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FIBROID UTERUS.pptx for mbbs students 2025
- 1. FIBROID UTERUS DR. SS NANDA ASSO. PROF.(O&G) MKCG MCH, BERHAMPUR
- 2. FIBROID Synonyms : Myoma,Leiomyoma, Fibromyoma Fibroids are benign smooth muscle cell tumors of the uterus Most common benign neoplasm in the female. Incidence : 20 to 40% of reproductive age women.
- 3. FIBROID Aetiology : • Itarises from smooth muscle cell of myometrium. • Exact etiology not known. • Monoclonal origin ( somatic mutation in a progenitor myocyte -arising from single cell) • Genetic basis definite.(Cytogenetic analysis) • Various growth factors like TGFβ , EGF, IGF-1, IGF2, BFGF TGF- transforming growth factor, EGF- Epidermal growth factor, IGF- Insulin like growth factor BFGF- basic fibroblast growth factor
- 4. Fibroid - Aetiology Epidemiologicalrisk factors • 20% > 20years • 40% > 40years Increased risk • age 35 to 45 years • nulliparous or low parity • Black women • Strong family history • Obesity • Early Menarche • Diabetes • Hypertension. Decreased risk • ↑↑ parity, exercise • ↑↑intake of green vegetables • Progesterone only contraceptives • Cigarette smoking
- 5. Fibroid - Aetiology Geneticbasis: • Responsible for 40 % cases of fibroids • Translocation between Chromosomes 12 & 14 • Trisomy 12 • Rearrangement of short arm of Chromosome 6 • Rearrangement of long arm of Chromosome 10 • Deletion of Chromosome 3 or Chromosome 7
- 6. Fibroid - Aetiology Estrogenalthough not proved for causing myoma definitely implicated in its growth. • Not detected before puberty & regresses after menopause • May increase during pregnancy • Estrogen receptors are in higher concentrations • Common in fifth decade due to anovulatory cycles with high or unopposed estrogen.
- 7. Site of origin Corporealfibroid (97% ) Cervical fibroid (3%) Round ligament/Broad ligament/uterosacral ligament (rare) Extrauterine Vulval
- 8. Fibroids are oftendescribed according to their location in the uterus CORPOREAL FIBROIDS SUBMUCOUSAL- Just below the endometrium INTRAMURAL/ INTERSTITIAL- Within the myometrial wall SUBSEROUS- Just below the peritoneal coat
- 10. OTHERS • Intravenous leiomyomatosis •Leiomyomatosis peritonalis disseminate • Bizzare leiomyoma UTERINE FIBROIDS BODY Interstitial(75%) Subserous (15%) Subserous Broad ligament Parasitic Submucous (10%) Sessile Pedunculated CERVIX Anterior Posterior Central Lateral
- 12. Cervical Fibroids Present in1 to 2 per cent of cases Usually seen in supravaginal portion Commonly single Either interstitial or subserous Rarely submucous and polypoidal Subserous tumour usually grows out into one or other broad ligament The cervical leiomyoma presents special clinical features because, being extraperitoneal It remains fixed in the pelvis and displaces the bladder and ureters Its removal is hazardous for the same reasons Myoma developing in the cervical stump after subtotal hysterectomy is a rare but interesting possibility and can create a surgical problem
- 13.
