Download MBBS Fibroid finl Lecture PPT

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FIBROIDS
The commonest benign
tumour of uterus
?Commonest benign solid

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tumour in female
?Arising from the myometrium or
muscles of its vessel walls
?Peak age 35-45
?One in 4 women of reproductive

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age are found to have atleast
one fibroid

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AETIOLOGY

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PREDOMINANTLY ESTROGEN
DEPENDENT
?EVIDENCES:
?INCREASED GROWTH DURING
PREGNANCY

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?RARE BEFORE MENARCHE
?CEASE TO GROW FOLLOWING
MENOPAUSE
?MORE ESTROGEN RECEPTORS
THAN ADJACENT MYOMETRIUM

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Bcl-2
in leiomyoma cells
Growth Factors
Angiogenic fibroblast growth factor
Transforming growth factor

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Granulocyte macrophage colony stimulating
factor
Insulin growth factor
Epidermal growth factor
Cytogenic abnormalities ? seen in 50% of

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fibroids Chr 6,7,12,14

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? NULLIPARITY
? OBESITY
? EARLY MENARCHE
RISK ?HYPERESTROGENIS

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M
FACTOR ?ETHNICITY ?
AFROCARRIBEAN
S
? FAMILY HISTORY

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? SMOKING

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CLASSIFICATION OF UTERINE
FIBROIDS
BODY(CORPOREAL) BROAD LIGAMENT CERVICAL
INTRAMURAL(75%) SUBSEROUS (15%) SUBMUCOUS(10%)
SESSILE PEDUNCULATED

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ANTERIOR POSTERIOR CENTRAL LATERAL

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FIGO CLASSIFICATION
TYPE DESCRIPTION

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v 0 Submucous;intracavitary
v 1 Submucous;<50% intramural
v 2 Submucous ;>50% intramural
v 3 intramural;just contacts endometrium
v 4 intramural

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v 5 subserous ;>50% intramural
v 6 subserous ;<50% intramural
v 7 subserous ;pedunculated
v 8 others with no myometrial invmt.

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INTRAMURAL FIBROID
Commonest
Lies within the wall of Uterus
Seperated from myometrium by a layer of

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connective tissue forming pseudocapsule
Blood supply through this capsule
Growth ? outwards, inwards or remain as such

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SUBSEROUS FIBROID
May be sessile or pedunculated
huge
Pressure symptoms
No menstrual symptoms

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Contains more fibrous tissue

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TUMOR GROWS OUTWARDS TO THE PERITONEAL
SURFACE
(further extrusion outwards with development of a pedicle)

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PEDUNCULATED SUBSEROUS FIBROID
(gets attached to vascular organ & cut off from
uterine origin)
WANDERING /PARASITIC FIBROID

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SUBMUCOUS
Intramural grows inwards into the cavity
Make the uterine cavity irregular & distorted
Pedunculated fibroid can come out through cervix and
present as polyp.

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maximum menstrual symptoms
It may become infected
Ulcerated
menorrhagia,
metrorrhagia

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Infertility, recurrent miscarriage
sarcomatous change

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CERVICAL FIBROID

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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

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of expanded cx
Surg.challengable
obstructed labour
impossible to do LSCS

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BROAD LIGAMENT FIBROIDS

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? True: rare with no

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attachment to uterus
? Originate from the
smooth muscle fibre
? Ureter & Uterine
artery - medially

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Two ?False: subserous
types fibroid from lat
uterine wall and grow
in between broad
ligament

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? Ureter & Uterine
artery -laterally

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PATHOLOGY

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Single or multiple
Firm and fibrous
CUT SURFACE
Smooth , white whorled appearance with
trabeculation

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Centre least vascular - degeneration

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SECONDARY CHANGES IN FIBROIDS
DEGENERATION
? HYALINE DEGENERATION-65%
? CYSTIC DEGENERATION

