details of fibromyoma uterus

1. Fibro-myoma Uterus
Dr. H.K.Cheema
Professor & Head
OBG-PIMS

3. 2.5cm
0.5cm
5.0cm
2.5cm

4. Uterus-three layers

5. Length of uterus

6. Lesions of the Uterus
Benign lesions
❑ Leio-myoma/ Fibro-myoma uterus
❑Uterine Polyps
❑1. endometrial polyp
❑2. fibroid polyp
❑3.Adenomatous polyp
❑4. placental polyp
Malignant lesions
❑Leio-myo-sarcoma
❑Uterine sarcoma
❑Endometrial carcinoma of uterus

7. Leio-myoma Uterus

8. Fibro-myoma
❑ Synonyms : Myoma, Leiomyoma, Fibromyoma
❑ It is most common benign neoplasm in the female.
❑ Common benign solid tumor in females
❑ Average age is 35-45 years.
❑ Incidence : 20 to 40% of reproductive age women.

11. Fibromyoma
Etiology :
It arises from smooth muscle cell of myometrium.
❑ Exact etiology not known.
❑ Monoclonal origin ( arising from single cell)
❑ Various growth factors like TGFβ , EGF, IGF-1, IGF- 2, BFGF
(Oestrogen dependent Tumor)

12. Fibromyoma - Etiology
Multiple chromosomal abnormalities-detected in 50% of fibroid patients
❑ Translocation between Chromo. 12 & 14,
❑ Trisomy 12,
❑ Rearrangement of short arm of Chromo 6
❑ Rearrangement of long arm of Ch. 10,
❑ Deletion of Ch.3 or Ch.7 or long arm of Y chromosome.

13. Fibromyoma - Etiology
Increase state of Estrogen in the body-
Hyper-oestrogenism has been proved for causing myoma
❑ Not detected before puberty
❑ They regresses after menopause
❑ Never arise in menopause.
❑ May increase during pregnancy
❑ Estrogen receptors are in higher concentration
❑ Common in Obesity, PCOS, DUB,Endometrial carcinoma
❑ Less in smokers
❑ Regresses with OCPs.

14. Fibromyoma - Epidemiological risk factors
Decreased risk
❑↑↑ parity,
❑white Race,
❑Post menopausal phase,
❑Progestrone only contraceptives,
❑ cigarette smoking
Increased risk
❑age 35 to 45 years ,
❑ nulliparous or low parity ,
❑Black women,
❑ obesity,
❑early Menarche,

16. Etiology
❑Rapid Growth
❑Pregnancy
❑Nulliparous
❑Black women
❑Hyper-oestrogenic states
❑Slow Growth
❑Mutiparous
❑smoking

17. Sites of origin
Corporeal
fibroid
97% )
Cervical
fibroid
(3%)

18. Fibroids are often described according to their location in
the uterus

19. Locations
Uterine Body- 95%
❑ Intramural or interstitial75%,
❑ Submucous15% (sessile /
Pedunculated )
❑ Subserous10%( pedunculatd
– torsion/ parasitic).
Cervical.<5%
❑ Primarycervical.
❑ Ligamentary-true/ false
broad ligamentfibroids,
round orsacral-ovarian

20. Origin- Fibromyoma
-

21. Different locations-fibromyoma

25. Gross examination
❑Enlarged Uterus
❑Distorted shape
❑Multiple, nodular growths of variable sizes
❑Feels firm
❑Some sessile, some pedunculated
❑If Pedunculated
❑Fibro-myomatous Polyp

26. Fibromyoma
Submucous fibroids are further classified
by European society for gynec endoscopy ( ESGE
Type 0 – No intramural extension
Type I – Intramural extension < 50 %
Type II – Intramural extension > 50 %

28. Pathology
Well circumscribed white
firm mass with a whorled
appearance
- surrounded by false
capsule formed by
compressed by uterine
muscle

29. Pathology
1.well circumscribed tumor
2.Pseudo- capsule.
3.Cut surface is pinkish white
4. whorled appearance.
5.Capsule consists of connective tissuewhich fixes tumorwith
myometrium.
6.Vessels that supply Blood to tumor lie in capsule and send radial branch to
tumor Hence central part of tumor is comparatively less vascular ,thereby
degenerative changes are noticeable in center.
7.Calcification at the peripheryand spreads inwards along the
vessels(Wombstone).

