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Uterine fibroids

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fibroids, newer techniques in fibroid, fibroid in pregnancy, types of fibroid, HIFU, myomectomy, fertility conservation surgery,

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Uterine fibroids

  1. 1. FIBROIDS DR. PREKSHA JAIN DR. PRACHI DIXIT
  2. 2. Contents • Introduction • Incidence • Etiology • Risk factors • Symptoms • Natural history • Secondary changes & complications • Diagnosis & Types • Fibroids in Pregnancy • Treatment (Medical & surgical) • Recent advances
  3. 3. Introduction • Definition • Myoma, leiomyoma, fibromyoma • Derived from smooth muscle cell rests from vessel wall or uterine musculature
  4. 4. Incidence • M/c benign tumors of myometrium • 77% of hysterectomy specimen • 60% in 35-49 yrs • 80% in >50 yrs • 40% in 35 yrs • 70% in 50 yrs Afro american White women
  5. 5. Etiology • Genetic (40%) • Hormonal • Growth factors
  6. 6. Genetics • Cellular, atypical & large fibroids • Translocations 12 & 14 chrm • Deletion of 7 chrm • Trisomy of 12 chrm • Leiomyosarcoma have different origin
  7. 7. Hormones • E & P increase in receptors no. & responsiveness. • Hyperestrogenic states- Obesity, Ca endometrium, early menarche, anovulatory infertility. • Highest mitotic counts encountered in peak progesterone production. • Before puberty & after menopause – less incidence
  8. 8. Growth Factors • TGF-β, bFGF, EGF, PDGF, IGF, VEGF, PRL
  9. 9. Risk Factors INCREASE DECREASE NO EFFECT Age Green veg OCP Endogenous hormone Exercise IUCD Family history (2.5 times) Parity STI, CMV, HSV, EBV Afro American Smoking Weight
  10. 10. Classification
  11. 11. UTERINE FIBROIDS BODY CERVIX INTERSTITIAL SUBSEROUS SUBMUCOUS SUBSEROUS BROAD LIGAMENT PARASITIC • ANTERIOR • POSTERIOR • CENTRAL • LATERAL • SESSILE • PEDUNCULATED 75% 15% 10% OTHERS- • Intravenous leiomyomatosis • Leiomyomatosis peritonalis disseminata • Bizzare leiomyoma
  12. 12. Symptoms Asymptomatic 50% (<5cm size & uterus <12cm) Abnormal uterine bleeding – 30%  Menorrhagia (intramural & submucous)  Metrorrhagia (submucous & endometrial cancer)  Polymenorrhea (cystic ovaries & PID)  Purulent discharge (infected fibroid polyp)
  13. 13. Symptoms Pain- • Congestive & spasmodic dysmenorrhea • Acute pain - torsion, hemorrhage & red degeneration. • Chronic Pelvic pain • Rapidly growing sarcoma
  14. 14. Symptoms Pressure symptoms – • Retention of urine premenstrual • Hydroureter & hydronephrosis • Constipation • Intestinal obstruction
  15. 15. Symptoms Infertility – 30% • >4cm • Distortion of cavity • PID, endometriosis, anovulation • Fertility rate – Submucous type Subserosal type- No effect Intramural type - slightly decrease
  16. 16. Symptoms Abdominal lump – • Rapid growth • Pseudo Meig’s syndrome Others – • Secondary to anemia • Vaginal discharge
  17. 17. Natural History • Grow slowly 9% over 1 year • Regress after menopause • Rapid growth in Premenopausal- indicates pregnancy not sarcoma • Postmenopausal with pain & bleeding- Sarcoma • Secondary or degenerative changes
  18. 18. Secondary changes & complications • Hyaline 65%, cystic, fatty, calcareous 10% & red degeneration, necrosis • Atrophy • Sarcomatous change • Torsion, Inversion, Hemorrhage, Infection • Association with endometrial cancer(3%), adenomyosis/ endometriosis 30%, salpingoophoritis 15%, Anovulation
