Fibroids are benign tumours composed of smooth muscle and fibrous tissue that develop in the uterus. The most common types are intramural, subserous, and submucous fibroids. Fibroids often cause heavy menstrual bleeding and can lead to infertility or pregnancy complications. Diagnosis is usually made through pelvic exam and ultrasound. While many small fibroids require no treatment, larger or symptomatic fibroids may warrant surgery.

1. FIBROIDS
P
Presented by Khumbulani Dzinamarira

2. MEANING:
Fibroids are the tumours composed
of smooth muscle and fibrous
connective tissue of uterus. These
are commonly benign tumours.
- D C. Dutta

3. ALTERNATIVE NAMES :
Myoma
Leiomyoma
Fibromyoma
Uterine tumour
Myomata
Fibromyomata

4. TUMOURS OF THE BODY OF
UTERUS
I. BENIGN :
1. Adenoma
2. Myoma
II. MALIGNANT :
1. Carcinoma
2. Sarcoma
3. Chorio-
carcinoma
4. Mesodermal
mixed tumour
5. Secondaries

5. INCIDENCE:
 20% of women at 30 years of age (asymptomatic)
 3% of women in OPD (symptomatic)
 10% more prevalence in England
 Higher rate in black race
 More common in nulliparous or in women having
infertility after 1 child
 Highest prevalence between 35-45years

6. SITES OF FIBROIDS:

7. HISTOGENESIS :
Risk factors for fibroids:
Increased risk Reduced risk
 Nulliparity
 Obesity
 Hyperestrogenic
state
 Black women
 Age between 35-45
F/h/o tumour
 Multiparity
 Smoking

8. ETIOLOGY :
1. Unknown
2. Immature muscle cells present in
myometrium
3. Excessive Oestrogens
- myomas grow during child
bearing age only.
- after menopause the growth of
tumour stops or regression in size

9. Causes of Neoplastic
transformation :
ORIGIN:
1. Chromosomal abnormality:
- About 30% the chromosome abnormality is seen in 6th or 7th
chromosome( rearrangement or deletion)
2. Role of polypeptide growth factors:
- Epidermal growth factors (EGF), Insulin like growth factor-1( IGF-1),
Transforming growth factor (TGF), stimulate the growth of leiomyoma
directly or via estrogen

10. GROWTH:
 Predominantly estrogen-dependent tumuor.Oestrogen dependency evidenced by:
 Growth potentiality is limited to during child bearing period
 Increased growth during pregnancy
 They don’t occur before menarche
 Following menopause, decrease in size of tumour or cessation of growth.
 Frequent association of anovulation
 More of oestrogen receptors than adjacent myometrium

11. Contd…
 Growth rate is slow & takes about 3-5 years to be felt
per abdomen
 Grows rapidly during pregnancy or pill users
 Rapid growth can be due to degeneration or malignant
change

12. FEATURES OF TUMOURS:
 Arise from muscles not from fibres
 Single or multiple ( upto 200)
 Size variable from millimeters to the size of foot ball (filling whole
abdomen)
 Spherical in shape & firm consistency
 Surrounded by pseudo-capsule
 Cut surface of the tumour becomes convex & has white whorled appearance
 Nuclei rod shaped, uniform in size & shape

13. TYPES OF FIBROIDS:
I. Body (Corporeal)
II. Cervical
1. Interstitial or Intramural
2. Sub-peritoneal or subserous
3. Submucous
4. Pseudo-cervical fibroids

14. TYPES OF FIBROIDS :

15. TYPES OF FIBROIDS :

16. INTERSTITIAL or INTRAMURAL:
- In this case the myomas grow & stay in the wall of the
uterus
- Surrounded by myometrial tissue
- Initially fibroids are intramural subsequently pushed
outward or inward
- 70% persist in position.

17. SUBSEROUS:
- Fibroid are partitially or completely covered by
peritoneum
- When completely covered it attains a pedicle called as
‘Pedunculated subserous fibroid’
- If the pedicle is torn then it gets nourishment from
omental or mesenteric adhesions called as ‘Wandering’
or ‘Parasitic fibroid’.