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? FATTY DEGENERATION
? CALCIFIC DEGENERATION-10%
? RED DEGENERATION

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HYALINE DEGENERATION

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Commonest type
Central portion more prone
Soft and elastic feel
Loss of whorled appearance
Microscopy reveals hyaline changes

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RED DEGENERATION
Carneous Degeneration
Occurs in large fibroid
During

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? Pregnancy
? Puerperium
Cause
? Vascular
? Thrombosis of blood vessels coagulative

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necrosis

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RED DEGENERATION
TUMOR APPEARS DARK
CUT SURFACE SHOWS HEMORRHAGIC MEATY

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APPEARANCE
PAIN AND TENDERNESS
MICROSCOPY
v
EVIDENCE OF THROMBOSIS

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v
NECROSIS OF VESSELS

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CALCIFIC DEGENERATION
Due to circulatory impairment

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Common after menopause
Occur in subserous fibroid with narrow pedicle
Calcium carbonate or phosphate deposits
WOMB STONE (CALCIFIED FIBROID)

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CYSTIC DEGENERATION
Liquefaction of areas that have undergone
hyaline change
Common in Intramural fibroids

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UNUSUAL COMPLICATIONS

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Sarcomatous change
Leiomyomatosis
Wandering fibroids
Infection
Torsion

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Pseudo meig syndrome
Polycythemia
Hypoglycemia

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SARCOMATOUS CHANGES

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Not>0.1% cases
More in submucous & intramural
Rare<40yrs
Most common - leiomyosarcoma
FEATURES OF HIGH RISK

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1. RECURRENCE OF FIBROID POLYP
2. SUDDEN ENLARGEMENT OF FIBROID
3. POST MENOPAUSAL WOMEN ____>PAIN,BLEEDING

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MACROSCOPY
irregular margin and variegted cut surface

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Microscopy
High cellularity
MITOSES PER 10
Nuclear
HPF

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pleomorphism
>10 leiomyosarcoma
Incresed mitoses
<5 benign
5-10 STUMP

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INFECTION
Common in SUBMUCOUS fibroids & especially
MYOMATOUS POLYPS projecting into vagina

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Covered by only a layer of endometrium that becomes
thinned out and sloughs
Blood stained purulent discharge
Often following delivery or abortion
puerperal sepsis

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LEIOMYOMATOSIS

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INTRAVENOUS LEIOMYOMATOSIS
BENIGN METASTASISING
DISSEMINATED PERITONEAL(Preg,OCP)
HYSTERECTOMY WITH
OOPHRECTOMY,DEBULKING

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OF TUMORS AND GnRH
AGONISTS

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TORSION
Subserous pedunculated fibroid may undergo rotation
at its site of attachment to the uterus

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Veins occluded & tumor engorged with blood
Very severe a/c abdominal pain

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PSEUDO MEIG SYNDROME
Meig syndrome ascites and
pleural effusion -ovarian fibroma

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Pseudo meig pelvic tumour
Discordancy b|w arterial supply
&venous supply of fibroid

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POLYCYTHEMIA
RARE

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Erythropoetin production by
fibroid
Pressure on ureter-alters
erythropoetic fn of kidneys

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CLINICAL FEATURES
SYMPTOMS
Depends upon the site of the mass
More than 50% are asymptomatic
?abnormal Uterine bleeding

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?Menorrhagia
?Metrorrhagia
?Menometrorrhagia

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? Increase in endometrial
surface area

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? Increased vascularity
? Interference with normal
uterine contraction
? Endometrial ulceration
Mechanism

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and hemorrhage over
of
submucous fibroid
Menorrhagi ?Compression of venous
a

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plexuses causing
venostasis
? Associated endometrial
hyperplasia and
anovulation

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? Increased growth factors

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? PRESSURE SYMPTOMS
? Pe?lvLicd
ow isco
bac m

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k for
pai tn ? posterior fibroids
?Sciatic nerve pain ? broad ligament fibroid
? Ur?inInarcrysy
eas mpt

