Fibroids by mavish

1. Prepared by:
Mahwish Gul
Roll # 08-089
Final yr MBBS

2.  What is fibroid?
 Its epidemiology?
 its gross & microscopic features?
 Its types?
 What causes fibroid?
 What are its signs and symptoms?
 Its treatment options?
 Its complications?
 Its differential diagnosis?
 Effect of fibroids on pregnancy & pregnancy on fibroids?

3. • Actually fibroid is a misnomer because there is very little
connective tissue in it.
• Its other name is LEIOMYOMA or MYOMA.
• It is chiefly composed of the smooth muscle fibers &
contains fibrous tissue in small amount.
• Tumor arises from the muscle tissue and NOT from the
fibrous tissue of the uterus.
• It is a BENIGN in nature.
• Predominantly occurs in the body of the uterus and less
commonly in the cervix.

4.  Most common tumor not only of the uterus but of the
whole female body!
 Present in 20-30% of the women of reproductive age.
 Disease of the reproductive age, never occurs before
menarche & regresses after menopause.
 Commonly occurs in infertile & women with low
parity.
 Incidence is more common in black women where it
presents at a younger age as well.
 Family history +

6.  Nodular outgrowth which causes enlargement of the
uterus and distortion of its normal structure.
 Could be single but are usually multiple.
 Size varies from a few millimeters to the size of the
football.
 Oval or rounded in shape.
 Firm in consistency.
 Characteristic whorled appearance on cut surface
which becomes convex.
 Its colour is generally lighter than surrounding
myometrium.
 Could be surrounded by the pseudo-capsule.

10.  Bundles on muscle cells seen running in all directions.
 Nuclei of these cells are rod shaped and uniform in
shape and size.
 Variable amount of connective tissue present in
between.

11.  Female hormones
 Mechanical stress
 Racial factors
 Genetic factors
 Parity

12.  Receptors
 Does not occur before menarche & regresses after
menopause
 In size when treated with GnRH analogues
 In size in response to oral contraceptives
 Incidence in obese women
 Incidence in smokers

13. • subserous
• Intramural
• submucous
body
cervical
intraligamentary

15. Originates from the outer
myometrium & projects
outwards from the uterine
surface covered with the
peritoneum.
May attain a large size because
of unrestricted growth.
May become pedunculated.
Subserous type

16. Lies within the uterine wall
& is surrounded by the
normal myometrium on all
sides.
May be surrounded by
pseudo-capsule.
Large intramural fibroid may
distort the uterine cavity &
increase its surface area.
Intramural type

17. Arises from the inner
myometrium & is covered
by the endometrium.
Projects inwards into the
uterine cavity & may
become pedunculated.
Submucous type

18. Less common.
1-2% of the cases.
Often single.
Usually confined to
supravaginal portion of cervix.
Either intramural or subserous.
Cervical type

19. Rare
Arises from smooth muscle
fibres within the broad ligament.
Should be differentiated from
the subserous fibroid.
Intraligamentary type

20. Usually silent (in more than 50% of the cases)
Menstrual problems e.g
I. Menorrhagia > surface area > endometrium
becomes ulcerated covering the submucous type
> vasularity
II. Intermenstrual bleeding
III. Postcoital bleeding
IV. Irregular bleeding

21.  Abdominopelvic mass (in the absence of pregnancy)
 Subfertility
occurs in 30% of the patients with fibroid (unclear whether
fibroid is a cause of subfertility or an effect)
possible explanations:
> delay in child bearing & interfere with implantation
of the fertilized ovum.
 Heaviness in the lower abdomen
 Pain
 Urinary retention
 Urinary frequency
 Dyspepsia
 Dyspnea
 Intestinal obstruction
 Constipation
 Haemorrhoids
 Edema of the legs
 Varicosities of the legs

