Complete information from exam point of view for medical students to refer for quick revision.

1. DEPARTEMNT OF GYNAECOLOGY AND
OBSTERTICS
UTERINE
FIBROIDS
DR. D. Y. PATIL HOMOEOPATHIC MEDICAL
COLLEGE AND RESEARCH CENTRE
- DR. RADHIKA KHANDEWAL -

2. OBJECTIVES
⚫Definition
⚫Incidence
⚫Etiology
⚫Risk factors
⚫Clinical manifestation
⚫Red degeneration
⚫Complications of fibroids
⚫Management

3. UTERINE FIBROID
What is a UTERINE FIBROID?
It is a commonest benign solid tumor of the muscular wall of the
uterus composed primarily of smooth muscle and fibrous connective
tissue. Also called as uterine leiomyoma, myoma or fibromyoma.
Although they can grow to huge size their malignant potential is
minimal.
Incidence:
• They are the most common pelvic tumors.
• It has been estimated 20% women at the age of 30 years have got
fibroid in their uterus, out of them 50% remain asymptomatic.
• In Black women the incidence rate is higher that of White women.

4. ETIOLOGY
⚫ The aetiology still remains unclear. The prevailing
hypothesis are –
⚫ Chromosomal abnormality
⚫ Polypeptide growth factors stimulate growth of
leiomyoma either directly or via oestrogen.
⚫ Predominantly an oestrogen – dependent tumor
⚫ They are not detectable before puberty
⚫ Progestrone increase mitotic activity & reduce apoptosis
in size
⚫ There may be genetic predisposition

5. RISK FACTORS
⚫Nultiparity and infertility.
⚫Increasing age .
⚫Ethinicity(two fold in
african american
compared with white
women.
⚫Increased BMI.
⚫Family history.
⚫Hyperoestrogenic state

6. CLASSIFICATION
UTERINE
FIBROIDS
BODY
(CORPOREAL)
Interstitial (75%)
(Intramural)
Subserous
(15%)
Subserous
Broad Ligament
(Pseudo)
Wandering (Parasitic)
Submucous
(5%)
Sessile
Pedunculated (Polyp)
CERVICAL
Anterior
Posterior
Central
Lateral

7. CLASSIFICATION

8. TYPES - Body
The fibroid are mostly located in the body of the uterus and
are usually multiple.

9. TYPES – Interstitial or intramural
• Initially the fibroid are intramural in position but
subsequently, some are pushed outwards or inwards.
• Eventually, in about 70% they persist in that position.

10. TYPES – Subperitoneal or subserous
• The intramural fibroid is pushed outwards towards the
peritoneal cavity.
• The fibroid is either partially or completely covered by
peritoneum.
• PEDUNCULATED SUBSEROUS FIBROID – The fibroid
when completely covered by peritoneum.
• WANDERING/PARASITIC FIBROID – When the
pedicle is torn the fibroid gets its nourishment from
omental or mesenteric adhesions.
• BROAD LIGAMENT FIBROID/PSEUDO or FALSE
FIBROID – Intramural fibroid may be pushed out in
between the layers of broad ligament.

11. TYPES – Submucous
• The intramural fibroid when pushed towards the uterine
cavity, and is lying underneath the endometrium, it is
called as submucous fibroid.
• This variety is least common but produces maximum
number of symptoms.

12. TYPES – Cervical
• Cervical fibroid is rare.
• In the supravaginal part of the cervix, it may be
interstitial or sub-peritoneal variety and rarely
polypoidal.
• Depending on the position it may be –
• Anterior
• Posterior
• Lateral
• Central

13. PATHOLOGY
⚫ Frequently multiple
⚫ May reach 15 cm in size or larger
⚫ Firm
⚫ Spherical or irregularly lobulated
⚫ Have a false capsule
⚫ Can be easily enucleated from
surrounding myometrium

14. MICROSCOPIC STRUCTURE
⚫Consists of smooth muscles and fibrous connective
tissue of varying proportion.
⚫Individual cells are spindle shaped uniform
⚫Varying amount of connective tissue are interlaced
between muscle fibers
⚫Pseudocapsule of areolar tissue & compressed
myometrium
⚫Arteries are less dense than myometrium & do not
have a regular pattern of distribution
⚫1-2 major vesseles are found at the base or pedicle

16. SECONDARY CHANGES

17. DEGENERATION - Hyaline
• Hyaline degeneration is the most common (65%) type of
degeneration affecting all sizes of fibroids except the tiny
one.
• The feel becomes soft elastic in contrast to firm feel of
the tumour.
• Naked eye examination on the cut surface shows
irregular homogenous areas with loss of whorl-like
appearance.

