This document discusses fibroid uterus (uterine fibroids). It begins by describing fibroids as benign smooth muscle tumors in the uterus that contain extracellular matrix. It then covers the etiology, including genetic and hormonal factors. Risk factors discussed include age, hormones, family history, ethnicity, weight, exercise, oral contraceptive use, pregnancy, and smoking. The document outlines growth factors that promote fibroid growth and details pathology findings. It discusses symptoms, diagnosis, effects on fertility and pregnancy. Various treatment options are covered including medical therapies, surgical procedures like myomectomy and uterine artery embolization, and potential fibroid degenerations.

1. Fibroid uterus
Dr. Gunjan Yadav

2. • Fibroids are benign, monoclonal tumours of
smooth muscle cells of the myometrium
• Contain large aggregations of extracellular
matrix composed of collagen, elastin,
fibronectin and proteoglycans

3. Etiology
• Genetics:
• Monoclonal
• 40% have genetic abnormalities-
1. Translocation between chr 12 and 14
2. Deletion chr 7
3. Trisomy chr 12

4. • Hormonal:
• Both estrogen and progesterone promote
development
• Fibroids have increased concentration of
progesterone receptors A and B compared
with normal myometrium.
• De novo production of estradiol is high due to
increased level of aromatase in fibroid
• Serum level of estrogen & progesterone is
similar in women with/ without clinically
detectable fibroid

5. Risk factors
1. Age- incidence increases with age
2. Greater exposure to endogenous hormones-
early menarche( <10 yrs age) , late
menopause
3. Family history- 1st degree relatives have 2.5
times higher risk
4. Ethnicity- African American women have 2.9
times higher risk than white women

6. 5. Weight- increases risk. Obesity increases
conversion of adrenal androgens to estrone
and decreases SHBG increased
biologically available estrogen
6. Exercise- women in highest category of
physical exercise (7 hrs / week) –less likely to
have fibroids
7. OCP- no definite relationship
8. Pregnancy- increased parity decreases risk
9. Smoking- decreases risk. Nicotine inhibits
aromatase decreased conversion of
androgens to estrone.

7. Growth Factors
• Proteins or polypeptides
• Increase smooth ms proliferation-TGF beta
• DNA synthesis- EGF, PDGF
• Promote mitogenesis- TGF beta, EGF, insulin
like growth factor, prolactin
• Promote angiogenesis- VEGF, basic fibroblast
growth factor

8. Pathology
• Naked eye appearance:
Firm, enlarged uterus
Shape – distorted or uniform
• Cut section:
Smooth, whitish
Whorled appearance
• False capsule is formed by compressed
adjacent myometrium. Pinkish in color

9. • Capsule is separated from fibroid by loose
areolar tissue
• Blood vessels run through this plane
• Tumour is shelled out from this plane durnign
myomectomy
• Periphery of tumour is more vascular
• Centre is least vascular and likely to
degenerate
• Microscopic appearance:
Smooth muscles
Fibrous connective tissue

10. Symptoms
• Asymptomatic (75%)
• Abnormal bleeding- menorrhagia or metrorrhagia
• Pelvic pain- degeneration of fibroid. Torsion of
pedunculated subserosal fibroid
• Pressure symptoms- Constipation, retention of
urine
• Urinary symptoms- frequency , urgency
• Abdominal enlargement

11. FIGO Leiomyoma classification

12. Diagnosis
• Pelvic examination: enlarged, irregularly
shaped, firm, non tender
• Imaging: TVS, MRI, saline infusion sonography
hysteroscopy.
• USG- symmetrical, well defined, hypoechoic,
heterogenous masses.

13. Fertility
• Submucous fibroids decrease fertilty,
removing them increases fertility
• Subserosal fibroids do not affect fertility,
removing them increases fertility
• Intramural fibroids slighlty decrease fertility,
removal does not increase fertility.