22. General physical examination
 No specific findings
 Excessive loss of blood may cause anemia ,presenting with
pallor and in extreme cases with breathlessness
 Edema and varicosities of limbs are rare findings with large
fibroids .
Abdominal examination :
Uterus palpable abdominally
 Single fibroid -- uterus with smooth surface
 Multiple fibroids – irregular mass maybe shifted to a side
 Fibroids – firm ,non tender unless undergone
degeneration.
Pelvic examination :
 Protruding fibroids easily seen

23. • ultrasound

24.  Hysteroscopy & curettage

26.  hysterosalpingogram

27.  CT scan

28.  MRI
 Complete blood picture
>Hb
>associated polycythemia

29. conservative treatment
Medical treatment
Surgical treatment
depends on symptoms, size & site of tumor, age of patient & her
reproductive status + patients choice

30. kept under observation, repeated follow ups done
>approaching menopause + no symptoms
+ small tumor + no complications
(should be examined every 4-6 months
interval till menopause)

31. Correct anemia
GnRH analogues (prescribed for 3-6months duration)
*IM injection> monthly *SC injection> 12 hourly *nasal spray> 6hourly
-- reduce size & vasularity > by causing pseudo-monopause > by
supression of ovaries
(menorrhagia is improved upto 80% & size reduced by 50%)
-- temporary treatment
-- only used now a days to prepare the patient for surgery > causes less
bleeding
DISADVANTAGES:
1. Expensive
2. Effects last for the duration of treatment
3. Causes postmenopausal symptoms (hot flushes, night sweats,
psychological disturbances)
4. If used for >6months– osteoporosis
Other drugs:
Danazol, antiprogestogens

32. Occlude uterine artery by particulate
emboli (polyvinyl alcohol)
Approached by trans femoral route
Causes ischemic necrosis of fibroids &
reduce their size
COMPLICATIONS:
>failure to canalize
>hematoma formation
>infection
>pain
3.Surgical treatment
>uterinearteryembolism (UAE)

33. (removal of the myomas & conservation of the uterus)
Preferred treatment for the following circumstances:
*age <40
*symptomatic fibroid
*patient wishing to have more children
*patient with recurrent abortions
*Infertile patients
*patient wishing to conserve her uterus

34. Contraindications:
>associated carcinoma
*treatment should be directed against
malignancy
>Suspicion of sarcomatous change
>pregnancy
* myomectomy should be postponed till 3months
after delivery > cuz of increased congestion of uterus
* pedunculated subserous must be removed
however to prevent torsion in puerperium

35. Preparation:
>Hb corrected
>rule out endometrial carcinoma or any other
abnormality by D & C before myomectomy
>X-ray abdomen
>IVU
Routes:
>abdominal
>vaginal
>endoscopic

36. COMPLICATIONS:
>sepsis
>recurrence (5-10%)
>persistant symptoms
>oozing from uterine wound
>intra peritoneal adhesions
>haemorrhage
*heavy intraoperative bleeding (atleast 2units blood
should be available prehand)
Minimized by applying bonney’s myomectomy clamp or
simple rubber tourniquet
Bonney’s myomectomy clamp

37. (removal of the uterus)
Treatment of choice under following conditions:
*age>40
*multiple fibroids
*completed her family
*severe symptoms
Carried out by:
>abdominal route
>vaginal route

38. complications
degeneration
torsion
Sarcomatous
change
infection

39. (cuz of reduced blood supply to the tumor)
types:
>atrophic
>hyaline
>cystic
>calcific
>septic
>red
>myxomatous(fatty)

40. ATROPHIC:
>size of tumor decreases after menopause or after pregnancy
>due to withdrawl of estrogens
>size decreases but the myoma does not disappear
HYALINE:
>commonest of all(except for tiniest tumors)
>homogenous & glassy areas on microscopy
>fibrous tissue gets involved first &then the Ms fibres
CYSTIC:
>hyaline degeneration(if extensive) may progress into cystic
degeneration
>liquifaction of hyalinized areascystic cavities
>walls of cavity irregular
>cavity filled withgelatinous material
>whole tumorone large cystic cavitysimulate pregnancy or
ovarian cyst