31. Pathology Microscopically
Smooth muscle
Connective tissues Whorled
appearance

32. Symptoms

36. Symptoms
.
1.Mennorhagia—
↑size of cavity,
↑vascularity,
↑ ostrogen,
2.Polymenorrhea—co-existing PCOD/PID
3.Metrorrhagia --sub-mucosal
4.Meno-metrorrhagia ---I/mural, sub-mucosal
5. Poly-menorrhagia-- I/mural,Sub-mucosal,PCOD/PID
6.Dysmenorrhea----sub-mucosal-spasmodic,congestive
7.No menstrual disturbance---sub-serosal
8.co-existing Carcinoma endometrium—3%

37. Symptoms---
Infertility
1. fibroid > 4 cm in size
2.distortion of cavity-poor nidation, cornual blockage
3.Recurrent abortions
4.associated PCOS,
endometriosis,
Anovulation

40. Other symptoms--
❑Increased frequency of micturation--
❑Retention of urine---
❑Constipation--
❑Vaginal discharge----
❑Abdominal lump----
❑& Anaemia—
❑Pseudo-Meig syndrome---(Fibromyoma+ Ascites+ Right Pleural
effusion)

41. Acute Pain in Fibro-myoma
Torsion of pedunculated -------Fibroid
Capsular Haemorrhage
Rapid growth of fibromyoma—Sarcomatous change(0.5%)
Red degeneration of fibroid---in Pregnancy

42. Shock
❑Capsular haemorrhage
❑Excessive bleeding with anaemia—large sub-mucosal fibroid

43. Fate of Sub-mucosal Fibroid
❑1.Polypoidal changes
❑Surface necrosis
❑Infection
❑Degeneration
❑Sarcomatous change
❑Symptoms
❑Mennorrhagia
❑Meno-metrorrhagia/metrorrhagia
❑Dysmennorrhea—Congestive & spasmodic
❑Vaginal discharge—blood stained/Foul smelling

44. Secondary pathological
degenerative changes and
complications of fibroids

45. Secondary changes- Degenerations
❑Degenerations
❑Hyaline degeneration
❑Red degeneration
❑Fatty degeneration
❑Calcific degeneration
❑Cystic degeneration
HRFC 2

46. Hyaline degeneration of fibro-myoma
Reproductive
age
Soft elastic
instead of firm
Central part of
fibromyoma
Loss of whorled
appearance

47. CYSTIC DEGENERATION
menopause
Occurs after
liquefaction with
hyaline degeneration
Common in
intra-mural
fibromyoma
D/D
Pregnancy
Ovarian cyst

48. HAEMORRHAGE & CALCIFICATION
Sub-serosal
Post-
menopausal
age
Calcium
carbonate/phos
phate deposits
Womb stone

49. CALCIFICATION OF FIBROID - RADIOGRAPH
Womb stone

52. RED DEGENERATION OF FIBROID - NECROBIOSIS

53. ❑2nd half of pregnancy/puerpurium
❑Larger fibroid, vascular in origin
❑Symptoms—
❑-Acute pain in pregnancy(tense, tender),high grade fever.
❑Cut section—
❑Reddish-purple in colour
❑Raw Beef appearance/cooked meat
❑Fishy odour
❑Cause—
❑vessels thrombosed,necro-biosis, haemolysed RBC
❑D/D—
❑Acute appendicitis, Torsion ovarian cyst ,acute pyelitis
❑Investigations---Hb,TLC,DLC,,ESR ↑,Treatment-Consevative—Admit,Analgesics,supportive therapy.

