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FIBROIDS
The commonest benign
tumour of uterus
?Commonest benign solid
tumour in female
?Arising from the myometrium or
muscles of its vessel walls
?Peak age 35-45
?One in 4 women of reproductive
age are found to have atleast
one fibroid
AETIOLOGY
PREDOMINANTLY ESTROGEN
DEPENDENT
?EVIDENCES:
?INCREASED GROWTH DURING
PREGNANCY
?RARE BEFORE MENARCHE
?CEASE TO GROW FOLLOWING
MENOPAUSE
?MORE ESTROGEN RECEPTORS
THAN ADJACENT MYOMETRIUM
Bcl-2
in leiomyoma cells
Growth Factors
Angiogenic fibroblast growth factor
Transforming growth factor
Granulocyte macrophage colony stimulating
factor
Insulin growth factor
Epidermal growth factor
Cytogenic abnormalities ? seen in 50% of
fibroids Chr 6,7,12,14
? NULLIPARITY
? OBESITY
? EARLY MENARCHE
RISK ?HYPERESTROGENIS
M
FACTOR ?ETHNICITY ?
AFROCARRIBEAN
S
? FAMILY HISTORY
? SMOKING
CLASSIFICATION OF UTERINE
FIBROIDS
BODY(CORPOREAL) BROAD LIGAMENT CERVICAL
INTRAMURAL(75%) SUBSEROUS (15%) SUBMUCOUS(10%)
SESSILE PEDUNCULATED
ANTERIOR POSTERIOR CENTRAL LATERAL
FIGO CLASSIFICATION
TYPE DESCRIPTION
v 0 Submucous;intracavitary
v 1 Submucous;<50% intramural
v 2 Submucous ;>50% intramural
v 3 intramural;just contacts endometrium
v 4 intramural
v 5 subserous ;>50% intramural
v 6 subserous ;<50% intramural
v 7 subserous ;pedunculated
v 8 others with no myometrial invmt.
INTRAMURAL FIBROID
Commonest
Lies within the wall of Uterus
Seperated from myometrium by a layer of
connective tissue forming pseudocapsule
Blood supply through this capsule
Growth ? outwards, inwards or remain as such
SUBSEROUS FIBROID
May be sessile or pedunculated
huge
Pressure symptoms
No menstrual symptoms
Contains more fibrous tissue
TUMOR GROWS OUTWARDS TO THE PERITONEAL
SURFACE
(further extrusion outwards with development of a pedicle)
PEDUNCULATED SUBSEROUS FIBROID
(gets attached to vascular organ & cut off from
uterine origin)
WANDERING /PARASITIC FIBROID
SUBMUCOUS
Intramural grows inwards into the cavity
Make the uterine cavity irregular & distorted
Pedunculated fibroid can come out through cervix and
present as polyp.
