Definition of fibroid / uterine leiomyoma Diagnosis of Fibroid Treatment of uterine fibroid Surgery for uterine fibroid When is surrogacy required for fibroid By Dr Gajendra Tomar, Indore Infertility Clinic, IVF center

1. FIBROIDS
LEIOMYOMA

2. Uterine Leiomyoma : Introduction
 Commonest benign solid tumor in females
 Incidence : Age dependent : Around 25-30 %
 Smooth muscle + Fibrous connective tissue
 Fibroid / Uterine Leiomyoma / Fibromyoma
 Neoplastic single smooth muscle cell of the
myometrium (Monoclonal)
 Leading indication of Hysterectomy

3. Causes
 Etiology still unclear
 Chromosomal : 40 % cases
 Polypeptide growth factors
 Hormones
 Familial (RR 2.5)

4. Hormones
 Predominantly an Estrogen-dependent tumor
 Both P & E promote development
 Serum Levels of E & P are same
 High Aromatase causes denovo production of
estrogen
 Increased Progesterone receptors – High mitotic
counts

5. Factors That Affect the Risk of Uterine
Fibroids
High Risk Low Risk
Early Menarche
Late Menopause
Late menarche
Early Menopause
Obesity Exercise
Nulliparity Increased Parity
African descent Smoking
High dose Oral contraceptive
pills
Low Dose Oral contraceptive
pills

6. Types of Fibroids

7. FIGO Classification

8. Fibroids:
Composition
• Round, firm, and well-circumscribed nodules
• Cut section shows whorled appearance
• False capsule
• There are often multiple tumours in a single
uterine specimen. They do not have a true capsule.
• They range in size from seedlings to large uterine
tumours.

9. Histology
Whorled (fascicular) pattern of Smooth
Muscle (SM) bundles separated by well
vascularized connective tissue
Pseudocapsule : part of the
myometrium which compresses the
leiomyoma.

10. Histology
 SM cells elongated with eosinophilic distinct cell membranes
 May develop areas of degeneration if large including;
hyaline/mucoid/Calcified/Cystic
 Usually < 5 mitotic figures per 10 HPFs
 Post lupron treatment: initially edema and necrosis, then
hyalinization and mild lymphocytic infiltrate

11. Origin

12. Diagnosis
Gynaecology assessment:
• History
• Abdominal-vaginal exam
• Speculum assessment
• Assess fibroid size
Investigations:
• Menstrual diary
• Pelvic US
• Saline TVUS (SIS)
• Hysteroscopy +/- Laparoscopy
• MRI (+/- contrast Gadolinium)

13. Pelvic Ultrasound
 Readily Available
 Cost Effective
 Symmetric, Well Defined, Hypoechoic
 Degenerative changes may change appearance
 90-95 % Sensitive but may miss submucosal
fibroids

14. Pelvic Ultrasound SIS
 Submucosal fibroids
 Very high sensitivity
and specificity

15. Saline Infusion Sonography
 Mainly for submucosal
fibroids
 Very high sensitivity and
specificity

16. MRI
 Accurate assessment of size, number and location
 Not technique dependent
 Low interobserver variation
 Impact on surrounding organs
 Conservative fertility preserving surgeries : Greater
role.
 Adenomyosis vs fibroid : Clear (Junctional zone is
more than 15mm, high and low intensity areas in
the myometrium)

17. MRI Imaging

18. MRI contrast Gadolinium

19. The role of Diagnostic Hysteroscopy
 Classify fibroid(s) and suitability for resection
 Option of ‘see and treat’
 Evaluate size and contour of endometrial cavity and
morphology of endometrium.
 Exclude concomitant pathology (e.g. endometrial
thickening, polyps, focal change/cancer).

