRI pelvis should be considered to rule out any features of sarcoma. If sarcoma is suspected, a gynaecology oncology opinion should be sought. The most common symptom arising from fibroids is menorrhagia. The usual treatments for menorrhagia such as tranexamic acid, levonorgestrel IUD, endometrial ablation and hysterectomy can be offered. Women need to be warned that conservative treatments for menorrhagia have a lower success rate than if fibroids are not present.

Ullipristal (a selective progesterone receptor modulator) was a medical treatment for fibroids but has been withdrawn from the market due to cases of severe liver failure. Myomectomy is, in general, a fertility-sparing operation and should be reserved for large fibroids 6cm and above. Laparoscopic myomectomy has been complicated by the withdrawal of laparoscopic motorised morcellators from the market. Morcellation can cause small fibroid chips to disseminate throughout the abdomen, which may result in unintended seeding of a malignancy.

Some surgeons have developed personalised techniques for in-bag morcellation but as the instruments and equipment are not widely available, in addition to the litigious aspects, most large fibroids are removed via an open procedure. Women undergoing this procedure should have elective Caesarean delivery prior to the onset of labour in any future pregnancy.

Uterine artery embolisation can be an effective treatment for fibroids where available. It avoids the need for surgery and general anaesthetic and generally can be done as a day procedure. It causes reduction in the size and volume of the fibroid, which can relieve symptoms.

Submucosal fibroids can be effectively treated via hysteroscopic morcellation. Commonly used devices do not use energy which greatly increases the safety of the procedure.

M.Clin.Aud., BHSc (Physiotherapy)

Post Dip. Aud., BSc Sudden sensorineural hearing loss (SNHL) affects 5-20 per 100,000 people per year. ̈Ã`iw˜i`>Ã>…i>Àˆ˜}œÃÀÎä` ˆ˜ĈÎ frequencies occurring within three days. It may be accompanied by aural fullness, tinnitus, vertigo and sound distortion.

SNHL generally occurs unilaterally but, after the initial insult, patients are at an increased risk of loss in the contralateral ear and ipsilateral relapse. Suspected aetiologies are genetic causes, viral infections, autoimmune diseases and vascular insults. A lack of good diagnostic ̜œÃÀiÃՏÌȘ>ÀœÕ˜`n䯜vV>ÃiÃLiˆ˜}`iw˜i`>È`ˆœ«>̅ˆV° >˜Þœv ̅iˆ`i˜Ìˆw>LiV>ÕÃiÃœvÃÕ``i˜- i°}°L>VÌiÀˆ> meningitis, diabetes mellitus, syphilis) have broader health implications for the patient, warranting thorough investigations in all cases for reasons beyond hearing recovery alone. Many aetiologies cause irreversible damage to the outer hair cells and cochlear support structures. In some cases, further damage can be prevented by timely diagnosis and treatment of the underlying condition. The most common medical treatment for idiopathic sudden SNHL are systematic corticosteroids. There is some evidence for the additional inclusion of hyperbaric oxygen therapy. Intratympanic steroid injections have been used successfully in some cases as a salvage treatment following initial unsuccessful systemic steroid treatment. Hearing recovery may not occur, can be complete or partial. The likelihood of recovery varies with a number of factors. Better recovery rates are seen at milder levels of hearing loss, in cases of low-frequency sloping hearing loss, and in cases without vertigo.

An urgent ENT referral is needed in cases of suspected sudden SNHL. The greatest recovery is seen if oral corticosteroids are administered within a week of symptom onset.

Long-term rehabilitation options look at treating the residual symptoms of sudden SNHL. Monitoring of hearing is recommended at two, six and 12 months to document recovery and guide aural rehabilitation (hearing aids or cochlear implants). Physiotherapy may be required for vestibular rehabilitation, and a structured tinnitus management program may be required for persistent tinnitus distress.