maximum menstrual symptoms
It may become infected
Ulcerated
menorrhagia,
metrorrhagia
Infertility, recurrent miscarriage
sarcomatous change
CERVICAL FIBROID
Rare
Compression on urinary bladder ;urinary
retention
"Lantern on the dome of St. Paul's" ? in case
of central cx fibroid where uterus sits on the top
of expanded cx
Surg.challengable
obstructed labour
impossible to do LSCS
BROAD LIGAMENT FIBROIDS
? True: rare with no
attachment to uterus
? Originate from the
smooth muscle fibre
? Ureter & Uterine
artery - medially
Two ?False: subserous
types fibroid from lat
uterine wall and grow
in between broad
ligament
? Ureter & Uterine
artery -laterally
PATHOLOGY
Single or multiple
Firm and fibrous
CUT SURFACE
Smooth , white whorled appearance with
trabeculation
Centre least vascular - degeneration
SECONDARY CHANGES IN FIBROIDS
DEGENERATION
? HYALINE DEGENERATION-65%
? CYSTIC DEGENERATION
? FATTY DEGENERATION
? CALCIFIC DEGENERATION-10%
? RED DEGENERATION
HYALINE DEGENERATION
Commonest type
Central portion more prone
Soft and elastic feel
Loss of whorled appearance
Microscopy reveals hyaline changes
RED DEGENERATION
Carneous Degeneration
Occurs in large fibroid
During
? Pregnancy
? Puerperium
Cause
? Vascular
? Thrombosis of blood vessels coagulative
necrosis
RED DEGENERATION
TUMOR APPEARS DARK
CUT SURFACE SHOWS HEMORRHAGIC MEATY
APPEARANCE
PAIN AND TENDERNESS
MICROSCOPY
v
EVIDENCE OF THROMBOSIS
v
NECROSIS OF VESSELS
CALCIFIC DEGENERATION
Due to circulatory impairment
Common after menopause
Occur in subserous fibroid with narrow pedicle
Calcium carbonate or phosphate deposits
WOMB STONE (CALCIFIED FIBROID)
CYSTIC DEGENERATION
Liquefaction of areas that have undergone
hyaline change
Common in Intramural fibroids
UNUSUAL COMPLICATIONS
Sarcomatous change
Leiomyomatosis
Wandering fibroids
Infection
Torsion
Pseudo meig syndrome
Polycythemia
Hypoglycemia
SARCOMATOUS CHANGES
Not>0.1% cases
More in submucous & intramural
Rare<40yrs
Most common - leiomyosarcoma
FEATURES OF HIGH RISK
1. RECURRENCE OF FIBROID POLYP
2. SUDDEN ENLARGEMENT OF FIBROID
3. POST MENOPAUSAL WOMEN ____>PAIN,BLEEDING
MACROSCOPY
irregular margin and variegted cut surface
Microscopy
High cellularity
MITOSES PER 10
Nuclear
HPF
pleomorphism
>10 leiomyosarcoma
Incresed mitoses
<5 benign
5-10 STUMP
INFECTION
Common in SUBMUCOUS fibroids & especially
MYOMATOUS POLYPS projecting into vagina
Covered by only a layer of endometrium that becomes
thinned out and sloughs
Blood stained purulent discharge
Often following delivery or abortion
puerperal sepsis
LEIOMYOMATOSIS
INTRAVENOUS LEIOMYOMATOSIS
BENIGN METASTASISING
DISSEMINATED PERITONEAL(Preg,OCP)
HYSTERECTOMY WITH
OOPHRECTOMY,DEBULKING
OF TUMORS AND GnRH
AGONISTS
TORSION
Subserous pedunculated fibroid may undergo rotation
at its site of attachment to the uterus
Veins occluded & tumor engorged with blood
Very severe a/c abdominal pain
PSEUDO MEIG SYNDROME
Meig syndrome ascites and
pleural effusion -ovarian fibroma
Pseudo meig pelvic tumour
Discordancy b|w arterial supply
&venous supply of fibroid
POLYCYTHEMIA
RARE
Erythropoetin production by
fibroid
Pressure on ureter-alters
erythropoetic fn of kidneys
CLINICAL FEATURES
SYMPTOMS
Depends upon the site of the mass
More than 50% are asymptomatic
?abnormal Uterine bleeding
?Menorrhagia
?Metrorrhagia
?Menometrorrhagia
? Increase in endometrial
surface area
? Increased vascularity
? Interference with normal
uterine contraction
? Endometrial ulceration
Mechanism
and hemorrhage over
of
submucous fibroid
Menorrhagi ?Compression of venous
a
plexuses causing
venostasis
? Associated endometrial
hyperplasia and
anovulation
? Increased growth factors
? PRESSURE SYMPTOMS
? Pe?lvLicd
ow isco
bac m
k for
pai tn ? posterior fibroids
?Sciatic nerve pain ? broad ligament fibroid
? Ur?inInarcrysy
eas mpt
ed uorminsary frequency
?Difficulty in initiating
?Incomplete voiding
?Bilateral ureteric compression -
Hydronephrosis
? Ot?heOredema of lower limbs,DVT
?Difficulty in defeacation, dyspareunia,
dyspnoea
? abdominal distension
? infertility
?Submucous fibroid known to cause
infertility
?By mechanical means and by defective
implantation
? recurrent miscarriage
?Early and 2nd trimester miscarriage
CAUSES OF ACUTE PAIN IN
FIBROIDS
INFECTION
RUPTURE
RED DEGENERATION
TORSION
HAEMORRHAGE
ACUTE RETENTION OF URINE IN CERVICAL FIBROID
EXPULSION OF A SUBMUCOUS FIBROID
SARCOMATOUS CHANGE
SIGNS
?Pelvic mass with smooth or irregular
Abdominal surface
?Firm in consistency
Examinatio ?Lower border may not be palpable
n
exception pedunculated subserous
fibroid
Bimanual ?In case of fibroid mass , uterus will not
be felt separately
Examinatio ?Transmitted mobility
n
FIBROID AND PREGNANCY
EFFECTS OF FIBROIDS ON PREGNANCY
Pregnancy
Labour
After Delivery
? Early and late
?Prolonged
?