54. Complications…….
A Atrophy
V vascular changes
I Infection
N Necrosis
S sarcomatous change
T Torsion
I Inversion
C Capsular Haemorrhage
A Associated Endometrial carcinoma
AVIN-STICA

55. Complications---
❑Atrophy
❑Vascular changes
❑Infection
❑Necrosis
❑Sarcomatous change
❑Torsion
❑Inversion uterus
❑Capsular Haemorrhage
❑Associated endometrial carcinoma—3%

56. Risk of Malignancy
0.1% in reproductive age group
1.7% after age of 60 years

57. Fibromyoma 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.

58. Fibro-myoma---Diagnosis
• 1.Clinical : From symptoms & signs
• 2.USG : Well defined hypoechoic
lesions. Peripheral calcification with distal
shadowing in old fibroids

59. ❑ 3.TAS&TVS
❑ size, site and number of fibroids
❑ differentiates the tumour from other swellings as
ovarian tumour

60. Fibromyoma ---USG

61. 4-Saline infusion sonography

62. .
5. Hysteroscopy

63. (6) Intravenouspyelogram (IVP)
In cervical and broad ligament fibroid
- Course of ureter.
- Hydroureter & hydroneprosis
- Kidney function.

64. Fibromyoma -Diagnosis
7. 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)
8. H S G : Not done for diagnosis , Done for infertility
evaluation filling defects may be seen.

65. Fibromyoma-MRI

66. Fibromyoma-- D/D
❑PHOBAE3P
❑Pregnancy
❑Haematometra
❑Benign ovarian tumour
❑Malignant ovarian tumour
❑Bicornuate uterus
❑Adenomyosis
❑Endometriosis
❑Endometrial carcinoma
❑Ectopic pelvic kidney
❑Myomatous Polyp

67. Pregnancy complicating Fibromyoma
Some fibromyomas’---can cause infertility.
During pregnancy, size ↑ ,can cause hyaline, cystic,
red degeneration-5%
↑ size in pregnancy—can cause
Respiratory embrassment
Retention of urine
Obstructed labour

68. Fibro-myoma complicating Pregnancy
❑Abortion
❑Mal presentation, Malposition
❑IUGR
❑Pre-term labour
❑Prolonged labour
❑P. sepsis
❑Inversion uterus
❑Sub-involution uterus
❑In-co-ordinated uterine action
❑Obstructed labour
❑PROM
❑Accidental haemorrhage
❑Cervical dystocia
❑PPH--

70. Investigations
❑CBC—
❑Hb,BT,CT,ABORH,
❑Platelet count, TLC,DLC
❑USG
❑Diagnosis
❑Pre-opeartive
❑Post-opeartive
❑After GnRh analogue therapy
❑HSG/Sonosalpingography
❑Hysteroscopy/D&C
❑Laproscopy
❑Laprotomy
❑Pregnancy with Fibromyoma –any doubt in diagnosis, location, size?
❑MRI

71. Fibromyoma; Treatment
❑ Expectant :
❑ asymptomatic ,
❑ Size < 12 weeks,
❑ near menopause .
❑ Regular follow up every 6 months

73. Indications for Medical Management
❑To treat anaemia, recover before surgery
❑To reduce the size & Facilitate surgery
❑Treat women in Peri-menopausal age group to avoid surgery
❑Women who are unfit for surgery
❑For fertility preservation in women with large fibriods before
conservative surgery-myomectomy

74. Medical treatment
❑Iron therapy
❑Purpose---Correct Anaemia, control bleeding,
❑pre-operative, post operative, regular treatment
❑Drugs—[to control mennorrhagia]
❑Tranxemic acid, Mefanemic acid
❑RU-486---(Mifipristone)
❑10-25mg o.d.x3m
❑Danazol—400-800 mg.dailyx3-6 months.
❑GnRh analogues
❑ Mirena IUCD