- 14. FIBROID Submucous fibroids areclassified by European society for gynaec endoscopy ( ESGE ): • Type 0 – No intramural extension • Type I – Intramural extension < 50 % • Type II – Intramural extension > 50 %
- 15. Pathology GROSS • Variable size,nodular structures, oval or rounded shape, firm/hard in consistency. CROSS SECTION • Well circumscribed white firm/hard mass with a whorled appearance - surrounded by pseudo- capsule formed by compressed normal uterine muscle HISTOPATHOLOGY • Smooth muscle, Connective tissues
- 16. CLINICAL FEATURES Symptoms • ASYMPTOMATIC50% • SYMPTOMATIC 50%
- 17. SYMPTOMS Abnormal uterine bleeding Pelvicpressure and pain Reproductive dysfunction Secondary symptoms Abdominal lump
- 18. SYMPTOMS Asymptomatic (50%) • Fibroidsize < 4cm • Uterine size < 12 cm The majority of small leiomyomas and some large ones are symptomless The nearer the leiomyoma to the endometrial cavity, the more likely it is to cause symptoms, especially menstrual symptoms
- 19. ABNORMAL UTERINE BLEEDING Itis the most common symptom. Menorrhagia Heavy menstrual bleeding an increased blood loss at normally spaced intervals, which is gradual in onset and progressive Metrorrhagia (Intermenstrual bleeding) Infected ulcerated fibroid polyp Postmenopausal bleeding are not characteristic of myomas except if associated with degenerative changes
- 20. The factors causingmenorrhagia are: an increase in size of the endometrial cavity and of the bleeding surface increased vascularity of the uterus associated endometrial hyperplasia Hyperoestrogenism compression of veins by the tumour(s) with consequent dilatation and engorgement of venous plexuses in the endometrium and myometrium interference with uterine contractions which are alleged to control the blood flow through the uterine wall (theoretical)
- 21. PAIN A leiomyoma doesnot cause pain unless it is complicated by: • extrusion from the uterus as a polyp - in this case the pain is caused by uterine colic which ‘aborts’ the myoma • torsion of its pedicle or of the uterus • Degeneration • sarcomatous change • adhesions to other organs. Pain which accompanies uterine leiomyomas is often caused by an associated lesion, especially endometriosis.
- 22. DYSMENORRHOEA Spasmodic dysmenorrhoea • whena submucous tumour stimulates expulsive uterine contractions • severe but one-sided, can be caused by a single but quite small leiomyoma which happens to be sited at the uterotubal junction from which uterine contraction waves arise Congestive dysmenorrhea • because of the associated pelvic congestion
- 23. PRESSURE SYMPTOMS Presence ofTumour • > 14WEEK size Alimentary Tract- • Dyspepsia • constipation Bladder- • irritability with diurnal frequency • Retention of urine when impacted in POD Veins and Lymphatics – • Oedema and varicosities of the legs & hemorrhoids are sometimes seen with large tumours Nerves • Pain from pressure on the nerves of the sacral plexus or on the obturator nerve is extremely rare
- 24. Symptoms Related toPregnancy Infertility- • the tumour interferes with implantation of the fertilised ovum • because it hinders the ascent of the spermatozoa by distorting the uterus and tubes, • or because of an associated disturbance of ovulation if the leiomyomas are not situated near the endometrium
- 25. Abortion and PrematureLabour when the leiomyoma interferes with enlargement of the uterus initiates abnormal uterine contractions prevents efficient placentation or causes impaction of the uterus in the pelvis
- 26. Malposition and Malpresentationof the Foetus These can result if the leiomyoma • distorts the shape of the uterus • prevents engagement of the head.
- 27. Obstructed Labour As pregnancyadvances, most leiomyomas lift into the abdomen and do not complicate delivery. Labour can be obstructed by cervical and broad ligament tumours which are fixed in the pelvis by pedunculated subserous leiomyomas which become trapped in the pouch of Douglas
- 28. Abnormal Uterine Action Inertiadue to leiomyomas is only a theoretical possibility predispose to third-stage difficulties (RETAINED PLACENTA) to postpartum haemorrhage especially if the placenta is implanted over the leiomyoma.(ADHERENT) delay involution.(SUB-INVOLUTION)
- 29. The Effect ofPregnancy on Leiomyomas Increased Growth of Tumour • They invariably enlarge • this is because of congestion, oedema and degeneration • they usually return to their original size afterwards
- 30.
- 31.
- 32. Physical Signs It ishard,rounded or lobulated and movable from side to side but not from above downwards. If palpable abdominally, the swelling arises from the pelvis is nearly always dull to percussion because the intestines lie behind and beside it. ‘Healthy’ leiomyomas are not tender. On bimanual examination, it is found that •the tumour either replaces or is attached to the uterus. • In a single and subserous leiomyoma with a long pedicle, the connection with the uterus may not be recognised. In such a case, distinction from an ovarian tumour is impossible. The diagnosis may be difficult if the leiomyoma is soft and cystic as a result of degeneration. •A submucous tumour produces symmetrical enlargement of the uterus but, if it is small, may be impossible to diagnose. Transvaginal sonography (TVS) aids in the diagnosis but may not detect some intrauterine tumours these may be demonstrated by •hysterography, •sonohysterography, •hysteroscopy or at hysterotomy •Preoperative hysteroscopy helps in planning the management.
