1. Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College,
Jaipur.
2. Introduction
Fibroids(Myoma, Leiomyoma,Fibromyoma)
5-20% women in their reporductive age are reported to
have fiboroids.
Most common Monoclonal Benign tumors of uterus
arising in the smooth muscle cells of myometrium.
Contain large aggregation of extracellular matrix
consisting of collagen, elastin, fibronectin and
proteoglycan.
Each fibroid is derived from smooth muscle cells rests
,either from vessel wall or uterine musculature
3. Incidence
Most common----77% specimen of hysterectomy were
having Fibroids invariable number ,size (micro-macro)
and site.
Sonographic survey in35-49yrs aged Africo- American
women reported Fibroids in 60% while about 80%
among the women > 50 yrs. of age.
White women have lower prevalence---40%at age 35
and almost 70% by age 50.
4. etiology
Precise cause of Fibroids is not known.
Advances have been made in understanding the
molecular biology of these benign tumors and there
dependence on genetic, hormonal and growth factors .
(A) Genetic
Fibroids are monoclonal and about 40% have
chromosomal abnormalities that include-
(a) translocations between chromosomes 12 and14.
(b) deletions of chromosome 7
(c) Trisomy of chromosome 12 in large tumors.
60% may have yet undetected mutations
5. Etiology
Genetic more than 100 genes were found to be up-
down regulated in fibroid cells.
Many of them appear to regulate cell growth,
proliferation, differentiation and mitogenesis.
Genetic differences between fibroid and
Leiomyosarcomas indicate that Leiomyosarcomas do
not result due to malignant changes in fibroids .
6. Etiology
(B) Hormones -
Both increase in number and responsiveness of receptors
for estrogen and progesterone appear to promote fibroid
growth, as these are rarely found before puberty, develop
and increase during reproductive period of life and so also
during pregnancy, regress after menopause/ bilateral
oophorectomy.
Found more with hyper estrogenic states like obesity,
increases after ERT therapy in menopausal women,
endometriosis, Cancer endometrium, an ovulatory
infertility and early menarche.
Decreased incidence are found in athletes with low body
mass, increased parity.
estrogen induces increased expression of progesterone
receptors thus promoting oncogenic effect of progesterone.
7. Etiology
Hormones
Progesterone is most important in pathogenesis of fibroids,
which have more concentration of receptors A & B as compared
to normal myometrium.
Highest mitotic counts are found in fibroid cells when
progesterone concentration is also high.
GnRH agonist decrease the size of fibroid.
Concurrent Progesterone and GnRH therapy prevent regression
in size of fibroid.
Anti progesterone RU486 reduces the growth of fibroids.
Estrogen dependent- never develop before puberty, regress after
menopause, newer tumor seldom develop after menopause,
8. Etiology
(C) Growth Factor
Growth factors, proteins polypeptides produced locally by
smooth muscle cells and fibroblasts appear to promote growth of
fibroids primarily by increasing extracellular matrix.
Many growth factors are participating in proliferation and
growth of cells of fibroid Tumor Growth Factor-Beta, Basic-
Fibroblast Growth Factor,increased DNA synthesis, Epidermal
Growth factor, Platelet Derived Growth Factor, Insulin like
growth factor, PRL,Vascular endothelial factor etc
12. Pathology
Gross
+A typical myoma is a well circumscribed tumor with a pseudo-
capsule. Cut surface is pinkish white and has a whorled appearance.
+Capsule consists of connective tissue which fixes tumor with
myometrium.
+Vessels that supply Blood to tumor lie in capsule and send radial
branch to tumor Hence central part of tumor is comparatively less
vascular ,thereby degenerative changes are noticeable in center.
Calcification at the periphery and spreads inwards along the
vessels(Tombstone).
Microscopic Tumor consists of bundles of plane cells, separated
by varying amount of fibrous strands . Areas of embryonic muscle
tissue may be present.
20. Risk Factors
Age – incidence increases with age till on set of menopause.
Endogenous Hormonal factors Early menarche ,late menopause,
hyper-estrogenic states & increased expression and responsiveness of
progesterone receptors A & B.
Family History—1st degree relatives are having 3.5 times more risk of
developing fibroids.
Ethnicity—Black women develop fibroids 2.9 times more than white
women.
Body weight—risk of fibroid increase by 21% with each 10 kg increase
in body weight. Increase bioavailable estrogen explains it well.
Diet—diet rich in red meat, ham, beef increase the risk of fibroids
while diet with green leafy vegetables decrease the risk.
21. Risk Factors
Exercise – women doing regular exercise (7hrs per week) are at low
risk than those who do not do exercise.
OCS --- no definite relationship.
ERT—variable reports—no increase, minimal increase, more increase
when progesterones were added.
Pregnancy—pre-existing fibroids may enlarge, undergo red
degeneration. Increased parity is associated with lower incidence of
fibroid.