  19. 19. CYSTIC DEGENERATION
  20. 20. HEMORRHAGE & CALCIFICATION
  21. 21. RED DEGENERATION
  22. 22. SARCOMATOUS – 0.1-0.5%
  23. 23. ENDOMETRIAL CANCER
  24. 24. Diagnosis • History • Pelvic Examination – enlarged irregularly, firm, non tender, mobile, arising from uterus. • FIGO classification • Imaging
  25. 25. Imaging IMAGING SENSITIVITY SPECIFICITY MRI 100% 91% TVS 83% 90% SIS 90% 90% Hysteroscopy 82% 87%
  26. 26. MRI
  27. 27. TAS
  28. 28. TVS
  29. 29. SIS
  30. 30. Differential diagnosis • Pregnancy • Hematometra • Adenomyosis • Bicornuate uterus • Ovarian cysts & tumors • Ectopic pregnancy • Pelvic kidney • Chronic inversion
  31. 31. Management  Routine investigations  Others – IVP, Laparoscopy  Treatment- • Conservative- 1. Observation 2. Medical 3. Non-invasive- MRgFUS 4. Minimally invasive- UAE, Myolysis 5. Invasive- Thermal Ablation • Surgical –Polypectomy, Myomectomy, Hysteroscopic resection, Hysterectomy
  32. 32. • INDICATIONS for intervention: 1. Infertility 2. Recurrent pregnancy losses 3. Asymp >12wk/pedunculated 4. Pressure symptoms 5. Rapidly growing fibroid/ growth after menopause 6. Symptomatic- AUB
  33. 33. Medical Management • Temporary palliation- 1. Menorrhagia 2. Before surgery- Correction of anemia, decrease size & vascularity 3. Postpone surgery • Alternative to surgery 1. Perimenopausal 2. Desiring fertility 3. Unfit for surgery
  34. 34. Drug Dose Advantage Disadvantage ANTIFIBRINOLYTICS Tranexamic Acid 1-4gm/d blood loss Correct anemia Size remain same GnRH AGONIST Goserelin (Zoladex) 3.6mg every 28days 3-6mth s/c 30% size 35% ut vol in 6mth • Hypoestrogenic effect • Rebound size • Loss of plane • Seedling fibroids missed • Expensive GnRH ANTAGONIST Cetorelix, Ganirelix 30% size in 3weeks Under evaluation ANTIANDROGEN Danazol 200-400mg 6-12mth Gestrinone Volume No regrowth Androgenic effect PROGESTERONE ANTAGONIST Mifepristone 25-30mg 3-6mth 25-75% size 50% ut vol Amenorrhea Endometrial hyperplasia Hot flushes, deranged LFT
  35. 35. • Antiestrogen- Faslox, Raloxifene, fadrozole (aromatase inhibitor) • MIRENA • Others- chinese herbal medicine
  36. 36. SPRM • Selective progesterone receptor modulator ULIPRISTAL - • Partial agonist & antagonist of Pg receptors ASOPRISNIL – • 10-25mg per day 3mth • Inhibits growth • Decreases uterine artery blood flow & menorrhagia • No effect on endometrial proliferation
  37. 37. Magnetic Resonance guided Focused Ultrasound • FDA approved Oct 2004 • Selection criteria- 1. 4-10cm fibroids 2. Family completed 3. Perimenopausal 4. Subcut tissue to fibroid <12cm 5. Clearly visible on MRI • Thermal ablation • 31% reduction ut vol in 6mth
  38. 38. • US is focused either 1. Geometrically via Lens, Curved Transducer 2. Electronically via Phased Array • Adv- 1. No scar 2. Short stay, early resuming of activities 3. Least chances of infection, complications 4. Repetition of procedure with low risk
  39. 39. Uterine Artery Embolization • Procedure • Indication-Symptomatic fibroid, surgery not feasible • Contraindications- 1. Immunocompromised 2. Genital tract infection or malignancy 3. Vascular disease 4. Contrast allergy/ impaired renal function 5. Infertility