20. Submucous Fibroids at
Hysteroscopy

21. USG / Hysteroscopy / Laparoscopy

23. Calcification uterine fibroids

24. Fibroids and Pregnancy
Fibroid on Pregnancy
 Mostly uneventful 2/3rd
 Increased rate of spontaneous miscarriage
 preterm labor , placenta abruption
 Malpresentation, labor dystocia
 cesarean delivery
 postpartum hemorrhage
Pregnancy on Fibroid
 Variable and Unpredictable
 2/3rd : No change
 1/3rd : Increase
 Growth usually limited almost exclusively to the first trimester
 Reduction in size towards pre pregnant – 4 weeks
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319/

25. Red Degeneration
Carneous Degeneration
 Large fibroid
 Mainly during second half of pregnancy and puerperium.
 The cause is not known but is probably vascular in origin.
 Infection does not play any part.
 Naked eye appearance of the tumor shows dark areas
 Cut section revealing raw-beef appearance often containing cystic
spaces.
 Color is due to the presence of hemolysed red cells and
hemoglobin.
 Microscopically, evidences of necrosis are present.
 Vessels are thrombosed but extravasation of blood is unlikely

26. Red Degeneration : Diagnosis and Management
during pregnancy
 Pain, Vomiting, and Fever
 Raised leucocytes, Raised CRP
 Acute appendicitis, sub acute salpingo-oophoritis,
Torsion of pedunculated subserosal leiomyoma,
threatened abortion
 Management: Conservative and symptomatic

27. Sarcomatous changes
 less than 0.1 percent cases.
 The usual type is leiomyosarcoma
High Suspicion
• Recurrence of fibroid polyp
• sudden enlargement of fibroid
• Pain, Bleeding, Closer to menopause
Diagnosis
• Serum LDH
• GD Enhanced MRI : Increased vascularity & perfusion

28. Differential diagnosis
(1) Pregnancy
(2) Full bladder
(3) Adenomyosis
(4) Myohyperplasia
(5) Ovarian tumor

29. Management of Leiomyoma

30. Do nothing
 Asymptomatic fibroids
 Mild to moderate symptoms that aren't significantly
affecting everyday activities.
 Fibroids usually shrink after the menopause, and
symptoms ease or resolve.

31. Symptomatic Medical Management
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
have been a regular solution for pain
 Tranexamic acid : procoagulant drug : reduces blood
loss in cases of mild bleeding

32. Combination Oral Contraceptive Pills
 In the past considered a risk factor
 Suppressive effects on endometrial proliferation
 No effect on decreasing uterine fibroid volume or
uterine size
 Easy accessibility, oral administration, and low
cost

33. Progestins
 Lack of high-quality evidence
 May even promote uterine fibroid cell growth
 Associated with histopathological changes that may
be mistaken for leiomyosarcoma or smooth-muscle
tumors of unknown malignant potential

34. LNG-IUS
 Causes Endometrial atrophy
 Improvement in menstrual bleeding and hemoglobin
levels
 No appreciable change in fibroid volume
 Effective for up to 5 years,
 Minimal side effects are reported
 No additional patient's compliance after insertion
 Symptomatic women with no endometrial distortion
 If cavity is distorted, expulsion rates are high

35. GnRH Agonists
 GnRH agonists are synthetic peptides with longer
half-life than native GnRH
 Increase (FSH) and (LH) secretion : flare effect
 After that, receptor down-regulation, followed 1–3
weeks later by a hypogonadotropic hypogonadal
state, often termed — “pseudomenopause”
 Induced Hypoestrogenic state

36. GnRH Agonists
 Significant improvement in both pre- and
postoperative hemoglobin levels
 Significant reductions in uterine volume, fibroid
volume
 More beneficial in cases of large uterine fibroids
(>10 cm) if myomectomy is to be performed, thus
reducing operative time, intraoperative bleeding,
and the risk of blood transfusion

37. GnRH Agonists Drawbacks
 Menopausal symptoms, such as hot flashes and
atrophic vaginitis, and a decrease in bone mineral
density (BMD) after long-term use limit GnRH
agonists.
 Myoma degeneration and obliteration of the
interface between the myoma and myometrium,
making removal difficult
 Small uterine fibroids that become too soft and
difficult to visualize : may be missed

38. SPRMs
 Progesterone stimulates proliferative activity in uterine fibroid cells,
but not in normal myometrial cells
 Compared with myometrium, fibroids overexpress ERs and
progesterone receptors (PRs)
 GnRH with addback P
 Mifepristone is thought to have almost pure antagonistic properties
 Other SPRMs such as ulipristal acetate exhibit mixed agonist and
antagonist properties
 Novel PRM-associated endometrial changes