Smoking---decreases by decreased conversion of androgen to estrone
caused by inhibition of aromatase enzyme by nicotine, increased 2-
hydroxylation of estradiol, increased level of serum sex hormone
binding Globulins.
Tissue injury—may increase the incidence probably by increasing
local production of tissue growth factors--?
22. Symptoms
Asymptomatic Fibroid size<4cm / uterine size <12 cm(50%)
Abnormal uterine bleeding menorrhagia > 64% woman present with
heavy blood loss in gushes needing more pads or tampons on the day of
heaviest blood loss. Metro menorrhagia present in cases of infected /
ulcerated fibroid polyp.
Infertility
Pain Dysmenorrhoea., slight discomfort to colicky pain in suprapubic
region, low backache. Degenerated / torsion of fibroid may cause Acute
abdomen /pelvic pain.
Urinary symptoms Increased uterine volume due to fibroids may cause
pressure and obstructive effect on urinary tract (frequency, nocturia,
urgency, uti )
Secondary symptoms progressive anaemia due to chronic blood loss --
CHF, ill-health, loss of appetite and work capacity.
Some patients rarely develop polycythemia due to erythropoiten production.
Abdominal Lump.
23. Natural History of Fibroids
Most fibroid grow slowly - 9% growth rate over 12 months, more
depending on growth factors rather than hormones.
Growth rate decreases after age 35 yrs in white women, but not in
blacks.
Most of them regress with onset of menopause.
Rapid uterine fibroid growth in premenopausal age almost never
indicate sarcomatous change.
O.5% women with pre-exisiting fibroid may develop pain and
bleeding in their postmenopausal age, as their fibroid might have
under gone sarcomatous changes.
Fibroids may become calcified in menopausal women.
Fibroids may develop variety of degenerative changes.
24. Degenerative Changes
Subserosal fibroid sessile pedunculated torsion acute
abdominal pain.
Detached wandering fibroid get attached to other
peritoneal structure parasite Fibroid.
Hyaline degeneration
Fatty degeneration
Red degeneration (Aseptic Necrobiosis) in pregnancy,
postpartum
Saponification
Cystic degeneration
Calcification
Hemorrhagic, torsion
Sarcomatous changes
Infection/ulceration of pedunculated fibroid
Association with endometrial Ca, endometriosis, follicular
enlargement of ovaries.
Inversion of uterus
31. Diagnosis
PA Examination—fibroid with uterus larger than 12-14
wks. of gestation are well palpable per abdomen .
Enlarged uterus may be as big as term pregnancy. Surface
is irregular nodular, bossed, firm, no Braxton Hick
contractions, no palpable fetal parts , movements and no
fetal heart sound . uterine soufflé due to increased blood
supply to uterus may be audible, it has to be
differentiated from umbilical soufflé.
32. Diagnosis
Pelvic Examination
Enlarged uterus due to fibroids is of variable size,
irregular surface, nodular or bossed .
Associated cystic enlargement of ovary may be noted.
Enlarged uterus is firm and non-tender, freely mobile—
up and down, side to side till it incarcerates in pelvis.
Enlarged uterus and cervix move together.
33.
34. Imaging
For symptomatic women, consideration of conservative
therapy, non invasive procedure or surgery often depends on an
accurate assessment of the size, number and position of
fibroids.
TVS Saline infusion USG, Hysteroscopy, MRI can be done. Sub
mucous fibroids were best identified by MRI (100%sensitivity,
91% specificity )
SIS (sensitivity 90%, specificity 89% )
Hysteroscopy (sensitivity 82%, specificity 87%).
MRI allows evaluation of number, size location and proximity
to bladder, rectum, tubal opening in uterine cavity and
endometrium, thus helping in planning surgery.
35. Imaging
Sonography is the most readily
available and least costly to
differentiate fibroids from other
pelvic pathology . It is reasonably
reliable for evaluation of uterus with
< 375 cc volume and 3-4 or fewer
fibroids.
41. Figo Leiomyoma classification
system
Submucosal 0
1
Pedunculated Intracvity
< 50% intramural
2 >50% intramural
0 other 3 Contacts endometrium., 100%
intramural
4 Intramural
5 subserosal >50% intramural
6 subserosal <50% intramural
7 subserosal pedunculated
8 other(specify.,cervical,parasitic
Hybrid Two numbers are listed separated by
Laiomyomas(impact both 2-5 hyphen.by convension , the 1st reffers to
endometrium and serosa) the relatioship with endometrium while
2nd torelationship with serosa
submucosal and subserosal , each
lessthan half the diameter in the
endometrim and peitoneal cavities
42. Fertility and Fibroids
Presence of submucous fibroids decrease fertility and removing
them increases fertility.