18. Contd…
- If the fibroid is pushed out in between the layers of broad
ligament, called as ‘ Broad ligament fibroid’ ( false or
pseudo)

19. SUBMUCOUS:
- Fibroids grow towards the uterine cavity or cervical canal, may form a polyp
in the cavity & covered by the endometrium.
- They come out through the cervix, may be infected or ulcerated causing
metrorrhagia.
FATE –
 Surface necrosis
 Polypoid change
 Infection
 Degerations

20. SUBMUCOUS FIBROID:

21. CERVICAL
o Rare about 1-2%
o Seen in supravaginal part of cervix, may be any one
above type
o May be anterior, posterior, lateral or central depending
on position
o Disturb the pelvic anatomy, specially ureter

22. PSEUDOCERVICAL:
Fibroid polyp
arising from the
uterine body
when occupies &
distends the
cervical canal, it
is called as
Pseudocervical
fibroid.

23. CORPOREAL FIBROIDS

24. PATHOLOGY OF FIBROIDS:
Secondary changes in fibroids:
1. Degeneration
2. Atrophy
3. Necrosis
4. Infection
5. Vascular changes
6. Sarcomatous change

25. 1.DEGENERATION:
a. Hyaline degeneration- common type, firm feel of tumour becomes soft
elastic.
b. Cystic degeneration- after the menopause, in interstitial fibroids.
Liquefaction of areas with hyaline changes, if becomes big may be
confused with ovarian cyst or pregnancy
c. Fatty degeneration- at or after menopause, fat globules get deposited in
muscle cells

26. d. Red (carneous) degeneration- occur in 2nd half of
pregnancy or puerperium. Cut section revealing raw
beef appearance, cystic space & fishy odor
e. Calcareous degeneration- common in subserous type
followed by fatty degeneration. There is precipitation
of calcium carbonate or phosphate then whole
tumour is converted into calcified mass called ‘Womb
stone’

27. 2. ATROPHY
 Following menopause due to loss of oestrogen support
 Reduction in size of tumour ( as similar to that occurs
after pregnancy)
3.NECROSIS :
 Inadequacy of circulation leads to central necrosis of
tumour ( in submucous polyp or subserous)

28. 4. INFECTION:
 Gains way to tumour through the thinned & sloughed surface epithelium of
submucous fibroid, following abortion or delivery
5. VASCULAR CHANGES:
 Dilatation of the vessels (telangiectasis)
 Dilatation of lymphatic channels occur.
6. SARCOMATOUS CHANGES:
 Occur in less than 0.1%
 Usual type is lieomyosarcoma.

29. CHANGES IN THE PELVIC
ORGANS:
> Uterus- Shape distorted, asymmetrical
-Endometrium with features of anovulation with hyperplasia, as result
becomes thick, congested & edematous
> Uterine tubes- Frequent infection
> Ovaries- Enlarged, congested & filled
with multiple cysts.
> Ureter- Compressed leading to
hydroureter or hydronephrosis

30. CLINICAL FEATURES:
 PATIENT PROFILE:
 Usually nalliparous
 Chronic secondary infertility
 Early marriage
 Frequent child birth
 Age between 35-45 years
 Delayed menopause

31. Contd…
 SYMPTOMS:
 Asymptomatic (75%)
 Symptoms depend on anatomic type & size
 Symptoms depend on the site than the size
 Small submucous fibroid may produce more symptoms than big subserous
fibroid

32. I. Menstrual abnormalities:
1. Menorrhagia (30%)
CAUSES:
 Increased surface area of endometrium
 Interference with normal contractility
 Congestion & dilatation venous plexuses
 Endometrial hyperplasia due to hyperoestrinism
 Pelvic congestion
 Role of prostanoids

33. Contd…
2. Metrorrhagia:
CAUSES:
 Ulceration of submucous fibroid or fibroid polyp
 Torn vessels from the sloughing base of polyp
 Associated endometrial carcinoma

34. Contd…
3. Dysmenorrhoea:
 Congestive variety- may be associated with pelvic congestion or
endometriosis
 Spasmodic type- may be associated with extrusion of polyp & its
expulsion from the uterine cavity

