This document discusses the management of uterine fibroids. It defines fibroids as benign tumors of the myometrium. Symptoms vary and include menstrual problems, pressure symptoms, and reproductive dysfunction like infertility. Diagnosis involves imaging like ultrasound and MRI. Treatment options include expectant management for asymptomatic cases, medical treatment to relieve symptoms using drugs like progesterone or GnRH analogues, and surgical options like hysterectomy or myomectomy. Factors in surgical decision making include size and location of fibroids, desire for future fertility, and expertise of the surgeon. Myomectomy aims to preserve the uterus but carries risks of recurrence and complications in future pregnancies.

1. Controversy in management of fibroid
Prof Rokeya Begum
ART specialised
Endoscopic Surgeon

2. What is fibroid
This is leiomyoma-neoplastic transformation
of single smooth muscle cells of the
myometrium.
This is usually benign tumour.
May transferred to malignancy-leiomyosarcoma
Though the incidence is less

3. Characteristics
1. Firm and well circumscribed
2. White whorled appearance on cross section
3. Capsulated received BL supply from it
4. Slow growing tumour
5. Size and number varies greatly
6. Mutiple > single
7. More common site is body of the uterus

4. FIGO CLASSIFICATION
0. Pedunculated
1.Submucosal <50% intramural
2.Submucosal ≥ 50% intramural
3.100% intramural in contact with endometrium
4.Intramural
5.Subserosal ≥ 50% intramural
6.Subserosal < 50% intramural
7Subserosal pedunculated
8 Other (Cervical,Parasitic)

6. Incidence
1. Increase with age in reproductive year
2. 20-40% of women during reproductive life
3. 25-30% in infertile population
4. 70% uterus removed at hysterectomy
5. Fibroid less in- Increase parity, prolong use of
OCP, Smoker

7. Aetiology
1.Individual muscle fibre
2.Cytogetic
3.Hormone
Control of growth
Sex steroid
Growth factors
Suppress
Apoptosis

8. • SYMPTOMS
20-50% symptoms are directly attributable to
fibroid
Symptoms are variable
a) Menstrual symptoms
b) Pressure symptoms-Bowel/Bladder
c) Reproductive dysfunction-Infertility,Abortion

9. Diagnosis
1. H/O ,Clinical examination-AB/Bimanual
2. Imaging-USG - AB/Vaginal
3. Doppler blood flow
4. MRI
MAPPING OF MYOMA
SARCOMA
Rapid growth
CA125, LDH-isoenzyme 3-Elevated
PET scan

10. Management
1 Expectant
2 Medical
3 Surgical
Symtoms
Size,type
Patient,s age
Desire for fertility

11. Expectant
1.Asymptomatic
2. Young
3.Newly married
4.Postmenopausal

12. Medical treatment
Do not eradicate fibroid but relief symptom
When indicated
1.Correction of anaemia
2.Delay the treatment
3.Not desire for pregnancy
4.Route change can be done
The choice of treatment depends on the patients personal treatment
goals as well as efficacy and need for repeated intervention

13. • Drugs
1. Progesterone
2. COC
3.Injectable Progesterone
4.Tranexamic acid
5. Aromatase inhibitors
6.Danazol
7.Gnrh analogue
8. Selective progesterone receptor modulator
9. Mefipristone

14. 1.Gnrh analogue
2. Selective progesterone receptor
modulator
3. Mefipristone

15. • GnRh analogue
3-6months
40% reduction in size
100% amenorrhea
Problems
Menopausal side effect
Regrowth when stop
Masking the plane cleavage

16. Selective progesterone receptor
modulators(SPRMs)
1. Reduce cell proliferation
2. Induces Apoptosis
3. Inhibits neovascularisation
4.No effect on normal
myometrium
Side effect- Liver damage/Cystic glandular
hypeplasia

17. • Mefipristone(RU-486)
10-25 mg/day 3-6months
Levonorgestrel– releasing IUS
Reduce blood loss
More chance of expulsion

18. • Surgery
1.Hysterectomy
Open/laparoscpy/vaginal(VALUE)
No desire for child/ age > 35yrs

19. 2.Myomectomy-Uterus preserving surgery
a) Chance of recurrence,
b)Rupture in subsequent pregnancy
c) Peritubal adhesion causes infertility
d) Hysterectomy may be required
during difficult myomectomy ??

20. Route
1. Laparotomy/laparoscopy/Laparoscopic assisted
myomectomy/Minilaparotomy.
2.Hysteroscopy
The route of myomectomy does not seem to have impact on
the fertility potential
Location,Size,Number,Expertise ,Cost and Facility available

21. Open operation
Microsurgical principle of
reproductive surgery
Laparoscopy/Hysteroscopy

22. Size of myoma
Small submucous myoma-
Asymptomatic but prevent implantation
Large pedunculated subserous-
Asymptomatic -Expectant

23. Location of myoma
Hysteroscope-0, 1 and sometime 2

24. Resectoscope-Unipolar/Bipolar
Morcellator-
Unipolar
Perforation
Fluid overload
Use of GnRh before operation
Two setting

25. • Intramural-3,4,5
Contact with endometrium
Endomyometrial junction
Size more than 3cm
Subserous-6,7
Cervical 8

26. Number > 5 Recurrence/Rupture- high
Technique
1.Enuculation
Vasopressin
Occlusion of uterine artery
Temporary/permanent
Incision- Transverse/Longitudinal
Minimal incision-80% reduction with 45 days
Incision more than 10 cm.chance of rupture high
Technique

27. 2.Suture-Myoma bed apposition and
haemostasis
Suture material
Vicryl
Beaded
suture/ V-lac

28. • Single layer/ Double layer
• Continuous/Base ball suture
• Endometrium open- Sutured or not
• Adhesive barrier-useful or not

29. • Retrieval of myoma
Morcellator
Minilaparotomy
Colpotomy

30. • Operation Note
Myomectomy
1. Number
2.Size of myoma
3.Uterine incision(ant/post)
4.How long the incision
5.Uterine cavity open or not

31. Alternative to surgery
1. Uterine artery embolisation
Infraction-Shrinkage
Myomectomy has superior
reproductive outcome than UAE-2002
2. High intensity focused ultrasound( HIFU)
Coagulation necrosis

32. Myoma in postmenopausal women
1. Expectant-tends to be smaller and
asymptomatic
2. Evaluation to exclude malignancy

33. • In pregnancy
complications
1.Early pg loss
2Preterm labour
3. Red degeneration
4.IUGR
5.Malpresentation
6. Prolong labour
7.↑ C/S rate
8. PPH

34. • Myomectomy during C/S is contrversial
There is no absolute contraindication for
myomectomy during C/S especially surgeon
has enough expertise ,size and location of
myoma is considered and also facilities .