Sub serous and intramural fibroid do not effect fertility but their
removal may increase fertility depending on their location.
Myomectomy carries risk of anesthesia, surgery , infection, post-
operative adhesions, likelihood of increased cesarean delivery,
rupture of myomectomy scar, expanse of surgeries and time for
recovery.
Therefore until submucous, intramural fibroids are surely found
to be the prime cause of infertility and repeated abortion,
myomectomy is advised and it will increase chances of fertility.
43. Fibroid and Pregnancy
Prevalence of fibroids in pregnancy is 18% based on 1st
trimester USG
Most of fibroids do not increase significantly in pregnancy.
Red degeneration of fibroids occurs in 5% cases. Patient
develops pain, fever, local tenderness of fibroid, increased
TLC
and DLC.
Bed rest, analgesics and plenty of fluids are needed to treat
them.
Influence of fibroids on pregnancy Abortions ,
Malpresentation, malposition, IUGR, PROM, Premature onset of
labour pains, uterine inertia, inco-ordinated uterine action,
prolonged labor obstructed labor due to cervical fibroid or
incarcerated fibroid, APH (abruptio, placenta praevia), Atonic
PPH, P Sepsis, inversion of uterus, sub involution of uterus.
Rupture of Myomectomy scar .
46. Treatment
Watchful Waiting
Medical Therapy NSAID, GnRH- Agonists. GnRH-
Antagonist, Alternative therapy.
Surgical Treatment options -
(a)Myomectomy—Laparotomy, laparoscopy,
Hysteroscopy, cesarean section and concurrent
myomectomy.
(b)Uterine Artery Embolization and occlusion.
(c)Endometrial ablation.
47. Watchful Waiting
Not having treatment for fibroids rarely results in harm,
except women with severe anemia from fibroid related
menorrhagia or hydronephrosis from ureteric
obstruction caused by massive fibroid pressing over.
Therefore, for women who are asymptomatic or having
mild to moderate discomfort with fibroids, watch full
may allow treatment to be deferred, perhaps indefinitely
.
A woman approaching menopause, watchful waiting
may be considered, because there is limited time to
develop new symptoms and after menopause bleeing
stops and fibroid decrease in size.
.
48. Medical Therapy
Non steroidal Anti inflammatory drugsNSAIDS found to
have minimal or no effect in controlling menorrhagia due to
fibroids and no decrease in size of fibrids.
GnRH Agonist Treatment with GnRh Agonist decrease
uterine volume, fibroid volume and bleeding. Monthly GnRH
Agonist given for 6 months reduced fibroid volume by 30% and
total uterine volume by 35%.bleeding also decreased well.
Following discontinuation of GnRH –A , uterine volume and
menses returns with in 4--8 weeks,2/3rd women remained
asymptomatic for 8-12 months. 95% women developed side
effects of hypo estrogen--- iatrogenic menopuase and
oseoporosis.Add back therapy given concurrently reduces these
side effcts.GnRH-a is recommended as temporary treatment for
premenopausal women with heavy menorrhagia.
49.
50. Medical Treatment
GnRH –Antagonist Immediate
suppression of endogenous GnRh by daily
SC injection 0f Ganirelix results in 30%
reduction in fibroid volume with in 3 wks.
Patient develops Hypo estrogenic
symptoms. Availability of long acting
compounds might be considered for
medical treatment prior to surgery.
51. Medical Treatment
Progesterone mediated
TherapyReduction in fibroid size
following treatment with progesterone –
blocking drug MIFEPRISTONE is similar to
that due to GnRH –a. Controlled trial with
mifepristone therapy( for 6 months) found
48% reduction in size of uterus. 28%patient
developed endometrial hyperplasia due to
unopposed action of estrogen
52. Medical Treatment
Progesterone releasing IUCD Mirena-Levonorgestrel
releasing IUCD may be a reasonable treatment for selected
women of child bearing age with fibroid associated
menorrhagia and interested to have contraception. 85% of
such women returned to their normal bleeding with in 3
months and 40% developed reversible amenorrhea at the
end of 1.5-2years .
53. Medical Treatment at least for 12 weeks
Alternative Medical Treatment Chinese herbal
medicine Kuie Chi –Fu –Ling –wan
found to complete resolution of fibroids (19%), decrease in
size in34%, increase in 4% , 95% got relief from
menorrhagia and 94% from dysmenorrhea (study group
consisted of 110 women with fibroids <10cm ). 14% women
preferred hysterectomy during the 4 year period of study.
56. Preoperative management
(1) severe anemia can be rapidly corrected by
recombinant forms erythropoietin alpha or epoetin250
iu/kg weekly for 3 weeks and parentral iron therapy along
with folic acid, vitamin C, protein suplementation.
(2)Auto transfusion / donor blood transfusion
(3)Control of bleedingGnRH agonist therapy
(4)Control of associated medical problems like
hypertension, CHF, Asthma, uti, kidney or liver illness.
