Uterine fibroids are benign tumors that develop from the muscular layer of the uterus. They are quite common, affecting 20-40% of women. While the exact cause is unknown, risk factors include genetic factors, hormones, and growth factors. Fibroids can be asymptomatic or cause heavy bleeding, pain, and pressure symptoms. Diagnosis involves physical exam, ultrasound, MRI and other imaging tests. Treatment options range from observation and medication to minimally invasive procedures like uterine artery embolization and myolysis to more invasive options like myomectomy and hysterectomy. Fibroids may also complicate pregnancy by increasing risks of miscarriage, preterm labor, and difficult delivery. Their removal during c-section is sometimes recommended if interfering

1. Dr. Razia Akter
FCPS ( Gyne & Obst.)
Deptt of Gynecology & Obstetrics
Dhaka Community Medical College and
Hospital.

2. Introduction
Definition :
 Uterine fibroid is a leiomyoma benign smooth muscle
neoplasm originating from the myometrial cell
Appearance gross elliptical pearly white and rubbery
consistency and covered by distinct connective tissue.

3. Incidence
 Incidence rate is 20-40% ,
 Age incidence: women in their 30s and 40s will most
commonly present.
 Race : Blacks suffers more.

4. Etiology
Unknown
Genetic (40%)
Hormonal
Growth factors
Familial
Nulliparity
Others : infection , Metabolic , Dietary , stress ,
environmental factors….

5. Etiology ..cont…
Genetics :
 Translocations 12 & 14 chromosomes
 • Deletion of 7 chromosomes
 • Trisomy of 12 chromosomes

6. Etiology .. Conti….
Hormonal :
 Estrogen & Progesterone increase in receptors no. &
responsiveness on fibroids…
 Hyperestrogenic states- Obesity, Ca endometrium,
early menarche, anovulatory infertility.
Before puberty & after menopause – less incidence
It contains more aromatase enzyme.

7. Etiology .. Conti…
Growth Factors
TGF-β- Tumour growth factor B
EGF - Epidermal growth factor
PDGF – Platelet derived growth factor
IGF - Insulin growth factor
VEGF - Vascular endothelial growth factor

8. Types
BODY OR CORPOREAL
FIBROIDS
• Intramural or
interstitial fibroids
• Subserosal fibroids
• Submucosal fibroids

9. Types .. Conti..
CERVICAL
FIBROIDS 1-2 %

11. Symptoms
1. Asymptomatic 50% (<5cm size & uterus <12cm)
2. Abnormal uterine bleeding – 30%
 Progressive Menorrhagia
 Metrorrhagia (submucous & endometrial cancer)
 Polymenorrhea (cystic ovaries & PID)
 Purulent discharge (infected fibroid polyp)

12. Symptoms… conti..
Pain:
• Congestive & spasmodic dysmenorrhea
• Acute pain - torsion, hemorrhage & red degeneration.
• Rapidly growing sarcoma

13. Symptoms..conti…
Pressure symptoms – (more in cervical fibriod)
I. • Retention of urine premenstrual
II. • Hydroureter & hydronephrosis
III. • Constipation
IV. • Intestinal obstruction

14. Symptoms..
Infertility – 30%
• >4cm
• Distortion of cavity
• Fertility rate –
Submucous type: reduce
Subserosal type- No effect
Intramural type - slightly decrease

15. SECONDARY CHANGES IN FIBROID
Degenerative changes
• Hyaline degeneration:
• Cystic degeneration:
• Calcification:
• Fatty degeneration:
• Red degeneration:
• Septic degeneration
. Liquefaction

16. Diagnosis ::
 History
Abdominal examination :
 Feel is firm more towards hard may be cystic
in cystic degeneration.
 Margins are well defined except the lowerpole.
 nodular may be uniformly enlarged
 Mobility is restricted from above downwards
but can be moved from side to side.
 Percussion : swelling is dull

17. Diagnosis…
Pelvic examination :
 Bimanual examination reveals uterus irregularly
enlarged
 Uterus is not felt separated from the swelling
and as such a groove is not felt between the uterus and
the mass.
 The cervix moves with the movement of the tumour felt
per abdomen.