14. Fibroids and pregnancy
• Prevalence: 18% in African American women
10 % in hispanic women
8 % in white women
• Most fibroids do not increase in size during
pregnancy
• Fibroid degeneration-seen in 5% cases
• Increased risk : preterm delivery, placenta
previa, PPH. C-section rate increased

15. Treatment

17. Treatment
• Medical therapy :
1. GNRH agonists: goserelin, luporelin,
buserelin, nafarelin
 MOA- Sustained pituitary downregulation
and suppresion of ovarian function
 Reduction in uterine size occurs within 3
months of treatment

18. Advantages:
1. Improvement of menorrhagia, may produce
amenorrhea
2. Improvement of anemia
3. Relief of pressure symptoms
4. Reduction in size(50%), when used for a
period of 6 months
5. Reduction in vascularity
6. Reduction in blood loss during myomectomy

19. Disadvantages:
1. Hypoesterogenic side effects- vasomotr
symptoms, bone loss, arthralgia, depression,
decreased libido (A low dose estrogen-
progestin may be added)
2. Regrowth of myomas on cessation of therapy
3. High cost

20. • GNRH antagonist :
Ganirelix, cetrorelix
Immediate suppression of pituitary and ovaries
• Antiprogesterone :
Mifepristone (RU-486)- reduce size and
menorrhagia
Dose- 25- 30mg daily for 3 months
Blocks progesterone; unopposed exposure of
endometrium to estrogen may lead to
endometrial hyperplasia. So, long term therapy
avoided

21. • Selective progesterone receptor modulator:
Asoprisnil- does not cause endometrial
hyperplasia
• LNG-IUD: recommended in uterine size <12
weeks, normal uterine cavity
Decreases uterine bleeding

22. Surgical treatment
• Treating preoperative anemia:
1. Recombinant eryhthropoeitin
( erythropoeitin alfa and epoetin)-
epoetin 250 IU/kg-(15000 U) per week for 3
weeks increases hemoglobin concentration
by 1.6g/dl.
2. Iron supplementation
3. GNRH agonists

23. Myomectomy
• Enucleation of myoma from the uterus
• Abdominal/ laparoscopic/ hysteroscopic
• May be done at the time of C section by
experienced surgeon
• Synthetic vasopressin (Pitressin) decreases
blood loss during myomectomy

24. • Contraindication of myomectomy:
1. Infected fibroid
2. Growth of myoma after menopause
3. Suspected sarcoma

25. Uterine artery embolization
• Leads to avascular necrosis followed by shrinkage
of fibroid
• Polyvinyl gelatin particles (PVA), gelatin sponges,
or trisacrly gelatin microspheres injected via
percutaneous femoral artery catheterization until
occlusion or slow flow is documented.
• Complications: Postembolization syndrome- pain,
fever, sepsis, myometrial infarction, necrosis,
amenorrhea, ovarian failure, femoral artery injury

26. • Contraindication of UAE:
1. Acute pelvic infection
2. Women desirous of future pregnancy( as
there is risk of premature ovarian failure)
3. Genital tract malignancy
4. Drug allergy

27. • Magnetic resonance guided focussed
ultrasound (MRgFUS):
Focussed high energy ultrasound waves
Coagulative necrosis in myomas by producing
sufficient heat
Multiple treatment
Less pain compared to UAE
Safe, feasible, minimally invasive
Contraindication- abdominal wall scar, uterine
size>24 weeks, desire for future fertility

28. Degenerations of fibroid
• Hyaline degeneration:
Most common(65%)
Feel becomes soft, elastic
Cut surface- irregular homogenous areas with
loss of whorl like appearances
• Cystic degeneration:
Usually following menopause
Common in interstitial fibroids
Liquefaction of areas with hyaline changes

29. • Fatty degeneration:
Usually found at or after menopause
Fat globules deposited mainly in muscle fibres
• Calcific degeneration:
Usually in subserous fibroid
Usually preceded by fatty degeneration
Precipitation of calcium carbonate or
phosphate in the tumour
Whole tumour converted into calcified mass-
‘womb stone’

30. • Red degeneration (carneous degeneration):
Occurs in large fibroid
Mainly in 2nd half of pregnancy and
puerperium
Cut section- raw beef appearance (d/t
hemolysed red cells and hemoglobin)
containing cystic spaces
Fishy odour d/t fatty acids
Microscopically- necrosis, thrombosed vessels

31. Other complications
1. Atrophy: following menopause. Loss of estrogen
support.
2. Necrosis: circulatory inadequacy -> central necrosis
3. Infection: following delivery/ abortion. Infection gains
access to tumour core through the thinned and
sloughed surface epithelium
4. Vascular changes
5. Sarcomatous changes: in <0.1% cases. Leimyosarcoma
is the usual type
6. Torsion

32. Thank you

33. D/D
• Adenomyosis: Focal, not well defined , highor
low intensity areas in USG
• Uterine sarcomas: Gd-DTPA dynamic MRI-
sarcomas have increased vascularity while
degenerating fibroids have decreased
perfusion and decreased enhancement.