miscarriage
PPH
Labour
?Retained
? 1st trimester
?Difficulty in
Placenta
bleeding
delivery
?Puerperal Sepsis
? Preterm
?Increased
Labour
chance of CS
? Placenta
?Chance of
Praevia
classical CS
?
?Increased
Malpresentati
bleeding at CS
on
? IUGR
? PROM
EFFECT OF PREGNANCY ON
FIBROID
INCREASE IN SIZE
RED DEGEN.
TORSION
INFECTION OF SUBMUCOUS FIBROID IN
PUERPERIUM
DIFFERENTIAL DIAGNOSIS
Pregnancy
Full Bladder
Adenomyosis
Pyometra
Endometrial Ca and sarcoma
Solid Ovarian Tumours
Pelvic Infection and tuboovarian mass
INVESTIGATIONS
Routine investigations
PAP Smear
USG - confirm Dx , hypoechoic,size,site,no.
ovary
ascites
hydronephrosis
Hysteroscopy -submucous fibroid
MANAGEMENT OF FIBROIDS
INDICATIONS FOR TREATMENT
? Infertility caused by cornual fibroid
? A fibroid >12 weeks size &a pedunculated fibroid
? An asymptomatic fibroid causing pressure on the
ureter &pressure on the bladder
? Rapidly growing fibroid in a menopausal woman
? All symptomatic fibroids require treatment
MANAGEMENT
1.EXPECTANT MANAGEMENT
2. MEDICAL
3. SURGICAL
4. UTERINE ARTERY
EMBOLISATION
EXPECTANT MANAGEMENT
Asymptomatic fibroid,provided the diagnosis is
certain
No evidence of ureteral compression
Size <12 to 14 weeks
Willing for follow-up
Large fibroid ?conservative management in
women nearing menopause.
Asymptomatic fibroid need not always be
removed
MEDICAL MANAGEMENT
? Objectives-reduction in tumour size &relief of
symptoms like menorrhagia
? Drugs -GnRH agonists
? -GnRH antagonists
? -Antiprogestins
? -danazol
? -others
GNRH AGONISTS
Reduce the tumour size by 50 to 80%
Reduces vascularity preoperatively
Amenorrhea ?restores haemoglobin level
Action-by gonadal suppression &hypo
oestrogenism
Tend to regain original size on discontinuation of
drug
Optimal duration prior to surgery-3 mnths
Dose-goserelin 3.6 mg OR leuprolide 3.75 mg
monthly s/c depot injection
Or leuprolide single dose 11.5 mg 3monthly
ADVANTAGES
Facilitates a laparoscopic/hysteroscopic
myomectomy
Facilitates a vaginal /laparoscopic hysterectomy
Intra operative bleeding less
Shrinkage of fibroid enable the use of a
pfannensteil incision
PROBLEMS
Hot flushes ,osteoporosis,vaginal dryness
In 1% a/c degeneration & pain
Fibroid capsule thin out making enucleation
difficult& small fibroids invisible at surgery recur
later
Antiprogestins-RU486/mifepristone10-25 mg
daily for 3 months causes amenorrhea
&shrinkage of tumour
Danazol-400-800mg daily for 3-6 months s/e-
hirsuitism,weight gain
GnRH antagonists cetrorelix/ganirelix
Ulipristal (progestrone receptor modulator)
Cabergoline (dopamine agonist)
Others-gestrinone, &tamoxifen.