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ed uorminsary frequency
?Difficulty in initiating
?Incomplete voiding
?Bilateral ureteric compression -
Hydronephrosis

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? Ot?heOredema of lower limbs,DVT
?Difficulty in defeacation, dyspareunia,
dyspnoea

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? abdominal distension
? infertility

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?Submucous fibroid known to cause
infertility
?By mechanical means and by defective
implantation
? recurrent miscarriage

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?Early and 2nd trimester miscarriage

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CAUSES OF ACUTE PAIN IN
FIBROIDS
INFECTION
RUPTURE

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RED DEGENERATION
TORSION
HAEMORRHAGE
ACUTE RETENTION OF URINE IN CERVICAL FIBROID
EXPULSION OF A SUBMUCOUS FIBROID

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SARCOMATOUS CHANGE

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SIGNS
?Pelvic mass with smooth or irregular
Abdominal surface
?Firm in consistency
Examinatio ?Lower border may not be palpable

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n
exception pedunculated subserous
fibroid
Bimanual ?In case of fibroid mass , uterus will not
be felt separately

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Examinatio ?Transmitted mobility
n

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FIBROID AND PREGNANCY
EFFECTS OF FIBROIDS ON PREGNANCY
Pregnancy

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Labour
After Delivery
? Early and late
?Prolonged
?

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miscarriage
PPH
Labour
?Retained
? 1st trimester

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?Difficulty in
Placenta
bleeding
delivery
?Puerperal Sepsis

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? Preterm
?Increased
Labour
chance of CS
? Placenta

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?Chance of
Praevia
classical CS
?
?Increased

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Malpresentati
bleeding at CS
on
? IUGR
? PROM

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EFFECT OF PREGNANCY ON
FIBROID
INCREASE IN SIZE
RED DEGEN.
TORSION

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INFECTION OF SUBMUCOUS FIBROID IN
PUERPERIUM

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DIFFERENTIAL DIAGNOSIS
Pregnancy
Full Bladder
Adenomyosis
Pyometra

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Endometrial Ca and sarcoma
Solid Ovarian Tumours
Pelvic Infection and tuboovarian mass

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INVESTIGATIONS
Routine investigations

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PAP Smear
USG - confirm Dx , hypoechoic,size,site,no.
ovary
ascites
hydronephrosis

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Hysteroscopy -submucous fibroid

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MANAGEMENT OF FIBROIDS

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INDICATIONS FOR TREATMENT
? Infertility caused by cornual fibroid
? A fibroid >12 weeks size &a pedunculated fibroid

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? An asymptomatic fibroid causing pressure on the
ureter &pressure on the bladder
? Rapidly growing fibroid in a menopausal woman
? All symptomatic fibroids require treatment

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MANAGEMENT

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1.EXPECTANT MANAGEMENT
2. MEDICAL
3. SURGICAL
4. UTERINE ARTERY
EMBOLISATION

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EXPECTANT MANAGEMENT
Asymptomatic fibroid,provided the diagnosis is
certain
No evidence of ureteral compression
Size <12 to 14 weeks

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Willing for follow-up
Large fibroid ?conservative management in
women nearing menopause.
Asymptomatic fibroid need not always be
removed

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MEDICAL MANAGEMENT
? Objectives-reduction in tumour size &relief of
symptoms like menorrhagia
? Drugs -GnRH agonists
? -GnRH antagonists

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? -Antiprogestins
? -danazol
? -others

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GNRH AGONISTS
Reduce the tumour size by 50 to 80%

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Reduces vascularity preoperatively
Amenorrhea ?restores haemoglobin level
Action-by gonadal suppression &hypo
oestrogenism
Tend to regain original size on discontinuation of

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drug

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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

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ADVANTAGES
Facilitates a laparoscopic/hysteroscopic
myomectomy
Facilitates a vaginal /laparoscopic hysterectomy
Intra operative bleeding less

