Uterine fibroids

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defnition, types.and managrent

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  • TYPES OF FIBROIDS
  • Uterine fibroids

    1. 1. LEIOMYOMALEIOMYOMA What is a leiomyoma?What is a leiomyoma? It is a benign neoplasm of the muscular wall of the uterusIt is a benign neoplasm of the muscular wall of the uterus composed primarily of smooth muscle and fibrouscomposed primarily of smooth muscle and fibrous connective tissues.connective tissues. What is the incidence of leiomyomas?What is the incidence of leiomyomas? They are the most common pelvic tumorsThey are the most common pelvic tumors It is found in 25% of white women & 50% of black womenIt is found in 25% of white women & 50% of black women
    2. 2. UTERINE FIBROIDUTERINE FIBROID BEINGN SOLID TUMOURSBEINGN SOLID TUMOURS
    3. 3. ETIOLOGYETIOLOGY UnknownUnknown Each individual myoma is unicellular in originEach individual myoma is unicellular in origin EstogensEstogens no evidence that it is a causative factor , itno evidence that it is a causative factor , it has been implicated in growth of myomashas been implicated in growth of myomas Myomas contain estrogen receptors in higherMyomas contain estrogen receptors in higher concentration than surrounding myometriumconcentration than surrounding myometrium Myomas may increase in size with estrogen therapy & inMyomas may increase in size with estrogen therapy & in pregnancy & decrease after menopausepregnancy & decrease after menopause They are not detectable before pubertyThey are not detectable before puberty Progestrone increase mitotic activity & reduce apoptosisProgestrone increase mitotic activity & reduce apoptosis  in sizein size There may be genetic predispositionThere may be genetic predisposition
    4. 4. PATHOLOGYPATHOLOGY Frequently multipleFrequently multiple May reach 15 cm in size or largerMay reach 15 cm in size or larger FirmFirm Spherical or irregularly lobulatedSpherical or irregularly lobulated Have a false capsuleHave a false capsule Can be easily enucleated from surrounding myometriumCan be easily enucleated from surrounding myometrium
    5. 5. CLASSIFICATIONCLASSIFICATION Submucous leiomyomaSubmucous leiomyoma Pedunculated submucousPedunculated submucous Intramural or interstitialIntramural or interstitial Subserous orSubserous or subperitonealsubperitoneal Pedunculated abdominalPedunculated abdominal ParasiticParasitic IntraligmentaryIntraligmentary CervicalCervical
    6. 6. MICROSCOPIC STRUCTUREMICROSCOPIC STRUCTURE Whorled appearanceWhorled appearance nonstriated muscle fibersnonstriated muscle fibers arranged in bundles running in different directionsarranged in bundles running in different directions Individual cells are spindle shaped uniformIndividual cells are spindle shaped uniform Varying amount of connective tissue are interlacedVarying amount of connective tissue are interlaced between muscle fibersbetween muscle fibers Pseudocapsule of areolar tissue & compressedPseudocapsule of areolar tissue & compressed myometriummyometrium Arteries are less dense than myometrium & do not haveArteries are less dense than myometrium & do not have a regular pattern of distributiona regular pattern of distribution 1-2 major vesseles are found at the base or pedicle1-2 major vesseles are found at the base or pedicle
    7. 7. SECONDARY CHANGESSECONDARY CHANGES
    8. 8. 11--BENIGN DEGENERATIONBENIGN DEGENERATION AtrophicAtrophic HyalineHyaline  yellow, soft gelatinous areasyellow, soft gelatinous areas CysticCystic liquefaction follows extreme hyalinizationliquefaction follows extreme hyalinization CalcificCalcific circulatory deprivationcirculatory deprivation precipitation of caprecipitation of ca carbonate & phosphatecarbonate & phosphate SepticSeptic circulatory deprivationcirculatory deprivation necrosisnecrosis  infectioninfection Myxomatous (fatty)Myxomatous (fatty) uncommon, follows hyaline oruncommon, follows hyaline or cystic degenrationcystic degenration