SURGICAL MANAGEMENT
Myomectomy-indicated in an infertile woman
/woman desirous of child bearing &wish to retain
uterus
Submucous &intramural fibroids best removed
PREREQUISITES
Hemoglobin should be restored &arrange blood
In infertility rule out other causes of infertility
Consent for hysterectomy
It should be performed in preovulatory menstrual
cycle
TO LIMIT BLOOD LOSS
Timing the surgery
Controlled hypotensive anaesthesia
Vasopressin instillation into the serosa
&myometrium overlying the myoma
Using tourniquets at the internal os to compress
the uterine vessels &at the infandibulopelvic
ligament to occlude ovarian vessels
Bonney s myomectomy clamp can be used to
occlude uterine vessels
Released at 20 min intervals
TYPES OF MYOMECTOMY
OPEN MYOMECTOMY
HYSTEROSCOPIC
LAPAROSCOPIC
VAGINAL
OPEN MYOMECTOMY
Pfannenstiel or vertical paramedian incision
Incise peritoneum
Confirm feasibility
Incision over anterior wall of uterus
Control hemorrhage
Capsule incised - enucleate
Many fibroids can be removed through a
minimal tunneling incision
HYSTEROSCOPIC MYOMECTOMY
Ideal for submucous fibriods
Fibroids are excised by cautery, laser,
resectoscope
Under laparoscopic guidance
Complications - cervical trauma , bleeding ,
adhesion
LAPAROSCOPIC MYOMECTOMY
Subserous &pedunculated fibroids
Unipolar or bipolar cautery and laser
Less hospital stay, less post operative pain &
cosmetic
Complication ? scar rupture
VAGINAL MYOMECTOMY - Submucous fibroids
- cervical fibroid
COMPLICATIONS of MYOMECTOMY
Intraoperative-primary haemorrhage
-injury to ureters
-injury to bladder/rectum
Postoperative-myoma fever
- reactionary and secondary
haemorrhage
Adhesions
Infection
Future surgery difficult
Recurrence of fibroids - 5-10%
HYSTERECTOMY
Abdominal -large fibroids
Vaginal - if uterus is mobile,size<14 wks,no
previous surgeries,no pelvic pathology
LAVH -avoids abdominal scar ,minimes
pain,less hospital stay
C/I -size>14 wks,broad ligament
&cervical fibroid
COMPLICATIONS OF HYSTERECTOMY
Haemorrhage
Trauma-bladder,ureter,bowel
Sepsis
Anaesthetic complications
Paralytic ileus
Dyspareunia
c/c pelvic pain
Residual ovarian syndrome& atrophy
Vault prolapse
Ovarian cancer
UTERINE ARTERY EMBOLISATION
Reduce vascularity &size of fibroid
Contraindications- subserous &pedunculated
large fibroid
calcified fibroid
inflammatory change
TECHNIQUE
Local sedation
Percutaneous femoral catheterisation -
poly vinyl alcohol, gel foam particles, metal coils
Discharged within 1-2 days
Follow up ? 6 months
UTERINE ARTERY EMBOLISATION
COMPLICATIONS
Fever &infection
Vaginal discharge &bleeding
Severe pain
Pulmonary embolism
Ovarian failure
Fertility reduced
Allergic reaction
NEW TECHNIQUES
MRI guided percutaneous laser ablation using
high intensity focused ultrasound (HIFU)
LAPAROSCOPIC MYOLYSIS-subserous fibroid
THANK YOU
This post was last modified on 12 August 2021