57. Myomectomy
Safe alternate to hysterectomy for young women who
even have large fibroid and want to retain uterus ,
fertility
“The restoration and maintenance of physiological
function is or should be the ultimate goal of surgery Victor
Bonney -1931”
In carefully selected women myomectomy may be safely
accomplished at the time of LSCS by experienced surgeon
instead of caesarean hysterectomy.
58. Myomectomy Indications
Infertility caused by cornual fibroid blocking
tube.
Habitual abortion due to sub mucous fibroid.
Treatment required.
Pedunculated fibroid likely to undergo torsion.
Fibroid > 12 weeks.
Broad ligament fibroid pressing on ureter.
Fibroid pressing over bladder causing retention of urine /
infection.
Rapidly growing uterine fibroid in post menopausal
women.
63. Laparoscopic myomectomy-steps of operation:
A. Fibromyoma uterus( subserous) not larger than 10 cm or
4 in number, Infiltrated with Pitressin ; B. Incision taken on
the fibromyoma; C. Fibromyoma exposed; D. Myoma screw
inserted to steady the myoma; E. Myoma dissected from its
bed; F. Edges of myoma bed approximated with interrupted
Vicryl sutures(Barbed). Removed myoma seen in POD; G.
Myoma being morcellated; H. Tunnel in myoma after
removal of cylindrical mass; I. Excised myoma cylinder
being removed from the morcellator.
64. Disadvantages of laparoscopic
myomectomy
More heaorrhage because of no applicability of myomectomy clamp /
tornicate.
Longer duration of operation—longer anesthesia.
More chances of post operative adhesions – infertility, ch,. Abdominal
pain, intestinal obstruction.
Increased incidence of scar rupture in pregnancy/ labour due to
impefect or inadequate suturing.
Laparoscopic myomectomy may not be safer for infertile women.
Unidentified or not removed small fibroid may grow later ---shoe up as
recurrence.
-
65. Hysteroscopic Myoma -
resection
Submucous fibroid < 1/3rd buried in myometrium to
avoid uterine perforation.
It can be excised either by electric cautery , laser or
resectoscope.
It is best done under laparoscopic guideance line to
avoid myometrial perforation.
66. Complications gut. Myomectomy
of
Primary, reactionary or secondary haemorrhage.
Trauma to urinary tract,
Infection.
Adhesions.
Intestinal obstruction.
Recurrence of fibroid or menorrhagia.
67. Uterine Artery Embolization(UAE)
Ravina (1991) first performed it to reduce blood supply to fibroid,
results in reduction in size, further growth of fibroid reduced and
minimum menstrual blood loss.
Menorrhagia reduced in 80-90 % , pressure symptoms in 40-70% and
volume decreased by 50% at the end of 3 months.
Contra indications Subserous and pedunculated fibroid
necrosis and fall of tumor in peritoneal cavity. Very big fibroid are not
suitable, submucous fibroid is not cured. It does not help the infertile
women rather it may increase the problem.
Technique under LA bilateral UAE approach through percutaneous
femoral catheterization, using poly vinyl alcohol gel (PVA gel) particles
are injected in the artery supplying the fibroid.
68. Results and complications of
UAE
Vascularity and size reduced by 40% at 6 weeks and
75% at the end of 1 year.
Symptoms are relieved in 70% women.
Post operative complications fever and infection,
vaginal discharge and bleeding , unbearable ischaemic
pain, pulmonary embolism, premature ovarian failure if
accidental occlusion of ovarian vessels occur, fertility rate
is reduced due to adhesions, failure due to incomplete
coagulation caused by arterial spasm or tortuosity of
blood vessel.
69. Advantages Of UAE
No major surgery.
No intra-operative bleeding.
Short hospital stay.
No abdominal adhesions.
75-80% women suffering from menorrhagia are satisfied.
70.
71.
72. Hysterectomy
Indication Women over 40 years of age , multiparous
women, complicated fibroids, unforeseen difficulties
during myomectomy.
Types of Hysterectomy
Abdominal-total, sub total, pan hysterectomy ,
extended or wertheim’s hyserectomy when fibroid are
associated with carcinoma endometrium or cervix.
Vaginal Hysterectomy.
LAVH.
73. Newer techniques
MRI guided per cutaneous laser ablation using High Intensity
focused Ultrasound (HIFU) has been recently attempted –
results are awaited.
Laparoscopic myolysis optimal surgery in multiparous
women by using Nd : YAG laser, cryo- probe or diathermy to
coagulate subserous fibroid . The contraindication are similar
to UAE.
Cervical fibroids preoperative GnRH will shrink the fibroid.
Fibroid enucleation will be easy to perform myomectomy /
hysterectomy, thus reducing ureteric and bladder injury.