    9. 9. 11--BENIGN DEGENRATION (cont’dBENIGN DEGENRATION (cont’d)) Red (carneous) degenerationRed (carneous) degeneration Commonly occurs during pregnancyCommonly occurs during pregnancy Edema & hypertrophyEdema & hypertrophy impede blood supplyimpede blood supply asepticaseptic degenration & infarction with venous thrombosis &degenration & infarction with venous thrombosis & hemorrhagehemorrhage Painful but self-limitingPainful but self-limiting May result in preterm labor & rarely DICMay result in preterm labor & rarely DIC 2-MALIGNANT TRANSFORMATION2-MALIGNANT TRANSFORMATION Transformation to leiomyosarcomas occurs in 0.1-0.5%Transformation to leiomyosarcomas occurs in 0.1-0.5%
    10. 10. CLINICAL FINDINGSCLINICAL FINDINGS
    11. 11. 11--SYMPTOMSSYMPTOMS Symptomatic in only 35-50% of PtSymptomatic in only 35-50% of Pt Symptoms depend on location, size, changes &Symptoms depend on location, size, changes & pregnancy statuspregnancy status 1-Abnormal uterine bleeding1-Abnormal uterine bleeding The most common 30%The most common 30% Heavy / prolonged bleeding (menorrhagia)Heavy / prolonged bleeding (menorrhagia)  ironiron deficiency anemiadeficiency anemia
    12. 12. 11--Abnormal uterine bleeding (cont’dAbnormal uterine bleeding (cont’d(( Submucous myoma produce the most pronouncedSubmucous myoma produce the most pronounced symptoms of menorrhagia, pre & post-menstrual spottingsymptoms of menorrhagia, pre & post-menstrual spotting Bleeding is due to interruption of blood supply to theBleeding is due to interruption of blood supply to the endometrium, distortion & congestion of surroundingendometrium, distortion & congestion of surrounding vessels or ulceration of the overlying endometriumvessels or ulceration of the overlying endometrium Pedunculated submucousPedunculated submucous  areas of venouseareas of venouse thrombosis & necrosis on the surfacethrombosis & necrosis on the surface intermenstrtualintermenstrtual bleedingbleeding
    13. 13. 22--PAINPAIN Vascular occlusionVascular occlusion  necrosis, infectionnecrosis, infection Torsion of a pedunculated fibroidTorsion of a pedunculated fibroid acute painacute pain Myometrial contractions to expel the myomaMyometrial contractions to expel the myoma Red degenrationRed degenration acute painacute pain Heaviness fullness in the pelvic areaHeaviness fullness in the pelvic area Feeling a massFeeling a mass If the tumor gets impacted in the pelvisIf the tumor gets impacted in the pelvis pressure onpressure on nervesnerves back pain radiating to the lower extremitiesback pain radiating to the lower extremities Dysparunea if it is protruding to vaginaDysparunea if it is protruding to vagina
    14. 14. 33--PRESSURE EFFECTSPRESSURE EFFECTS If large may distort or obstruct other organs like ureters,If large may distort or obstruct other organs like ureters, bladder or rectumbladder or rectum urinary symptoms, hydroureter,urinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edemaconstipation, pelvic venous congestion & LL edema Rarely a posterior fundal tumorRarely a posterior fundal tumor extreme retroflexion ofextreme retroflexion of the uterus distorting the bladder basethe uterus distorting the bladder base urinary retentionurinary retention Parasitic tumor may cause bowel obstructionParasitic tumor may cause bowel obstruction Cervical tumorsCervical tumors serosanguineous vaginal discharge,serosanguineous vaginal discharge, bleeding, dyspareunia or infertilitybleeding, dyspareunia or infertility
    15. 15. 44--INFERTILITYINFERTILITY The relationship is uncertainThe relationship is uncertain 27-40% of women with multiple fibroids are infertile27-40% of women with multiple fibroids are infertile  but other causes of infertility are presentbut other causes of infertility are present Endocavitary tumors affect fertility moreEndocavitary tumors affect fertility more 5- SPONTANEOUS ABORTIONS5- SPONTANEOUS ABORTIONS ~2X N~2X N  incidence before myomectomy 40%incidence before myomectomy 40% after myomectomy 20%after myomectomy 20% More with intracavitary tumorsMore with intracavitary tumors
