4. CURRENT INCIDENCE
About 20% to 80% of women develops fibroids by the age of 50 .
Globally in 2013 it was estimated that a171 million women were affected.
The chance of being diagnosed with fibroids increases with age .There are
significant difference in prevalence of fibroid between women of different
racial and ethnic background. Fibroids are diagnosed at a younger age , are
more often multiple and tended to be larger in African and Americans
5. DEFINITION
Fibroid is the commonest benign tumor of the uterus and also the
commonest benign solid tumor in female. Histologically, this tumor is
composed of smooth muscle and fibrous connective tissue, so named as
uterine leiomyoma, myoma or fibromyoma.
14. Interstitial or intramural (75%) Initially, the fibroids are intramural in
position but subsequently, some are pushed outward or inward.
Eventually, in about 70 percent, they persist in that position.
Subperitoneal or subserous (15%) In this condition, the intramural
fibroid is pushed outwards towards the peritoneal cavity. The fibroids are
either partially or completely covered by peritoneum. When completely
covered by peritoneum, it usually attains a pedicle is called pedunculated
subserous fibroid.
15. Submucous :The intramural fibroid when pushed toward the uterine cavity, and is
lying underneath the endometrium, it is called submucous fibroid.
Submucous fibroid can make the uterine cavity irregular and distorted.
Pedunculated submucous fibroid may come out through the cervix . It may be
infected or ulcerated to cause metrorrhagia.
Cervical fibroid is rare in the supravaginal part of the cervix, it may be interstitial
or sub peritoneal variety and rarely polypoidal.
Depending upon the position, it may be anterior, posterior, lateral or central.
Interstitial growths may displace the cervix or expand it so much that the external
os is difficult to recognize. All these disturb the pelvic anatomy, specially the ureter
16. HISTOGENESIS
Origin
The etiology still remains unclear. The prevailing hypothesis is that, it arises from the
neoplastic single smooth muscle cell of the myometrium. The stimulus for initial
neoplastic transformation is not known.
Chromosomal abnormality-6 or 7
Role of polypeptide growth factors-EGF,IGF
17. GROWTH
It is predominantly an estrogen-dependent tumor. Estrogen and progesterone is incriminated as
the cause. Estrogen dependency is evidenced by
Growth potentiality is limited during childbearing period.
™™ Increased growth during pregnancy.
™™ They do not occur before menarche.
™™ Following menopause, there is cessation of growth and there is no new growth at all.
™™ It seems to contain more estrogen receptors than the adjacent myometrium.
™™ Frequent association of anovulation.
19. NAKED EYE APPEARANCE
The uterus is enlarged; the shape is distorted by multiple nodular growth of varying
sizes. Occasionally, there may be uniform enlargement of the uterus by a single fibroid. The
feel is firm. Cut surface of the tumor is smooth and whitish. The cut section, in the absence of
degenerative changes, shows features of whorled appearance and trabeculation. These are due
to the intermingling of fibrous tissues with the muscle bundles.
20. FALSE CAPSULE
The false capsule is formed by the compressed adjacent myometrium. They have more
parallel arrangement and are pinkish in color in contrast to whitish appearance of the
tumor.
The capsule is separated from the growth by a thin loose areolar tissue. The blood vessels
run through this plane to supply the tumor. It is through this plane that the tumor is shelled
out during myomectomy operation.
The periphery of the tumor is more vascular and have more growth potentiality. The center
of the tumor is least vascular and likely to degenerate. It is due to contraction of the false
capsule that makes the cut surface of the tumor to bulge out.
26. CLINICAL FEATURES
Bleeding
Infertility
Menstrual abnormalities
Menorrhagia (30%) is the classic symptom of symptomatic fibroid. The menstrual loss is
progressively increased with successive cycles. It is conspicuous in submucous or interstitial
fibroids. The causes are:
™™Increased surface area of the endometrium (Normal is about 15 sq cm).
™™Interference with normal uterine contractility due to interposition of fibroid.
™™Congestion and dilatation of the subjacent endometrial venous plexuses caused by the
obstruction of the tumor.
™™Endometrial hyperplasia due to hyperestrinism (anovulation).
27. Metrorrhagia or irregular bleeding may be due to:
™™Ulceration of submucous fibroid or fibroid polyp.
™™Torn vessels from the sloughing base of a polyp.
™™Associated endometrial carcinoma.
Pelvic pressure and pelvic pain
Pressure symptoms
Abdominal swelling
28. SIGNS
General examination reveals varying degrees of pallor depending upon the magnitude and duration of
menstrual loss.
Abdominal examination
The tumor may not be sufficiently enlarged to be felt per abdomen. But if enlarged to 14 weeks or more, the
following features are noted
Palpation
Feel is firm, more toward hard; may be cystic in cystic degeneration.
