3. Leiomyomas (fibroids)
Benign smooth muscle tumors of the uterus
Commonly called “fibroids”
Estrogen dependent
Rarely occur before menarche or after menopause
Grow larger during pregnancy
Rarely malignant
Most common indication for pelvic surgery in
women
4. Epidemiology of Leiomyomas
Develop from smooth muscle cells by means of
hyperplasia
Occurs in 20% of women of reproductive age
Most often occurs among
Nulliparous women
Women older than 35
Nonsmokers
Oral contraceptive or IUD users
Obese
Positive family history
African American women
5. Classification of Leiomyomas
Submucous - Protrude into the uterine cavity
Sessile submucous
Pedunculated submucous
Intramural - Within the myometrial wall
Subserous - Growing toward the serous surface of the
uterus
Sessile Subserous
Pedunculated Subserous
Intraligamentous - Located in the cervix or in between
the folds of the broad ligament
Parasitic fibroid – No connection with uterus
6. Pathology
Macroscopy
Firm
Composed of fibrous tissue and myometrial tissue
If myometrial tissue high - Myoma
If fibrous tissue high - Fibromyoma
Growing fibroid Myometrium compressed and
atrophied
False capsule
7.
8. Leiomyomas:Symptoms
Usually asymptomatic
Symptoms increase as tumors grow
Common symptoms
Menstrual disturbance Pressure symptoms
Menorrhagia Feeling of “heaviness”
Dysmenorrhea Bloating
Spotting between periods Pelvic congestion, Varicose veins
Urinary retention, frequency,
dysurea
Dyspareunia
Back pain
A lump or swelling in the lower abdomen
Subfertility
9. Leiomyomas
Physical Examination
Abdomino pelvic lump
Firm
Non tender
Irregular
Mobile in transverse direction
Mobility restricted in longitudinal direction except
in pedunculated fibroids
Absence of ascites
Normal bowel sounds
May be mistaken for adnexal mass if situated laterally
If mass moves with the uterus, likely to be a leiomyoma
14. Diagnosis
USS
Characteristically appears hypoechogenic and well
defined lesions
Hysteroscopy
Pedunculated and submucous myomas can be
identified
Laparoscopy
Operative diagnosis
17. Management
Depends on
Symptoms
The location of fibroids
Size and number of the fibroid
Fertility wishes
Patient’s wishes
Facilities of the unit and the experience of the
operator
18. Management cont…
1. Monitoring
If the fibroids are causing no symptoms and are
not large,
‘wait and see’ approach
Re-evaluate every 3-6 months
Pelvic ultrasound as needed
Monitor Hb frequently
19. Management cont…
2.Medical treatment
Drugs
Oral contraceptive pills, either combination pills or
progestin-only, in an effort to manage symptoms
Hormones, used in combination to shrink the
fibroids prior to surgery
Long term progesterone
GnRH - analogues
Danazole
Gestrinone
Mifepristone
Letrazole
20. Management cont…
3.Arterial embolisation
Under local anaesthesia, a fine tube is passed via an
artery in the arm or leg into the main artery
supplying the fibroid with blood
The whole process is monitored by x-ray
Fine particles (like sand) are injected into the artery
to block the blood supply to the fibroid
The fibroid slowly dies and symptoms should settle
over a few months
22. Management cont…
4.Ablation Therapy
HIFU (High intensity focused ultrasound), (Magnetic
Resonance guided Focused Ultrasound)
Non-invasive intervention
Uses high intensity focused ultrasound waves
to ablate (destroy) tissue in combination with
Magnetic Resonance Imaging (MRI)
Laser ablation
23. Management cont…
5.Surgical management
Myomectomy Hysterectomy
Only the fibroid is
removed
1. Hysteroscopic
myomectomy
2. Laparoscopic
myomectomy
3. Open
myomectomy
Entire uterus is
removed
1. Abdominal
hysterectomy
2.Vaginal
hysterectomy
24. Management cont…
Myomectomy is indicated when,
Solitary pedunculated myoma
Nature or location of the myoma
appears to be interfering with fertility – sub
serous myoma or myomatous polyps
Myoma is causing pregnancy loss
Preservation of fertility is required
25. Myomectomy
Hysteroscopic myomectomy
Fibroids are removed via the cervix, using a hysteroscope
Recommended for submucosal fibroids
Laparoscopic myomectomy
Myomectomy through laparoscopy
Open myomectomy (Laparotomy & myomectomy)
Larger fibroids removed via an abdominal incision.
This weakens the uterine wall and makes Caesarean
sections for subsequent pregnancies more likely
Management cont…
27. Management cont…
Hysterectomy
Hysterectomy will indicated in,
Rapid enlargement of the uterus may mean possible
malignancy
Abnormal uterine bleeding not responding to other
methods of treatment and that may lead to anaemia
Pelvic pain
Secondary dysmenorrhea
Urinary symptoms
Uterine growth after menopause
Patient has completed childbearing
29. Fibroids — prevention
As the cause of fibroids is still unknown, there are no clear
guidelines for preventing them
There are some things you could do that may help to
reduce the risk
Keep your weight in check. This will minimize oestrogen
levels in body
Eat green vegetables and fruit, and avoid red meat
Some studies suggest the combined pill may protect
against fibroids by keeping hormone levels from peaking
and falling