39. Mifepristone
 Mifepristone (RU-486) is a progesterone receptor
modulator that has almost pure antagonistic
properties and may directly decrease the PR in the
myometrium and leiomyoma
 Significantly reduced uterine and leiomyoma
volume and related symptoms
 2.5 mg daily for 3 to 6 months as the optimum
treatment.
 Insufficient Evidence : Atypical endometrial
hyperplasia

40. Ulipristal Acetate
 Exhibits anti proliferative effects on leiomyoma
cells and the endometrium
 Repeated intermittent 3-month open-label UPA
courses
 Decreased uterine bleeding symptoms with
treatment
 As effective as leuprolide acetate in controlling
heavy menstrual bleeding

41. Ulipristal Acetate
 Rapid control of the symptoms
 decreasing volume by 50% after 12 months of treatment,
 Similar manner as GnRH analogs, excellent safety and
tolerability profile
 Amenorrhea in 80% of the patients
 Considered as a first-line treatment once symptomatic
treatment is not effective
 Surgery, when necessary, is not compromised
 Combination with another treatment method, like LNG-
IUS, is recommended after finishing UPA

42. Others
 SERM’s
 AI
 https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C5592915/
 https://www.jogc.com/article/S1701-
2163(15)30338-8/pdf
 https://www.aafp.org/afp/2017/0115/p100.html
 https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C5854898/

43. Surgical & Other non Medical Modes
 Hysterectomy
 Myomectomy
 Conservative Radiological Interventions

44. Hysterectomy
 In women who have completed childbearing,
hysterectomy
 Permanent solution for symptomatic leiomyomas
 The only indications for hysterectomy in a woman
with completely asymptomatic fibroids are
enlarging fibroids after menopause without HRT

45. Type of hysterectomy
 Abdominal, Laparoscopic, or Vaginal route :
Surgeon’s training, experience, and comfort
 Abdominal supracervical or total hysterectomy :
randomized trials have demonstrated no differences
in sexual and urinary function
 Less blood loss and complications associated with
supracervical hysterectomy

46. Vaginal hysterectomy
 Preferred technique
 provides several statistically significant advantages,
 decreased blood loss, shorter hospitalization, and
shorter paralytic ileus time
 limited by the size of the myomatous uterus.
 Abdominal hysterectomy is an alternative approach

47. Laparoscopic Hsyterectomy
 The laparoscopic extraction of the uterus may be
performed with morcellation
 Rotating blade cuts the tissue into small pieces.
 This technique has come under scrutiny because of
concerns about iatrogenic dissemination of benign
and malignant tissue

48. Myomectomy
 Women who wish to retain their uterus, regardless of
their fertility desire.
 Well planned, site, size, number.
 Women should be counselled about the risks of
requiring a hysterectomy at the time of a planned
myomectomy.
 Five years following laparoscopic myomectomy, the
cumulative probability of recurrence in women who
subsequently gave birth was 42%. In those who did
not give birth, it was 55%

49. Myomectomy
 Hysteroscopic Myomectomy
 Laparosocopic Myomectomy
 Open Myomectomy

50. Hysteroscopic Myomectomy
 Submucous myomas (types 0, I, and II) up to 4 to 5
cm in diameter can be removed hysteroscopically.
 Type II myomas are more likely to require a 2-staged
procedure
 Risk of excessive fluid absorption and uterine
perforation, particularly with those with less than 5
mm thickness between the fibroid and the uterine
serosa

51.  Laparoscopic myomectomy is a procedure associated with less
subjectively reported postoperative pain, lower postoperative fever
and shorter hospital stay
 No evidence suggested a difference in recurrence risk
 After the completion of myomectomy, application of antiadhesion
barriers has been proposed. None of these adjuncts has
demonstrated an improvement in fertility and pregnancy outcomes

54. Uterine Artery Embolization

56. Uterine Artery Embolization
 Carried out by interventional radiologists and consists of
injecting an occluding agent into one or both uterine arteries
 Most common alternative offered to women with
sympotomatic uterine fibroids
 Very large uteri (over 20 weeks) may not have a clinically
significant response
 Single submucosal fibroids or subserosal fibroids may
respond better to surgery than UAE
 Post Embolization syndrome : Pain, Fever, Expulsion
 Pregnancy rates were lower and miscarriage rates higher
following UAE
 Best reserved for women who do not desire future pregnancy

57. UAE v/s Myomectomy
 RCT for UAE versus myomectomy : comparable
symptom improvement and improved QoL.
 The re-intervention rate is > for UAE.