75. Mnemonic ; Drugs used to decrease the size of fibromyoma
❑2 Gynae M D
❑GnRh agonists
❑GnRh antagonists
❑Mifepristone
❑Danazol

77. GnRh analogues
GnRh analogues
GnRh
Antagonist
GnRh Agonist

78. GnRh analogues
GnRh agonists
❑Leuprolide acetate
❑Buserelin
❑Goserelin
❑Naferelin
❑Triptorelin
GnRh antagonists
❑Cetrorelix
❑Ganirelix

79. GnRH agonists
❑ Agonists are commonly used drugs :-
❑ Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot
❑ 3.75 mg I/M for 3 months
❑ Advantages :
❑ Decrease in size of myoma by 20 to 30 %
❑ Decrease in bleeding
❑ Increase in Hb level
❑ Decreases blood loss during surgery
❑ Converts hysterectomy into myomectomy
❑ Converts Abd. hyst into vaginal.hysterectomy

80. GnRh agonists
❑Action
❑It decreases uterine volume-35%,fibroid volume-30% .
❑Effective Bleeding control is also seen
❑Dosage
❑Monthly GnRh Agonistis given for 6 months.
❑Post effect
❑Following discontinuation of GnRh agonist, uterine volume and menses returns with in 4--8 weeks, 2/3rd
women remained asymptomatic for 8-12 months.
❑95% women developed side - effects of hypo estrogen--- iatrogenic menopause and oseoporosis.
❑Add back therapy(OCP) given concurrently reducesthese sideeffcts.
❑GnRH-agonist is recommended
❑1. as temporary treatment for premenopausal women with heavymenorrhagia.
❑2.One month before myomectomy to reduce size of fibromyoma to reduce intra operative bleeding.

81. GnRh agonists
❑ Disadvantages :
❑ High cost
❑ Hypoestrogenic side effects.
❑ Effect is reversible
❑ Rarely ↑↑ bleeding due to degeneration
Occasionally difficulty in enucleation
❑

82. Price 5500-6000/Inj
GnRh Agonist-Inj Leuprolide 3.75mg

83. Price Rs 11,000/Inj
Inj Leuprolide 11.25mg

84. Immediate suppression of endogenous GnRh
by daily SC injection 0f Ganirelix results in 30%
reduction in fibroid volume with in 3wks.
Patient develops Hypo estrogenic symptoms.
Availability of long acting compounds might be
considered for medical treatment prior to
surgery.
GnRh Antagonist→
.

85. Rs 2700-3000/Inj
GnRh Antagonist

86. Levonorgestral IUCD-Mirena
❑Progesterone releasing IUCD-
❑Mirena-Levonorgestrel releasing IUCD (Third generation IUCD) may be a
reasonable treatment for selected women.
❑Used in child bearing age gp. with fibroids associated with menorrhagia and
women interested to have contraception.
❑ Contains Progesterone LNG 60 mg releasing 20 ug/day
❑ Fibroids decreases in size within 6 – 12 months of use.
❑85% of such women returned to their normal bleeding within 3 months and
40% develop reversible amenorrhea at the end of 1.5-2 years .

87. Rs. 4500

88. Indications for Surgical treatment
❑Fibromyoma > 12 weeks size.
❑Patient is symptomatic-decide the mode of treatment
❑Subserous and pedunculated likely to undergo Torsion
❑Unexplained infertility / Recurrent abortions
❑Rapidly growing fibroid
❑If likely to produce complications in future pregnancy
❑If there is doubt about the nature of tumor.