- 33. D/D OF CALCIFIEDMYOMA Finding of calcification in the tumour during radiological examination of the trunk for another purpose (‘wombstone’) • an ovarian tumour • a calcified tuberculous pyosalpinx • a calcified mucocele of the appendix • a retroperitoneal connective tissue tumour • or a tumour of the bony pelvis
- 34. D/D OF CALCIFIEDMYOMA
- 35. Secondary pathological degenerativechanges and complications of fibroids Atrophy Necrosis Degeneration • Hyaline, Cystic, Fatty, Calcific, Red, Necrobiosis Malignancy • Sarcoma Infection Torsion Incarceration Inversion of the uterus
- 36. Degeneration Red degeneration • israther special to pregnancy but other types are more common Degeneration of any kind is said to occur • because the enlarging uterus puts tension on the capsule of the tumour and thus reduces its blood supply
- 37. Risk of Malignancy 0.1%in reproductive age group 1.7% after age of 60 years
- 38. Fibroid Signs G/E –Pallor P/A – If > 12 weeks size firm, nodular, arising from pelvis, lower limit can’t be reached, relatively well defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen P/S – Cervix pulled higher up P/V – Uterus enlarged, nodular. D/D from ovarian tumour • Uterus not separately felt • transmitted movement present • notch not felt.
- 39.
- 40. DIAGNOSIS • From symptoms& signs Clinical • Well defined hypoechoic lesions. Peripheral calcification with distal shadowing in old fibroids USG
- 41. Clinical diagnosis ofFibroid Uterus
- 42. USG • size • site •number of fibroids 1. TAS&TVS e.g. ovarian tumour differentiates the tumour from other swellings
- 43.
- 44. HYSTEROSCOPY (3) Hysteroscopy To visualize asub mucous fibroid or a small fibroid polyp.
- 45. IVP (4) Intra venouspyelogram (IVP) In cervical and broad ligament fibroid – Course of ureter. Hydroureter & hydroneprosis Kidney function.
- 46. MRI 5. MRI : •Most accurate imaging modality for diagnosis of fibroid. • It does precise fibroid mapping & characterization • Detects all fibroids accurately • D/D from adenomyosis • D/D from adnexal pathology • Ovaries are easily seen • Detects small myomas(0.5 cm)
- 47.
- 48. H S G: 6. H S G : Not done for diagnosis Done for infertility evaluation filling defects may be seen.
- 49. FIBROID D/D Exclude Pregnancy Uterine Extra-uterine (Ectopic) Excludeother pelvic masses Ovarian tumour Tubo-Ovarian abscess Endometriosis Adenexa, omentum or bowel adherent to the uterus Exclude other causes of uterine enlargement Adenomyosis Myometrial hypertrophy Congenital anomalies Endometrial Carcinoma
- 50.
- 51. Fibroid Management Expectant : Asymptomatic, Size < 12 weeks, near menopause Regular follow up every 6 months Recent guidelines suggest up to 16 wks size , however difficult to practice
- 52.
- 54. MEDICAL MANAGEMENT Not adefinitive Rx For symptomatic relief Preoperatively to decrease the size • Progestogens • Antiprogestogens ( Miefpristone ) • Androgens ( Danazol, Gestrinone ) • GnRH analogues are used
- 55. GnRH analogues Agonists arecommonly used drugs :- Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 months Advantages : Decrease in size of myoma by 20 to 50 % Decrease in bleedingà increases Hb level Decreases blood loss during surgery Converts hysterectomy into myomectomy Converts Abd. hyst into vag.hysterectomy Makes hysterectomic resection possible
- 56. GnRH analogues Disadvantages : Highcost Hypoestrogenic side effects Effect is reversible Rarely ↑↑ bleeding due to degeneration Occasionally difficulty in enucleation
- 57. Gn-RH Antagonist Cetrorelix isused 60 mg I/M repeated after 3-4 months if necessary Initial flare up does not occur
- 58.