41. CALCIFIC:
>carbonate &phosphate salts deposited in the tumor
>seen as radioopaque shadows
>more commonly in subserous myomas

42. SEPTIC:
>necrosis in the center of large myoma
MYXOMATOUS:
>rare
>Fatty change occurs in the fibroid
>Require differentiation from uterine lipoma
RED:
>most commonly seen durong pregnancy & puerperium but may occur without
pregnancy as well
>due to thrombosis of the veins  ischemia & necrosis
>soft, on section looks red or pink with areas of necrosis in the center
>microscopically structureless
>onset of symptoms sudden
*pain *increased size
(mistaken for torsion of myoma or ovarian cyst,concealed accidental
haemorrhage etc)
>TREATMENT: analgesics, bed rest & observation
(usually settle down within a week or so)

45. >very rare (0.2% of cases)
>usually starts in the center of the tumor
*if myoma enlarges rapidly or becomes painful &tender  malignant change
should be suspected
INFECTION
>more common during puerperium &after abortion
>more common in myomas that have undergone necrosis
TORSION
>pedunculated subserous
>more commonly seen during pregnancy &puerperium
>sudden pain, enlarges in size & becomes tender
*difficult to differentiate from red degeneration & torsion of
ovarian cyst

46.  Usually easily diagnosed
 Exclude pregnancy
 Exclude other pelvic masses
-Ovarian Ca
-Tubo-ovarian abscess
-Endometriosis
-Adenexa, omentum or bowel adherent to the uterus
 Exclude other causes of uterine enlargement:
-Adenomyosis
-Myometrial hypertrophy
-Congenital anomalies
-Endometrial Ca

47. Exclude other causes of abnormal bleeding
 Endometrial hyperplasia
 Endometrial or tubal Ca
 Uterine sarcoma
 Ovarian Ca
 Polyps
 Adenomyosis
 Endometriosis
 Exogenous estrogens
*Endometrial biopsy or D&C is essential in the evaluation of
abnormal bleeding

48. 1. adenomyosis
• Disease of multiparous
women
• Menorrhagia is
associated with severe
dysmenorrhea
• Uterus : uniformly
enlarged ,tender
• Ultrasound : thickened
myometrium with swiss
cheese appearance
• Cut surface : lacks
whorled appearance and
capsule.
2.Ovarian tumor
• Confused with
pedunculaed sub serous
tumor
• Menorrhagia often
absent
• Mass feels separate
from the uterus while
fibroids has limited
mobilty
• Ultrasound may be
helpful but diagnosis is
not confirmed until
laproscopy or laprotomy
is performed

49. 3. Pregnancy with or without myomas
>amenorrhea +
>uterus soft nd cystic
>clinical signs of pregnancy
>pregnancy test +
>U/S
4. PID & endometriosis
>tenderness on bimanual examination
>adhesions on pelvic examination
5. Myohyperplasia
>in response to excessive or prolonged unopposed estrogen
influence e.g metropathia haemorrhagica

50. EFFECTS OF MYOMAS>
On pregnancy
1.abortion
*distortion of uterine cavity
*interference in accommodation & increase in size
*defective placentation
*impacted myomas in pelvis
2.premature onset of labour
3.malpresentations
*interfere with descent of the presenting part

51. During labour
1. Abnormal uterine contractions  prolonged
labour
2. Cervical dystocia
*interfere with dilatation of the cervix
3. Obstructed labour
*usually with cervical & broad ligament myomas
4. Retained placenta
*interfere with its separation
5. PPH
*cuz of retained placenta & abnormal uterine
contractions

52. During puerperium
1. Sepsis
*submucous myomas may get infected
2. Delayed involution of uterus

53. Effects of pregnancy on myomas
1. increase in size
• Due to congestion & odema of tumor
• After pregnancy return to their original size
2. Change in consistency
• Become soft
• Due to congestion & odema of tumor
3. Red degeneration
• More common during pregnancy & puerperium
• Due to increased tendency for thrombosis
4. Torsion & infection
• These complications are more common during pregnancy
& puerperium