35. Contd… II. INFERTILITY:
CAUSES:
1. Uterine –
> Distortion & or elongation of uterine cavity difficult sperm ascent
 Prevent rhythmic uterine contraction during intercourse impaired
sperm transport
 Congestion & dilatation of endometrial venous plexuses defctive
nidation
 Atrophy & ulceration of endometrium

36. Contd…
2. Tubal –
 Conual block due position of fibroid
 Marked elongation of tubes over big fibroid
 Association salpingitis with tubal block
3. Ovarian – Anovulation
4. Peritoneal – Endometriosis
5. Unknown

37. III. Pregnancy related
problems:
 Abortion
 Preterm labour
 IUGR
 PPH
Causes:
- Defective implantation of placenta
- Poorly developed endometrium
- Reduced space for the growing fetus

38. IV. Pain lower abdomen
 Usually painless
CAUSES:
- Due to tumour degeneration
- Torsion subserous pedunculated fibroid
- Extrusion of polyp
- Associated pathology like PID, endometriosis

39. V. Abdominal swelling
- Heaviness in lower abdomen
VI. Pressure symptoms:
- Constipation
- Dysuria
- Retention of urine
- Hydroureter
- Hydronephrosis
- Infection
- Pyelitis

40. SIGNS:
1. Pallor
2. Enlargement of abdomen
3. Firm feel on palpation
4. Restricted mobility
5. Dullness on percussion
6. bimanul findings
- Irregular uterus
- Cervix moves with movement of tumour

41. INVESTIGATIONS:
1. History
2. Pelvic examination
3. USG & Colour doppler (TVS)
- Uterine contour enlarged & distorted
- Echogenecity vary
- Vascularisation at periphery
- Central vascularisation indicate degeneration

44. DIFFERENTIAL DIAGNOSIS
Pregnancy
Full bladder
Adenomyosis
Myohyperplasia
Ovarian tumour
TO mass

45. COMPLICATIONS:
 Persistent menorrhagia, metrorrhagia or vaginal
bleeding leading to severe anaemia
 Severe intraperitoneal haemorrhage
 Severe infection leading to peritonitis or septicaemia
 Sarcoma

46. ASYMPTOMATIC FIBROID:
1. Observation:
 Perform diagnostic tests
 Begin expectant therapy
 Size < 12 wks of pregnancy
 Diagnosis certain
 Follow up
 Periodic examination at 6mth interval
 Observe the symptoms of fibroids

47. Contd…
2. Surgery:
Indications:
- Size >12 wks of pregnancy
- Diagnosis not certain
- Fibroid grows during follow up
- Subserous pedunculated fibroid
- Unexplained infertility with distortion of uterine cavity
- Unexpalined recurrent abortion
- Present in lower pole of uterus likely to complicate delivery

48. CERVICAL FIBROIDS

49. SYMPTOMS:
1. Anterior cervical:
- Frequency or retention of urine
2. Posterior cervical:
- Rectal symptoms (constipation)
3. Lateral cervical:
- Vascular obstruction
- Haemorrhoids
- Pedal oedema
- Ureters pushed laterally & below tumour

50. Contd…
4. Central cervical:
- Produce bladder symptoms
- Cervix expanded on all sides
- Asymptomatic during pregnancy
- Obstruction during labour.
- If pedunculated, sensation of something coming out, if infected a foul
smelling discharge per vagina

51. TREATMENT:
1. Supravaginal fibroids:
 Myomectomy – Its not only technically difficult but the anatomic &
functional restoration of cervix cannot be adequate to achieve the
future reproduction
 Hysterectomy
2. Vaginal part fibroids:
 Myomectomy
 If, pedunculated polypectomy

52. PREGNANCY AND MYOMAS
EFFECTS OF MYOMAS ON PREGNANCY:
1. During pregnancy
 Abortion: distortion pf uterine cavity, defective implantation,
interference with accomodation & increase in size, impaction of
myoma in pelvis
 Premature onset of labour
 Malpresentation

53. contd…
2. During labour:
 Abnormal uterine action
 Cervical dystcia
 Obstructed labour
 Retainned placenta
 Post partum haemorrhage
3. During puerperium:
 Puerperal sepsis
 Delayed involution of uterus

54. Contd…
EFFECTS OF PREGNANCY ON MYOMAS:
 Increase in size
 Change in consistency
 Red degeneration
 Torsion & infection