- 59. SURGICAL MANAGEMENT Vaginal hysterectomyis favoured in following if Uterus < 16 wks, preferably < 14 wks No associated pathology like endometriosis , PID, adhesions Uterus mobile & adequate lateral space in pelvis Experienced vaginal surgeon
- 60. SURGICAL MANAGEMENT Myomectomy isdone in following: Infertility Recurrent pregnancy loss & no other cause Young patients Patients who wish to preserve menstrual function
- 61. HYSTEROSCOPIC MYOMECTOMY For submucousmyoma causing infertility Recurrent pregnancy loss AUB or pain Criteria :- < 5 cm in size < 50 % intramural component < 12 cm2 uterine size
- 62.
- 63. LAPAROSCOPIC MYOMECTOMY In 3phases • excision of myoma • repair of myometrium • Extraction Suitable for subserous & intramural fibroids up to 10 cm size Complications are those of operative laparoscopy + myomectomy
- 64.
- 65. ABDOMINAL MYOMECTOMY Other factorsfor infertility should be ruled out (Male factor) Consent for hysterectomy Blood cross matched & ready Pap’s smear & endometrial sampling to rule out malignancy Medical or mechanical means to control blood loss • Bonney’s Myomectomy clamp • rubber tourniquet • manual ( finger compression) pressure at isthmic region • use of vasopressin 10 – 20 units diluted in 100ml saline infiltrated before putting the incision .
- 66. Use of Bonney’sMyomectomy clamp
- 67. ABDOMINAL MYOMECTOMY Minimum incisionsare kept – preferably single midline vertical, lower, anterior wall . Removal of as many fibroids as possible through one incision & secondary tunneling incisions. Meticulous closure of all dead space. Proper haemostasis Multiple small fibroids can be removed enbloc by wedge resection. Measures for adhesion prevention should be taken.
- 68.
- 69. VAGINAL MYOMECTOMY Submucous pedunculatedor small sessile cervical fibroids are removed vaginally. Ligation of pedicle if accessible Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids To gain access to pedicle of higher & big fibroid incision on the cervix can be made.
- 70.
- 71. SURGICAL MANAGEMENT Laparoscopic myolysis: By ND-YAG laser or long bipolar needle electrode through laparoscope, blood supply of myoma is coagulated. Without blood supply, myoma atrophies. Applicable to 3 -10 cm size & myomas < 4 in number
- 72.
- 73. UTERINE ARTERY EMBOLIZATION Byinterventional radiologist Catheter is passed retrograde through right femoral artery to bifurcation of aorta & then negotiated down to opposite uterine artery first. Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or gelfoam are used for embolization. 60 – 65 % reduction in size of fibroid 80 – 90 % have improvements in menorrhagia & pressure symptoms
- 74.
- 75. UTERINE ARTERY EMBOLIZATION Highvascularity & solitary fibroid are associated with greater chance of long term success. Pregnancy, active infection & suspicion of malignancy are absolute C I . Desire for fertility is also a contraindication The risk of ovarian failure must be counselled Post embolization syndrome ( fever, vomiting, pain) can occur
- 76.
- 77. NEWER MANAGEMENT Mirena : Thirdgeneration IUCD Contains Progesterone LNG 60 mg releasing 20 ug /day Fibroids decreases in size 6 – 12 months of use. Future research in fibroid Rx : MRI guided focused ultrasound therapy SPRM –Selective progesterone Receptor modulator à Asoprisnil Somatostatin analogues à Lanreotide
- 78. MRI-guided Focused Ultrasound(MRIFUS)
- 79. MCQs in Fibroid •Most common type of uterine leiomyoma . a) Intramural. b)Subserosal. c) Submucosal. d)Broad ligament. • Which of the following is used for symptomatic treatment of fibroid. a) OCPs b)Testosterone. c) GnRH agonist. d)GnRH antagonist.
- 80. MCQs • Most commonsymptom of fibroid a) Abnormal uterine bleeding. b) Pelvic pain. c) Mass in abdomen. d) Abdominal discomfort • Most common pelvic tumour of reproductive age group is a) Uterine fibroid b) Dermoid cyst . c) Ovarian cysts. d) Ovarian tumour.