  40. 40. • Adv- 1. 80% decrease in menorrhagia, 33% reduction of fibroid in 3mth. Success rate 85-95%. 2. Short stay 3. No bleeding, adhesions • Disadv- 1. Postembolization syndrome 2. Early ovarian failure & early menopause 3. Effect on fertility & pregnancy 4. May require hysterectomy 5. Death, sepsis, loss of organs
  41. 41. Myolysis • Lap procedure • Destroys by laser, cryotherapy, electrosurgical energy • Indications- 1. Perimenopausal 3-10cm 2. Ut size < 14wk
  42. 42. Surgical Management • I/c- 1. Severe anemia 2. Torsion 3. Pain, urinary symptoms compromising QOL • Preoperative- 1. Correction of anemia 2. Control menorrhagia 3. Control medical problems
  43. 43. ACOG criteria for Hysterectomy • Confirmation of indication: 1. Asymptomatic 12wk concern to patient 2. Excessive bleeding- Profuse bleeding >8days or anemia 3. Pelvic discomfort- Acute & severe or chronic pain, Pressure symptoms
  44. 44. Myomectomy I/c : Unexplained infertility with cavity distortion Unexplained RPL Fertility conservation Subserous pedunculated • Prerequisities- 1. Correct Hb, oral iron, GnRH-a, Autotransfusion 2. Other causes of infertility should be ruled out 3. Consent for hysterectomy 4. Perform in preovulatory menstrual cycle 5. Endometrial cancer rule out by D&C
  45. 45. Myomectomy • Types- 1. Vaginal 2. Hysteroscopic resection of submucous myomata 3. Laparoscopic 4. Abdominal
  46. 46. Abdominal Myomectomy 1. Examination rectovaginal abdominal bimannual examination under anesthesia 2. Cervical dilatation 3. Maylard incision & retraction 4. Prevent adhesions 5. Prevent blood loss- Hypotensive anesthesia, temporary uterine artery occlusion or vasoconstrictive agents, CO2 laser 6. Planning Uterine incision 7. Dissection & Enucleation 8. Repairing defects - Bonneys hood method, Complete obliteration of cavity 9. Serosal closure - Baseball sutures. 10. Confirm hemostasis.
  47. 47. Results of Myomectomy • Complications- 1. Intraperitoneal bleeding 2. Infections • 80% menorrhagia controlled • 40-60% pregnancy rate • 5% take home baby rate • 30-50% recurrence • 20-25% relaparotomy
  48. 48. VAGINAL MYOMECTOMY
  49. 49. BONNEY’S HOOD PROCEDURE
  50. 50. Radiofrequency Ablation • Halt’s method • Under Phase 3 clinical trials awaits approval • 3 small incisions- 1. Laparoscopic camera 2. Intraabdominal ultrasound probe 3. Halt Device
  51. 51. Gene Therapy • Recent evidence suggests that, fibroids develop as an over expression of p14Arf Gene. • This drives a negative feedback loop between, p53 & MDM2 genes, which governs the fate of each individual fibroid. • NUTLIN -3, a known MDM2 antagonist, was thus used to oppose the proliferative activity in cell cultures from fibroids. • It also stimulates Senescence Gene- p21 & Apoptosis Gene- BAX, in vitro.
  52. 52. Fibroids in Pregnancy • Incidence – 18%, 1 in 1000 • Effect of pregnancy – 1. Increase in vascularity & size 2. Torsion of subserous 3. Puerperal infection 4. Red degeneration – 5% Presentation Appearance Cause • Effect of fibroid on pregnancy –RPL, Ante, intra, postpartum
  53. 53. • Indication of removal during CS- 1. Pedunculated subserosal 2. Interfering with delivery or closure 3. Intractable pain 4. Incarcerated fibroid 5. Rapid growth with pressure symptoms

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