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Hey everyone. Welcome to this talk on uterine fibroids. This talk is one of the talks created as part of the MLA Teaching Series and is presented by the Glasgow University Radiology Society in association with Ir Juniors. Fibroids are the most common benign uterine tumors in women of reproductive age. They are formed by the proliferation of smooth muscle cells and fibroblasts to give rise to the hard round and world tumors in the myometrium, they can be either single or multiple and they can be of different sizes as shown in here. More than 70% of women were said to have at least one fibroid in their lifetime. Fibroids can grow anywhere within the myometrium depending on the location. They can be classified as different types such as subserosal, intramural or submucosal. Sometimes they grow on a stalk which is described as pedunculated. The symptoms severity largely depends on both size number and the position of the fibroids. Different risk factors for fibroids are listed in here. Notably, ethnicity such as African descent, positive family history, older age nulliparity, obesity and early menarche can lead to increased fibroids risk as illustrated in the graph on the right black women have a much higher incidence and prevalence of developing fibroid when compared to white women. Unfortunately, almost half of the patients with fibroids do not develop any symptoms. When they do, they can develop nonspecific symptoms such as heavy or painful periods, pelvic pain, urinary or bowel symptoms or even infertility. So, a careful history taking is very important to help guide individualized management impact of symptoms, risk profiles and fertility issues should be adequately explored and discussed. Physical examinations such as abdominal exam and bimanual pelvic exam can be helpful to assess for the presence of pelvic tenderness and masses. Other further investigations may sometimes be required for women suspected to have fibroids. They should be arranged for a routine pelvic ultrasound to assess the number size and the location of fibroids. MRI can also be useful especially when the result of ultrasound scan is not conclusive or to guide treatment with uterine artery embolization, which we are going to discuss in later slides in terms of management for asymptomatic fibroids. No treatment or routine follow up is required. Patients should though be advised to arrange a review if there are any new symptoms, clinical features suggesting a gynecological or other malignancy or rapid growth of pelvic mass for patients with menorrhagia. In other words, heavy menstrual bleeding associated with uterine fibroids management is generally guided by the size of fibroids. This is taken from nice guidelines for fibroids less than three centimeters in diameter. The first line treatment is levonorgestrel intrauterine system. This is a intrauterine device that releases a daily dose of levonorgestrel and androgenic progesterone. It works locally and prevents endometrial proliferation and thickening of cervical mucus, treating menorrhagia. If levonorgestrel intrauterine system is unsuitable. We should consider other pharmacological treatment options. Non hormonal options include T trim acid and nsaids. Hormonal treatment options include combined hormonal contraception and cyclical oral progesterone. If the aforementioned options are unsuitable or ineffective, specialist referrals should be considered for interventions such as endometrial ablation where you surgically destroy the lining of the uterus, hysterectomy or hysteroscopic removal of submucosal fibroids for fibroids three centimeters or above in diameter. A specialist referral should be made if treatment is required while the patient is waiting for a referral appointment or treatment. Tranexamic acid or NSAID is the treatment of choice. Secondary care treatment depends on the size location, number of fibroids and the severity of symptoms listed here are a few of the treatment options when deciding on treatment. Discussion should also be made with patients. Regarding plans for pregnancy, the potential impact on fertility and whether they would like to retain their uterus. For example, hysterectomy and ablation could result in the loss of fertility while uterine artery embolization and myomectomy may potentially preserve fertility. There are also a few medications which can be used to shrink the size of fibroids. GNRH analogs such as goserelin and triptorelin is often used before surgery to reduce fibroid size and minimize complications. But because of its side effects profile such as risk of osteoporosis and menopausal symptoms. It is typically only for short term use. Ulipristal acetate, which is a selective progesterone receptor modulator was also used in the past but is rarely used. Now due to risk of serious liver injury and hepatic failure, uterine fibroid embolization is a minimally invasive alternative to myomectomy or hysterectomy. The aim of the procedure is to stop the blood flow into the vessels, supplying the fibroid while preserving perfusion to surrounding structures. Once vascular access via femoral or radial artery, he has been established, an interventional radiologist under image guidance would selectively catheterize the uterine artery, supplying the fibroid and inject embolization particles to cut off blood supply to the fibroid, resulting in its reduction in size over time. The main benefits of uterine fibroid embolization like in its minimally invasive nature, patients often have minimal or no hospital stay and shorter recovery time. Additionally, in 85% cases, there is significant reduction in fibroid size and therefore improvement in symptoms as demonstrated here by the series of MRI scans months, post procedure given its benefits. There are some risks associated with UF E. This includes rare complications of nontarget embolization such as to the ovary, which may affect fertility in up to 15% of cases. There is a need to reintervene either by repeat UF E or surgery. Additionally, patients may present with pain, fever, nausea and vomiting within 72 hours post procedure as part of the self limiting post embolization syndrome, uterine fibroid embolization is recommended as the first line treatment for fibroid alongside surgical management. In various guidelines including nice ACOG joint guideline, Bi RCOG and RCR. When given the options, it is ultimately up to the patient to choose which treatment they would like to have. However, some contraindications to uterine fibroid embolization to be noted include active pelvic infection, endometrial cancer, extremely large fibroid and patient's desire for fertility preservation. Thank you.