2. Uterine fibroid is a leiomyoma (benign (non- cancerous) tumor
from smooth muscle tissue) that originates from the smooth
muscle layer (myometrium) of the uterus
DEFINITION
3. Etiology
Tumours are estrogen dependent
Each myoma develops from a single muscle cell
Genetic predisposition - Aberrations (translocations & deletions)
in chromosome 7,6,12 and 14
Action of hormones on myoma is mediated by elevated levels of local growth factors
(epithelial Growth Factor,vascular endothelial growth factor,transforming growth factor )
Sex steroids - Oestrogen & Progesterone receptors in myomas
5. Sub mucous Fibroid
Type 0 :-Pedunculated, lie entirely within the uterine
cavity
Type 1:-> 50 % in the Uterine cavity
Type 2:-< 50 % in the Uterine cavity
Cervical Fibroids
Anterior
Central
Posterior
7. Broad ligament Fibroids;-
True-From smooth muscles in the broad ligament.
Clinical significance-displaces ureters medially
False (Pseudo)-arise from lateral wall of uterus and
protrude between layers of broad ligament and displace
ureters laterally
8.
9. Degenerations;-
1.Hyaline degeneration- common, start at the centre
2.Cystic
3.Myxomatous
4.Fatty
5.Calcareous(calcification)- womb stones
6.Red degeneration
Red degeneration-(Carneous)
-5-10 % of pregnant women
-Thrombosis & coagulative necrosis
-peritoneal irritation-pain & constitutional symptoms
-GnRH therapy, OC pill, UAE
-Self limiting
-Conservative management
-Analgesics, Antipyretics
13. Causes for abnormal bleeding
• Increase in endometrial surface area
• Increase in vascularity of uterus
• Interference with normal uterine contractility
• Ulceration of submucous fibroid
• Stasis and dilatation of venous plexus
• Associated anovulation
• Associated endometrial hyperplasia
14. Physical examination
• General examination- anemia
• Abdominal exam.. – mass arising from pelvis , midline mass, firm, irregular
• Speculum exam.. – displacement of cervix , fibroid polyp
• Pelvic exam..- uterus irregularly enlarged,
movt of mass transmitted to cervix
uterus not separately made out
15. Differential Diagnosis
Solid Ovarian Tumours
Adenomyosis
Tubo ovarian masses
Pregnancy
Full bladder
Pyometra
Other Abdominal masses not related to genital
tract
16. Investigations
• Hemoglobin
• USG ( TAS and TVS)- location of fibroid, number, size, adnexal mass, adenomyosis, HUN
• Hysteroscopy- S/M fibroid , type, resectability, endometrial sampling
• Laparoscopy- uterus < 12 wks size, evaluation of pelvic pain, subfertility, R/O ovarian mass
17. Expectant Mx
Medical
Surgical
Minimal Invasive-Uterine Artery Embolisation
-Myolysis(Laparoscopic )-Laser, Cryo or
electrosurgical
Non Invasive - MRG FUS(Magnetic Resonance - Guided Focused
USS )
Management
18. Management of asymptomatic fibroid
• Initial assessment of size, number and location
• Counselling
• Annual assessment by USG
• Interfere when required
Indication for medical management
• Young women attempting conception
• Control bleeding while waiting for surgery
• Control bleeding while anemia is being corrected
• Women approaching menopause
• Shrink myoma preop
19. Non hormonal
Hormonal
GnRH agonists
LNG – IUS
Antiprogestins
medical management
20. Non hormonal
Antifibrinolytics – Tranexamic Acid 1 gm thrice daily
50% reduction in blood loss
PG synthetase inhibitors – Mefanamic Acid 500 mg tid
25-40% reduction in blood loss
Hormonal
Combined OC pills
Progestogens like norethisterone
21. GnRH Agonists-induce a state of Pseudomenopause
- Decrease in size of fibroid & correction
of anaemia
Inj.Leuprolide 3.75 mg s/c monthly for 3 months
Disadv-decrease bone mineral density
-Menopausal symptoms
-High Cost
Role is for short duration therapy(3-6 months) while waiting
for surgery
22. LNG-IUS-
in small myomas
not useful in myomas distorting uterine cavity
Antiprogestins-SPRMS (Selective progesterone
ReceptorModulators)
Mifepristone -5-10 mg daily for 3 months
Ulipristal Acetate-5mg daily
23. Surgical Treatment
Indications-
Symptomatic Fibroids
Large Fibroids
AUB not controlled with medical management
Associated hydroureteronephrosis
Rapid enlargement in Postmenopausal
24. Conservative –Myomectomy in young women
Routes-
-Laparoscopic
-Abdominal
-Hysteroscopic (Depending on the size
and location of fibroid
<4cm,Type 0-1 Submucous
25. Myomectomy
Surgery in post menstrual phase
Optimal Hb status and adequate arrangement of blood
Preoperative counselling -Risk of Haemorrhage and need
for blood transfusion
-Recurrence-30-50%
-Rare chance of
hysterectomy
26. Surgery-Anterior midline incision if possible
Steps of reducing blood loss-
Tourniquet at the level of internal os or
Vasopressin instillation in to the myometrium
Enucleation through the cleavage plane of the capsule
Cavity may be opened in submucous fibroid
Closure of Myoma bed & due care of Haemostasis
27. Hysterectomy
Definitive treatment
- Symptomatic and large fibroids , not desirous of
preserving uterus
Routes depending on size, location of fibroid and expertise
-Laparoscopic
-Abdominal
-Vaginal
28. Uterine Artery Embolisation
Alternative for symptomatic
Ischaemic necrosis of fibroids
Under Radiological guidance
Embolisation by Poly vinyl alcohol particles
Not recommended in young ,infertile women
Post embolization syndrome –Necrosis and release of inflammatory
mediators
29. MRG FUS
Non Invasive
Thermal ablation using high intensity focussed
ultrasound waves
Fibroid in perimenopausal age
Fibroids between 4-10 cm
Depth of subcutaneous tissue to fibroid <12cm
Clearly visible on MRI