    16. 16. EXAMINTIONEXAMINTION Most myoma are discovered on routine bimanual pelvicMost myoma are discovered on routine bimanual pelvic exam or abdominal examinationexam or abdominal examination Retroflexed retroverted uterusRetroflexed retroverted uterus  obscure the palpationobscure the palpation of myomasof myomas LABORATORY FINDINGSLABORATORY FINDINGS AnemiaAnemia Depletion of iron reserveDepletion of iron reserve Rarely erythrocytosisRarely erythrocytosis pressure on the ureterspressure on the ureters backback pressure on the kidneyspressure on the kidneys  erythropoietinerythropoietin Acute degeneration & infectionAcute degeneration & infection  ESR, leucocytosis,ESR, leucocytosis, & fever& fever
    17. 17. IMAGINGIMAGING Pelvic U/S is very helpful in confirming the Dx &Pelvic U/S is very helpful in confirming the Dx & excluding pregnancy /excluding pregnancy / Particularly in obese PtParticularly in obese Pt Saline hysterosonographySaline hysterosonography can identify submucouscan identify submucous myoma that may be missed on U/Smyoma that may be missed on U/S HSGHSG  will show intrauterine leiomyomawill show intrauterine leiomyoma MRIMRI  highly accurate in delineating the size, location &highly accurate in delineating the size, location & no. of myomas , but not always necessaryno. of myomas , but not always necessary IVPIVP  will show ureteral dilatation or deviation & urinarywill show ureteral dilatation or deviation & urinary anomaliesanomalies HYSTROSCOPYHYSTROSCOPY  for identification & removal offor identification & removal of submucous myomassubmucous myomas
    18. 18. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Usually easily diagnosedUsually easily diagnosed Exclude pregnancyExclude pregnancy Exclude other pelvic massesExclude other pelvic masses -Ovarian Ca-Ovarian Ca -Tubo-ovarian abscess-Tubo-ovarian abscess -Endometriosis-Endometriosis -Adenexa, omentum or bowel adherent to the uterus-Adenexa, omentum or bowel adherent to the uterus Exclude other causes of uterine enlargement:Exclude other causes of uterine enlargement: -Adenomyosis-Adenomyosis -Myometrial hypertrophy-Myometrial hypertrophy -Congenital anomalies-Congenital anomalies -Endometrial Ca-Endometrial Ca
    19. 19. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Exclude other causes of abnormal bleedingExclude other causes of abnormal bleeding Endometrial hyperplasiaEndometrial hyperplasia Endometrial or tubal CaEndometrial or tubal Ca Uterine sarcomaUterine sarcoma Ovarian CaOvarian Ca PolypsPolyps AdenomyosisAdenomyosis DUBDUB EndometriosisEndometriosis Exogenouse estrogensExogenouse estrogens Endometrial biopsy or D&C is essential in the evaluation ofEndometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Caabnormal bleeding to exclude endometrial Ca
    20. 20. COMPLICATIONSCOMPLICATIONS
    21. 21. 11--COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY ≥≥ 2/3 of women with fibroids & unexplained2/3 of women with fibroids & unexplained infertility conceive after myomectomyinfertility conceive after myomectomy Red degenerationRed degeneration In the 2In the 2ndnd or 3or 3rdrd trimester of pregnancytrimester of pregnancy rapidrapid  in sizein size  vascular deprivationvascular deprivation  degenerationdegeneration Causes pain & tendernessCauses pain & tenderness May initiate preterm laborMay initiate preterm labor Managed conservatively with bedrest & narcoticsManaged conservatively with bedrest & narcotics + tocolytics if indicated+ tocolytics if indicated After the acute phase pregnancy will continue toAfter the acute phase pregnancy will continue to termterm
    22. 22. COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY DURING LABORDURING LABOR Uterine inertiaUterine inertia MalpresentationMalpresentation Obstruction of the birth canalObstruction of the birth canal Cervical or isthmeic myomaCervical or isthmeic myoma  necessitate CSnecessitate CS PPHPPH