58. Focused Energy Delivery Systems
 A number of focused energy delivery systems have been tested in the past
decade including those based upon radiofrequency electricity, supercooled
cryoprobes, and most recently, MRg-FUS or high frequency ultrasound guided
transcutaneous focused ultrasound ablation
 A major disadvantage of all systems and techniques used to desiccate or ablate
fibroids may be that they treat one fibroid at a time and they target the centre
of fibroids, while fibroids have been shown to grow mostly from their periphery
 These technologies are relatively new and although many are promising, they
often lack long-term data, which interferes with our ability to present all risks
and benefits with assurance.
 Ongoing research and data collection are required to assess the relative merit of
newer options as the technology continues to expand

59. MR-guided focused ultrasound
 Shortterm efficacy is adequate
 Skin burns have occurred in up to 7% of
patients and at least one bowel
perforation was reported
 Disadvantages of the MRg-FUS system
include high exclusion rate, requirement
of an MR machine, prolonged time
(minutes to several hours), treatment of 1
fibroid at a time, and ablation of fibroids
centrally, while fibroids seem to grow
peripherally

60. Radiofrequency myolysis
 Delivering of RF energy to myomas under ultrasonic guidance in an
attempt to dessicate them directly
 well tolerated and results in rapid recovery, high patient satisfaction,
improved quality of life, and effective symptom relief
 Total mean fibroid volume was reduced by 45.1% and mean blood loss
by 38.3% at 12 months post-procedure.
 Disadvantages include the requirement of laparoscopy and
concomitant use of ultrasound, additional percutaneous skin
incision(s), its treatment of 1 fibroid at a time (< 8 cm diameter), and
its ablation of fibroids centrally while fibroids grow peripherally

61. TREATMENT
ALGORITHMS
SYMPTOMATIC FIBROIDS

62. Hysteroscopic Access ?

63. No Hysteroscopic Acess, No Gestational Desire

64. No hysteroscopic access, Desire future fertility

65. Cervical Fibroid
Lantern on St Paul’s Cathedral

66. Cervical Fibroid
 The paucity of smooth muscles in the cervical stroma
makes leiomyomas in the cervix uncommon
 The incidence of cervical fibroids is around 0.5% –
2%
 Depending on the position, cervical fibroids can be
anterior, posterior, lateral or central
 Symptoms are mainly due to pressure effects on the
bladder leading to acute urinary retention and
increased frequency of micturition, the pressure
effect on the rectum can cause constipation

67. Surgery for cervical fibroid
 In case of hysterectomy, the principal to be followed is
enucleation followed by hysterectomy to minimize injury
to ureter and also uretric stenting can be done prior to
surgery.
 Enucleation in case of central cervical fibroid,
 The problems anticipated during hysterectomy for large
cervical fibroid are due to distortion of normal anatomy
of ureter and uterine vessels and sometimes due to
pulled up bladder anteriorly. Therefore, there are more
chances of injury to ureter, bladder and uterine
vessels.5,6
 Intracapsular enucleation of fibroid is the best approach
to prevent injury to bladder and ureters

68. In my early years as a gynaecological surgeon, a case occurred which
profoundly affected my outlook. A lady, recently married, wishing above all
things to have a child underwent a subtotal hysterectomy on account of a
single submucous fibroid. Being a woman of strong character and reticent
fortitude, she accepted the blow without complaint and by assuming a proud
indifference to children, held her insistent mother instinct at bay and none
but those who knew her well perceived the tragedy. I was among this
number and the grief of it is still keen in me today