Margins are well-defined except the lower pole which cannot be reached suggestive of pelvic in origin.
Surface is nodular; may be uniformly enlarged in a single fibroid.
Mobility is restricted from above downwards but can be moved from side to side.
Percussion
The swelling is dull on percussion
32. MEDICAL MANAGEMENT
Drug therapy has established a firm place in the management of
symptomatic fibroids. The drugs are used either as a temporary palliation or
may be used in rare cases, as an alternative to surgery. Prior to drug therapy,
one must be certain about the diagnosis.
The objectives of medical treatment are:
™™To improve menorrhagia and to correct anemia before surgery.
™™ To minimize the size and vascularity of the tumor in order to facilitate
surgery.
™™In selected cases of infertility to facilitate hysteroscopic or laparoscopic
surgery
33. Antiprogesterones Mifepristone (RU 486) is very effective to reduce fibroid size and also
menorrhagia. It may produce amenorrhea. It reduces the size of the fibroid significantly. A
daily dose of 25–30 mg is recommended for 3 months. 5 mg daily dose is also found
effective. Long-term therapy is avoided as it causes endometrial hyperplasia. Asoprisnil is
used with success. It is a selective progesterone receptor modulator. It does not cause
endometrial hyperplasia.
34. Danazol can reduce the volume of a fibroid slightly. Because of androgenic side effects,
danazol is used only for a period of 3–6 months. Danazol administered daily in divided
doses ranging from 200-400 mg for 3 months minimizes blood loss or even produce
amenorrhea by its anti gonadotropin and androgen agonist actions.
GnRH agonists Drugs commonly used are goserelin, luporelin, buserelin or nafarelin
Mechanism of action is sustained pituitary down regulation and suppression of ovarian
function. Optimal duration of therapy is 3 months. Addback therapy may be needed to
combat hypestrogenic symptoms
35. GnRH antagonists Cetrorelix or ganirelix causes immediate suppression of pituitary and the
ovaries. They do not have the initial stimulatory effect. Benefits are same as that of agonists
Onset of amenorrhea is rapid
Advantages of GnRH
• Improvement of menorrhagia and may produce amenorrhea.
• Improvement of anemia.
• Relief of pressure symptoms.
• Reduction in size (50%) when used for a period of 6 months.
• Reduction in vascularity of the tumor.
• Reduction in blood loss during myomectomy.
• May facilitate laparoscopic or hysteroscopic surgery.
36. Disadvantages
• Hypoestrogenic side effects (Vasomotor symptoms, Trabecular bone loss).
• Cost (high).
• Regrowth of myomas on cessation of therapy.
• Degeneration (some leiomyomas) causing difficulty in myoma enucleation.
37. Prostaglandin synthetase inhibitors : These are used to relieve pain due to
associated endometriosis or degeneration of the fibroid. They cannot improve
41. It should be done mainly to preserve the reproductive function.
The wish to preserve the menstrual function in parous women should be
judiciously complied with.
Myomectomy is a more risky operation when the fibroids is too big and too
many.
Risk of recurrence and persistence of fibroid is about 30–50 percent.
Risk of persistence of menorrhagia is about 1–5 percent.
Risk of relaparotomy is about 20–25 percent.
Pregnancy rate following myomectomy is about 40–60 percent.
Pregnancy following myomectomy should have a mandatory hospital delivery,
although the chance of scar rupture is rare.
42. INDICATIONS OF MYOMECTOMY
™™ Persistent uterine bleeding despite medical therapy.
™™Excessive pain or pressure symptoms.
™™Size >2 weeks, woman desirous to have a baby.
™™Unexplained infertility with distortion of the uterine cavity.
™™Recurrent pregnancy wastage due to fibroid.
™™ Rapidly growing myoma during follow-up.
™™ Subserous pedunculated fibroid.
43. CONTRAINDICATIONS
During pregnancy or during cesarean section.
Pelvic or endometrial tuberculosis.
Function less fallopian tubes (bilateral hydrosalpinx, tubo-ovarian mass)
decision must be judicious with the advent of microsurgery and ART .
Parous women where hysterectomy is safer and is a definitive treatment
Suspected malignant change (sarcoma).
Growth of myoma after menopause
Infected fibroid
58. ROBOTIC MYOMECTOMY
Robotic myomectomy, a type of laparoscopic myomectomy, is a minimally
invasive way for surgeons to remove uterine fibroids. Compared to open
abdominal surgery, with robotic myomectomy you may experience less blood loss,
have fewer complications, have a shorter hospital stay and return to normal
activities more quickly.
62. NURSING DIAGNOSIS
Acute pain on lower abdomen related to compression of
fibroid
Situational low esttem related to change in health status
Risk for infective tissue perfusion related to blood loss
Constipation related to weaking of abdominal muscles
Dysfunctional grieving related to infertility secondary to
fibroid uterus