89. Surgical Management
❑ Myomectomy
❑ Abdominal, Vaginal
❑ Hysteroscopic
Laproscopic
❑ Hysterectomy
❑ Abdominal
❑ Vaginal
❑ LAVH, TLH

90. Hystrectomy—
Routes=abdominal, vaginal (open/laproscopic)
Sub-total hysterectomy= uterus minus cervix is removed
Total hysterectomy= uterus + cervix
Total abdominal hysterectomy with Bilateral salpino-oophorectomy=Pan-
hysterectomy
Werthiem’s hysterectomy-
1. Modified Radical = TAH+ B/L S.O + Medial part of parametrium+ Upper vaginal
cuff+ pelvic lymphadenectomy
2. Radical= TAH+ B/L S.O + parametrium up to lateral pelvic wall + Upper vaginal
cuff+ pelvic lymphadenectomy

92. Surgical Management
Myomectomy is done in following :-
Indications for surgery→
 Infertility caused by cornual fibroidblocking
tube.
Habitual abortion due tosub mucous fibroid.
 Pedunculated fibroid likely to undergotorsion.
 Fibroid > 12 weeks.
 Broad ligament fibroid pressing onureter.
 Fibroid pressing over bladdercausing retention of urine /
infection.
 Rapidly growing uterine fibroid in postmenopausal
women.

93. Myomectomy-Routes
❑ Abdominal
❑ Vaginal
❑Method
❑Laproscopic
❑Hysteroscopic
❑Open
Myomectomy is enucleation of myoma
from the uterus leaving behind
potentially funtional uterus capable of
future reproduction.

94. Indications of Myomectomy
❑Persistent uterine bleeding despite medical treatment.
❑Excessive pain or pressure symptoms
❑Size> 12 weeks, woman desrious of having pregnancy
❑Unexplained infertility with distortion of uterine cavity.
❑Recurrent pregnancy loss.
❑Rapidly growing fibro-myoma during follow up
❑ Pedunculated Sub-serosal fibromyoma

95. Contra-indications of Myomectomy
❑Infected fibroid
❑Growth of fibroid after menopause
❑Suspected malignant change
❑Parous woman where hysterectomy is a safe choice.
❑Pelvic or endometrial Tuberculosis
❑During prernancy
❑During c. section.

96. Time of myomectomy
❑Immediate Post-menstrual period to reduce blood loss
❑Should not be performed during pregnancy
❑Should not be performed during c.section.
❑Results
❑Pregnancy rate after myomectomy=40-60%
❑Recurrence rate=30-50%
❑20-25% ultimately come for Hystrectomy in later life.

97. Pre-operative management Protocol
❑ Anemia should be corrected.
❑ (parentral iron therapyalong with folicacid, vitamin C, proteinsuplementation.)
❑ Arrange for Blood transfusion.( atleast 2 units) (Auto transfusion / donor blood
transfusion)
❑ Control of bleeding→GnRH agonisttherapy( atleast one month prior to surgery)
❑ Control of associated medical problems like hypertension, CHF, Asthma, UTI,
kidney or liverillness.
❑ D& C must prior to myomectomy
❑ Patient should be investigated prior to myomectomy for complete infertility
investigations including Husband’ seminology to rule out other causes of infertility.
❑ Written consent for hysterectomy has to be taken prior to myomectomy because of
risk of heavy bleeding during surgery.
Before surgery
Hb, BT, CT, ABORh
Platelet count, PTI/INR
TLC,DLC,ESR,PBF
S.TSH,LFT,RFT
RBS,HbA1C
VDRL, Viral Markers
ECG,X-Ray Chest(P-A view)
Urine C/E, Urine C/S
Medical fitness from Physician
PAC by anasthetist

98. Abdominal myomectomy
Pre-requisites
❑ Other factors for infertility should be ruled out
❑ Take written consent with risk of hysterectomy
❑ Cross matched Blood should be ready.
❑ Pap smear & endometrial sampling to rule out malignancy.
❑ Medical or mechanical means to control blood loss -available
❑ Bonney’s Myomectomy clamp, rubber tourniquet, manual ( finger
compression) pressure at isthmic region
❑ or use of vasopressin 10 – 20 units diluted in 100ml saline infiltrated
before putting the incision .