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Shrinkage of fibroid enable the use of a
pfannensteil incision

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PROBLEMS
Hot flushes ,osteoporosis,vaginal dryness
In 1% a/c degeneration & pain

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Fibroid capsule thin out making enucleation
difficult& small fibroids invisible at surgery recur
later

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Antiprogestins-RU486/mifepristone10-25 mg
daily for 3 months causes amenorrhea

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&shrinkage of tumour
Danazol-400-800mg daily for 3-6 months s/e-
hirsuitism,weight gain
GnRH antagonists cetrorelix/ganirelix
Ulipristal (progestrone receptor modulator)

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Cabergoline (dopamine agonist)
Others-gestrinone, &tamoxifen.

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SURGICAL MANAGEMENT
Myomectomy-indicated in an infertile woman
/woman desirous of child bearing &wish to retain

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uterus
Submucous &intramural fibroids best removed

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PREREQUISITES
Hemoglobin should be restored &arrange blood
In infertility rule out other causes of infertility

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Consent for hysterectomy
It should be performed in preovulatory menstrual
cycle

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TO LIMIT BLOOD LOSS
Timing the surgery

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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

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ligament to occlude ovarian vessels

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Bonney s myomectomy clamp can be used to
occlude uterine vessels
Released at 20 min intervals

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TYPES OF MYOMECTOMY

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OPEN MYOMECTOMY
HYSTEROSCOPIC
LAPAROSCOPIC
VAGINAL

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OPEN MYOMECTOMY

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Pfannenstiel or vertical paramedian incision
Incise peritoneum
Confirm feasibility
Incision over anterior wall of uterus
Control hemorrhage

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Capsule incised - enucleate
Many fibroids can be removed through a
minimal tunneling incision

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HYSTEROSCOPIC MYOMECTOMY
Ideal for submucous fibriods

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Fibroids are excised by cautery, laser,
resectoscope
Under laparoscopic guidance
Complications - cervical trauma , bleeding ,
adhesion

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LAPAROSCOPIC MYOMECTOMY
Subserous &pedunculated fibroids
Unipolar or bipolar cautery and laser
Less hospital stay, less post operative pain &
cosmetic

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Complication ? scar rupture
VAGINAL MYOMECTOMY - Submucous fibroids
- cervical fibroid

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COMPLICATIONS of MYOMECTOMY
Intraoperative-primary haemorrhage
-injury to ureters

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-injury to bladder/rectum
Postoperative-myoma fever
- reactionary and secondary
haemorrhage

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Adhesions

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Infection
Future surgery difficult
Recurrence of fibroids - 5-10%

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HYSTERECTOMY
Abdominal -large fibroids

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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

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&cervical fibroid

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COMPLICATIONS OF HYSTERECTOMY
Haemorrhage
Trauma-bladder,ureter,bowel
Sepsis

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Anaesthetic complications
Paralytic ileus
Dyspareunia
c/c pelvic pain
Residual ovarian syndrome& atrophy

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Vault prolapse
Ovarian cancer

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UTERINE ARTERY EMBOLISATION
Reduce vascularity &size of fibroid
Contraindications- subserous &pedunculated

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large fibroid
calcified fibroid
inflammatory change

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TECHNIQUE
Local sedation

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Percutaneous femoral catheterisation -
poly vinyl alcohol, gel foam particles, metal coils
Discharged within 1-2 days
Follow up ? 6 months

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UTERINE ARTERY EMBOLISATION

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COMPLICATIONS
Fever &infection
Vaginal discharge &bleeding
Severe pain
Pulmonary embolism

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Ovarian failure
Fertility reduced
Allergic reaction

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NEW TECHNIQUES
MRI guided percutaneous laser ablation using

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high intensity focused ultrasound (HIFU)
LAPAROSCOPIC MYOLYSIS-subserous fibroid

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THANK YOU

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