18. Diagnostic Tools
o Abdominal , trans-vaginal or pelvic ultrasound,
Saline infusion sonogram
o MRI
o Laparoscopy
o Hysteroscopy
o Hysterosalpingography
o Endometrial biopsy
o Inravenous pyelogram

19. Imaging 1( Trans-abdominal Sonogram)

20. Imaging 2 ( TVS)

21. Imagings 3 ( Saline infusion sonogram)

22. Imaging 4( MRI )

23. Treatments
Conservative-
a) Observation
b) Medical
c) Non-invasive- MRgFUS
d) Minimally invasive- UAE, Myolysis
e) Invasive- Thermal Ablation
Surgical –
Polypectomy, Myomectomy, Hysteroscopic
resection, Hysterectomy

24. Mx.. Continue..
INDICATIONS for intervention:
1. Infertility
2. Recurrent pregnancy losses
3. Asymptomatic >12wk/pedunculated
4. Pressure symptoms
5. Rapidly growing fibroid/ growth after menopause

25. Mx…Medical Management
Temporary palliation-
 1. To improve Menorrhagia
 2. Before surgery-Correction of anemia, decrease size
&
vascularity
 3. Postpone surgery
Alternative to surgery
 1. Perimenopausal
 2. Desiring fertility
 3. Unfit for surgery

26. Medical Mx…conti..
Pharmacological Rx Is indicated when:
( NICE Guideline , Jan , 2007)
 Fibroids less than 3 cmm in diameter.
 Causing no distortion of the uterine cavity.

27. Anti-Fibrinolytic Agents
(Tranexamic Acid)

28. Non-Steroidal
Anti-Inflammatory Drugs

29. Combined oral
contraceptives(COCs) reduces blood loss

30. Levonorgesrel-releasing
intrauterine system (LNG-IUS)

31. Gonadotropin-releasing hormone
analogues

32. Selective progesterone receptor
modulators(SPRMs)

33. AROMATASE INHIBITORS

34. Other hormonal agents

35. Magnetic resonance-guided focused
ultrasound surgery (MRgFUS)
FDA approved Oct 2004
 Thermal ablation( temp 55C-90c – Coagulative
necrosis)
 • 31% reduction ut vol in 6mth
Selection criteria-
 4-10cm fibroids
 Family completed
 Perimenopausal
 Subcut tissue to fibroid <12cm
 Clearly visible on MRI

36. MRgFUS conti…

37. MRgFUS ..

38. Minimal Invasive technics
Uterine Artery Embolisation
 Procedure :
Placement of an angiographic catheter-Common
Femoral artery-Uterine artery-Injec. of embolic
agent( polyvinyl alcohol)- causes sluggish flow.
 Indication-Symptomatic fibroid, surgery not
feasible

39. Uterine Artery Embolisation

40. Myolysis
Lap procedure
 Destroys by laser, cryotherapy, electrosurgical energy
Indications-
1. Perimenopausal 3-10cm
2. Ut size < 14wk

41. Surgical Mx
Myomectomy
Indications:
 Unexplained infertility with cavity distortion
 Unexplained RPL
 Fertility conservation
 Subserous pedunculated
Types :
 Vaginal
 Hysteroscopic resection of submucous myomata
 Laparoscopic
 Abdominal

42. Myomectomy
Prerequisities-
 Correct Hb, oral iron, GnRH-a, Autotransfusion
 Other causes of infertility should be ruled out
 Consent for hysterectomy
 Perform in preovulatory menstrual cycle
 Endometrial cancer rule out by D&C

43. Hysterectomy
ACOG criteria for Hysterectomy:
 Asymptomatic 12wk concern to patient
 Excessive bleeding- Profuse bleeding >8days or
anemia
 Pelvic discomfort- Acute & severe or chronic pain,
 Pressure symptoms

44. Radiofrequency Ablation
Halt’s Method
3 small incisions-
1. Laparoscopic camera
2. Intraabdominal ultrasound probe
3. Halt Device

45. Gene Therapy
Recent evidence suggests that, fibroids develop as an
over expression of p14Arf and MDM2 Gene.
NUTLIN -3, a known MDM2 antagonist, was used
which :
oppose the proliferative activity in cell cultures from
fibroids
Stimulates apoptosis Gene- BAX, in vitro.

46. SOGC Clinical Practice Guideline
(No. 318, Feb 2015)

47. SOGC Clinical Practice Guideline
(No. 318, Feb 2015)

48. Fibroids in Pregnancy
Incidence – 18%, 1 in 1000
Effect of pregnancy –
 Increase in vascularity & size
 Torsion of subserous
 Puerperal infection
 Red degeneration – 5%
Effect of fibroid on pregnancy –RPL, Preterm
labour ,intrauterine growth restriction ,prolong
labour ,PPH .

49. Indication of removal during C/S
 Pedunculated sub-serosal
 Interfering with delivery or closure
 Intractable pain
 Rapid growth with pressure symptoms

50. Fibroids Complicating Pregnancy