99. Myomectomy specimen

100. Hysteroscopic myomectomy/Resection
• For submucous myoma causing infertility, Recurrent pregnancy
loss, AUB or pain
• Criteria :- < 5 cm in size
< 50 % intramural component
< 12 cm2uterine size

101. Laparoscopic myomectomy
❑ In 3 phases
❑ excision of myoma, repair of myometrium & extraction
❑ Suitable for subserous & intramural fibroids upto 10 cm size
❑ Complications are those of operative laparoscopy + myomectomy

102. Myomectomy Instruments

103. Abdominal myomectomy
❑ Minimum incisions are kept – preferably single midline
vertical, lower, anterior wall .
❑ Removal of as many fibroids as possible through one incision
& secondary tunnelling 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.

104. Open Myomectomy

105. Vaginal myomectomy
❑ Submucous pedunculated or 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.

106. Important considerations- Myomectomy
❑It should be done to preserve the reproductive function.
❑It is more risky operation than hysterectomy when fibroids are too many or too big.
❑Risk of recurrence is about 30-50%
❑Risk of persistence of menorrhagia is 1-5%
❑Risk of re-laparotomy is about 20-25%
❑Pregnancy rate after myomectomy is 40-60%
❑Pregnancy after myomectomy should be done in hospital to avoid chances of scar rupture during labour.
❑Complications- hemorrhage during operation, within 24 hrs ( reactionary),>24hrs-secondary Hge
❑Trauma to bladder, ureter, Gut, Rectum
❑Infection-wound sepsis,
❑Complications of anaesthesia include aspiration Pneumonia, Paralytic ileus etc.

107. Radical Surgical Management
❑ Abdominal or Vaginal hysterectomy
❑ Vaginal hystrectomy is favoured in following;
❑ If Uterus < 14 wks
❑ With no associated pathology like endometriosis , PID, adhesions
❑ Uterus mobile & adequate lateral space in pelvis
❑ Experienced vaginal surgeon

108. Uterine artery embolization

109. Uterine artery embolization
❑ By interventional radiologist
❑ Catheter is passed retrograde thro. 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

110. .

111. Uterine artery
embolization

112. Advantages Of UAE
❑ No majorsurgery.
❑ No intra-operative bleeding.
❑ Short hospital stay.
❑ No abdominaladhesions.
❑ 75-80% women suffering from menorrhagia aresatisfied.

113. Uterine artery embolization
• High vascularity & 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

114. Latest 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
❑ Cryomyolysis is under investigation

115. Leio-myosarcoma
❑Incidence=0.2-0.5%
❑Age= usually Post-menopausal.
❑When fibroid starts growing rapidly with acute pain in Post-menopausal woman
with tenderness. Always suspect leio-myosarcoma.
❑Most common in sub-mucous, followed by intra-mural fibroid.
❑Average 6-9 cm.
❑The malignant change starts from the centre.
❑Soft, fleshy, poorly defined margins, non encapsulation of tumour.
❑Cut surface= greyish yellow, with areas of hemorrhage & necrosis.
❑Poor prognosis=5 yr survival rate is 15-25%

116. Type equation here.

118. 5-10 mitosis/10 HPF
With cellular atypia
> 10 mitosis/10 HPF
With/without cellular
atypia

119. 15-20%

121. Uterine Polyps

128. Questions
32 yrs.F, MF=10 yrs, infertile
H/O progressive mennorhagia
Pallor ++
A non-tender, hard mass, arising from pelvis, movable from side to
side
Diagnosis ?
How will u manage the case?

129. Question
47 yrs, Para 2,progressive meorrhagia, with foul smelling, blood
stained discharge in between
Pallor++
Non-tender hard mass ,irregular in shape, size>16 weeks, arising
from pelvis
P/S ulcerated pedunculated mass seen coming out of external os of
cervix
Diagnosis?
Management?

130. Questions
Case based Questions
Types of Fibro -myoma
Fate Of sub-mucosal fibro-myoma
Symptoms of fibro-myoma
Menstrual problems in fibro-myoma
S.N --Degenerations in fibro-myoma
Complications of fibro-myoma
Myomectomy, polyps
Specimens
Short case
Grand Viva