    23. 23. COMPLICATIONS IN NONPREGNANT WOMENCOMPLICATIONS IN NONPREGNANT WOMEN Heavy bleeding with anemia is the most commonHeavy bleeding with anemia is the most common Urinary or bowel obstruction from large parasitic myomaUrinary or bowel obstruction from large parasitic myoma is much less commonis much less common Malignant transformation is rareMalignant transformation is rare Ureteral injury or ligation is a recognized complication ofUreteral injury or ligation is a recognized complication of surgery for Cx myomasurgery for Cx myoma No evidence that COCPNo evidence that COCP  the size of myomasthe size of myomas Postmenopausal women on HRT must be followed upPostmenopausal women on HRT must be followed up with pelvic exam or U/S every 6 Mwith pelvic exam or U/S every 6 M
    24. 24. TREATMENTTREATMENT
    25. 25. TREATMENTTREATMENT DEPENDS ON:DEPENDS ON: AgeAge ParityParity Pregnancy statusPregnancy status Desire for future pregnancyDesire for future pregnancy General healthGeneral health SymptomsSymptoms SizeSize LocationLocation
    26. 26. A-EMERGENCY MEASURESA-EMERGENCY MEASURES Blood transfusion/ PRBC to correct anemiaBlood transfusion/ PRBC to correct anemia Emergrncy surgery indicatd for:Emergrncy surgery indicatd for: - infected myoma- infected myoma -acute torsion-acute torsion -intestinal obstruction-intestinal obstruction Myomectomy is contraindicated during pregnancyMyomectomy is contraindicated during pregnancy
    27. 27. B-SPECIFIC MEASURESB-SPECIFIC MEASURES Most cases asymptomaticMost cases asymptomatic  no treatmentno treatment PostmenopausalPostmenopausal  no treatmentno treatment Other causes of pelvic mass must be excludedOther causes of pelvic mass must be excluded The Dx must be certainThe Dx must be certain Initial follow up every 6 MInitial follow up every 6 M  to determine the rate ofto determine the rate of growth of the myomagrowth of the myoma Surgery is contraindicated in pregnancySurgery is contraindicated in pregnancy The only indication for myomectomy in pregnancy isThe only indication for myomectomy in pregnancy is torsion of a pedunculated fibroidtorsion of a pedunculated fibroid Myomectomy is not recommended during CSMyomectomy is not recommended during CS Pregnant women with previous multiple myomectomy /Pregnant women with previous multiple myomectomy / especially if the cavity was enteredespecially if the cavity was entered  should beshould be delivered by CS todelivered by CS to  risk of scar rupture in laborrisk of scar rupture in labor
    28. 28. GNRH AGONISTSGNRH AGONISTS RX results in:RX results in: 1-1- size of the myomas 50% maximumsize of the myomas 50% maximum 2- This shrinkage is achieved in 3M of RX2- This shrinkage is achieved in 3M of RX 3-Amenorrhea & hypoestrogenic side-effects occur3-Amenorrhea & hypoestrogenic side-effects occur 4-Osteopososis may occur if Rx last > 6M4-Osteopososis may occur if Rx last > 6M It is indicated forIt is indicated for 1-1- bleeding from myoma except for the polypoidbleeding from myoma except for the polypoid submucous typesubmucous type 2-Preoperative to2-Preoperative to  sizesize  allow for vaginal hysterectomyallow for vaginal hysterectomy myomectomymyomectomy laparoscopic myomectomylaparoscopic myomectomy
    29. 29. C-SUPPORTIVE MEASURESC-SUPPORTIVE MEASURES PAP smear & endometrial sampling for all Pt withPAP smear & endometrial sampling for all Pt with irregular bleedingirregular bleeding Before surgeryBefore surgery -Correct Hb-Correct Hb -Prophylactic antibiotics-Prophylactic antibiotics -Mechanical & antibiotic bowel preparation-Mechanical & antibiotic bowel preparation  if difficultif difficult surgery is anticipatedsurgery is anticipated Prophylactic heparin postoperativeProphylactic heparin postoperative
    30. 30. D-SURGICAL MEASURESD-SURGICAL MEASURES 1-Evaluation for other neoplasia1-Evaluation for other neoplasia 2-Myomectomy2-Myomectomy For symptomatic Pt who wish to preserve fertilityFor symptomatic Pt who wish to preserve fertility Open myomectomyOpen myomectomy Laparoscopic myomectomyLaparoscopic myomectomy Hysteroscopic myomectomyHysteroscopic myomectomy 3-Hysterectomy3-Hysterectomy Vaginal hysterectomyVaginal hysterectomy Abdominal hysterectomyAbdominal hysterectomy 4-Uterine artery embolisation4-Uterine artery embolisation

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