most common tumors of uterus

1. Prof Malahat Mansoor
Sahara Medical College
Fibroids

2. Fibroids
 Also known as Leiomyomas
 Benign ,smooth muscle tumors arising in the
uterus
 Mostly asymptomatic
 Most common tumors & most common reason for
hysterectomy in women

3. Types of Fibroids
 Pedunculated Intracavitary---- polyp like projecting
into the uterine cavity
 Submcosal---just below the mucosal linning of the
endometrium
 subserosal---just below the serosa ,outer most layer
of the uterus
 Intramural ---completely inside the myometrium

4. Fibroids sites

5. Risk of Malignancy with Fibroids
 Extremely low malignancy potential
 The malignant form is known as Liomyosarcomas
 0.64 per 100000 to 1 per 1000
 Extremely rare chance of malignancy in women
below 40 years of age

6. Facts & Figures
 Most common BENIGN tumors of female genital
tract
 Cause symptoms in 20%-30% women
 Remain asymptomatic in 50% of women
 Improve fertility in 50% of women after
myomectomy
 Malignant changes in 0.5%- 0.9%

7. Fibroids---Risk Factors
 Ethnicity—more in African women (2-9X)
 Nulliparity
 Obesity
 Familial
 Hormonal

8. Clinical presentation of Fibroids
 Menstural Disturbances/Abnormal Vaginal
Bleeding
 menorrhagia
 irregular cycle
 post coital bleeding
 dysmennorhea
 Pressure Symptoms
 urinary symptoms
 bowl complains
 back ache
 sciatic nerve pain

9. Clinical Presentation of Fibroids
 Reproductive /obstetric Symptoms
 subfertility
 Miscarriages
 Antepartum hemorrhage
 Post partum hemorrhage
 Pre term labour

10. Fibroids Locations

11. Laparoscopic View of Fibroid

12. Why Fibroids Grow ??
 Estrogens & Progesterone's dependant
 Increased estrogen receptor gene expression
in uterine fibroids
 Reduced apoptosis meaning that autolytic
process of uterine fibers is delayed leading to the
accumulation of myofibrils

13. Pathophysiology
 Fibroids increase the surface area of the uterus
 Increased vascularity of uterus
 Increased contractility of uterus
 Disturb the shape of endometrial cavity
 May block the tubal ostia
 May hang out of the uterus into vagina or out of
vagina as a Fibroid polyp

14. How to investigate Fibroids
 History
 Examination
signs & symptoms of anemia
palpable mass in lower abdomen
 Pelvic Examination
increased uterine size
a separate mass in adenexa

15. Investigations
 Abdomino- Pelvic Ultrasound Mainstay
 Trans Vaginal Scan (TVS) Investigations
 MRI when difficulty in differentiating between a
fibroid & an ovarian mass
 Hysteroscopy when differentiation required
between an endometrial polyp/submucosal fibroid

17. Complications of Fibroids
 Degenerations
Hyaline
Red
 Torsions
 Acute urinary retention
 Renal failure
 Thrombo-embolism
 Acute vaginal or peritoneal hemorrhage
 Anemia complications

18. Treatment of Fibroids
 Depends on
age of the patient
location &/or size of Fibroid
symptoms produced
fertility wishes
fertility issues
patient’s own choice
associated medical/surgical problems

19. Conservative Treatment
 Means NO Treatment
 Advised when
Only incidental finding
Pt is asymptomatic
Younger age group
fertility NOT an immediate issue
 What to do then
explain & counsel the patient
advise 6-12 months follow up ultrasound
treat only if size increase or symptoms appear

20. Medical Management of Fibroids
 When fibroids cause Menorrhagia
 Tranexemic acid
 mefanimic acid
 combined contraceptive pills
• When size,fertility or surgery is the
issue
 GnRH Analogues which will cause
hypoestrogenic state & reduction in
size of fibroids
 Mefiprestone ( Anti-progesterone)

21. Limitations of Medical Treatment
 Only treat the symptoms
 May become ineffective any time
 Needs very well compliant patient
 No control over growth of fibroids
 GnRH Analogues may have intolerable side
effects

22. Medical treatment of fibroids
 NSAIDS
 Tranxemic acid
 Mirena
 COCs
 Progesterone only

23. Surgical Treatments of Fibroids
 Hysteroscopic removal;
 in submucous or fibroid polyps with a
small pedicle & causing menorrhagia
 Myomectomy;
 younger women
 wishes for fertility
 surgically easy procedure
 hope for improvement in fertility
 Hysterectomy;
 older women
 No fertility wishes
 surgically difficult procedure

24. Uterine Artery Embolization– A new technique
 performed by interventional radiologist
 Done under local anesthesia
 Both uterine arteries are embolized through
femoral artery
 Helps in
size reduction—50%
reduced menstrual blood loss—80%-90%
reduced pressure symptoms---- 40%-&70%
reduced further growth

25. Why fibroids degenerate ?

26. Uterine Artery Embolization

28. Brain Teaser
 A 35 yrs old P2 has 4 cm fibrod in the fundus of
the Uterus. She complains of weight gain,
oligomenorrhea & hirsuitism.
She should be offered
a) No treatment
b) surgical removal of fibroid
c) Uterine embolization
d) combined oral contraceptive Pills
e) myomectomy

29. Advantages of UAE
 No surgery/anesthesia complications
 No intra-operative blood loss/need of blood
transfusion
 Short hospital stay
 No abdominal adhesions
 80% satisfaction in women with menorrhagia

30. Contra indications of UAE
 Subserous & pedunculated fibroids
 Large sized fibroids
 Fertility issues
 Fertility required

31. Post UAE complications
 Fever & infection
 Vaginal discharge
 Vaginal bleeding
 Excruciating ischemic pain
 Pulmonary embolism
 Pre-mature ovarian failure

32. Modern Techniques in Fibroid Treatment
 Laparoscopic Assisted Vaginal Hysterctomy LAVH
 HIFU- High Intensity Focused Ultrasound
MRI guided per cutaneous laser ablation
 Laparoscopic Myolysis
using Nd.YAG Laser or Diathermy to coagulate
subserosal fibroids

33. Fibroids & Pregnancy
 During pregnancy ,the fibroids can
increase in size
maintain pre-pregnancy size
disappear
degenerate( red degeneration)
have torsion

34. Affect of fibroids on Pregnancy
 Abortions
 Pre-term labor
 PPROM(preterm premature rupture of
membranes)
 IUGR (intrauterine growth retardation)
 Ante partum hemorrhage

35. Fibroids Complications related to
Pregnancy
 Abortions
 Preterm labour
 Malpresentations
 Malpositions
 Increased risk of operative deliveries
 Post partum hemorrhage

36. Fibroids & Labor
 Malpresentation of baby ( breech,obliqueor
shoulder)
 Malposition (occipito posterior, occipito
transverse)
 Prolonged or Obstructed labor
 Rupture of previous myomectomy scar

37. Fibroids&Post partum period
Can cause
 Postpartum hemorrhage
 Expulsion of Contraceptive Devices
 Ischemic degeneration

38. Fibroids during Caesarean
section
 Must be LEFT ALONE at the time of C-section
 If present on incision line just deviate the incision a
little away
 Avoid handling with fibroid/s during C-Section at all
cost

39. Ultrasound View of Fibroid

40. MRI view of Fibroid

41. Brain Teaser
 A 28 yrs old PG is at 32 weeks of pregnancy. She
has one Intramural &one Subserosal fibroid
diagnosed before this pregnancy. Regarding her
problem
a) She must have C section & removal of fibroid
b) Trial of labour is possible but depends on lie
&presentation of the baby
c) Uterine artery embolization can be done now
d) There is high probability of placenta previa
e) Myomectomy should be offered within a week
of delivery

42. Questions ???

43. Test Alert
 Test of all topics covered from February to Date will be
held on 17th May , 2019
 Topics
endometriosis
multiple pregnancy
Pre term labor
Fibroids
Early pregnancy loss
Placenta Previa
It will have
5 SEQs + MCQs