18. DEGENERATION - Cystic
• Usually occurs following menopause and is common in
interstitial fibroids.
• It is formed by liquefaction of the areas with hyaline
changes.
• The cystic changes of an isolated big fibroid may be
confused with an ovarian cyst or pregnancy.

19. DEGENERATION - Fatty
• Usually found at or after menopause.
• Fat globules are deposited mainly in the muscle cells.

20. DEGENERATION - Calcific
• Seen in 10% of the cases.
• Usually involves the subserous fibroids with small
pedicle or myomas of postmenopausal women.
• Usually preceded by fatty degeneration.
• There is precipitation of calcium carbonate or phosphate
within the tumor.
• When the whole of the tumor is converted into a calcified
mass it is called as ‘WOMB STONE.’

22. DEGENERATION - Red
• Also known as carneous degeneration occurs in a large
fibroid mainly during second half of pregnancy and
puerperium.
• Naked eye appearance of the tumor shows dark areas
with cut section revealing raw-beef appearance often
containing cystic spaces.
• Odor is fishy due to fatty acids and the color is due to
presence of haemolysed red cells and haemoglobin.
• Microscopically, evidence of necrosis are present.

23. DEGENERATION - Red

24. DEGENERATION - Atrophy
• Atrophic changes occur following menopause dur to loss
of support from oestrogen.
• There is reduction in the size of the tumor.
• Reduction also occurs following pregnancy enlargement.

25. DEGENERATION - Necrosis
• Circulatory inadequacy may lead to central necrosis of
the tumor.
• This is present in submucous polyp or pedunculated
subserous fibroid.

26. DEGENERATION - Infection
• The infection gains access to the tumour through the
thinned and sloughed surface epithelium of the
submucous fibroid.
• This usually happens following delivery or abortion.
• Intramural fibroid may also be infected following
delivery.

27. DEGENERATION – Vascular changes
• Dilatation of the vessels or dilatation of the lymphatic
channels inside the myoma may occur.
• The cause is unknown.

28. CHANGES IN PELVIC ORGANS
• UTERUS –
• Shape – distorted
• Myohyperplasia is a constant finding
• Endometrium normal
• Anovulation
• Dilatation and congestion of myometrial and
endometrial venous plexuses.
• Uterine cavity may be elongated and distorted in
intramural and submucous varieties.
OVARIES –
• Enlarged, congested and studded with multiple cysts.

29. CHANGES IN PELVIC ORGANS
• URETER –
• Displacemment of the anatomy of the ureter in broad
ligament fibroid.
• ENDOMETRIOSIS –
• Increased association of pelvic endometriosis and
adenomyosis.
• ENDOMETRIAL CARCINOMA.

30. CLINICAL FINDINGS

31. SYMPTOMS
⚫ Symptomatic in only 30% of Patient.
⚫ Symptoms depend on location, size, changes &
pregnancy status
⚫ Menstrual abnormality – Menorrhagia,
metrorrhagia.
⚫ Dysmenorrhea
⚫ Dyspareunia
⚫ Infertility
⚫ Recurrent abortion
⚫ Lower abdominal or pelvic pain
⚫ Abdominal enlargement

32. SYMPTOMS
⚫ MENSTRUAL ABNORMALITIES –
⚫ Submucous myoma produce the most pronounced
symptoms of menorrhagia, pre & post-menstrual
spotting
⚫ Bleeding is due to interruption of blood supply to the
endometrium, distortion & congestion of surrounding
vessels or ulceration of the overlying endometrium
⚫ Pedunculated submucous areas of venous
thrombosis & necrosis on the surface inter-
menstrtual bleeding

33. SYMPTOMS
⚫ DYSMENORRHOEA –
⚫ The congestive variety may be due to associated
pelvic congestion or endometriosis.
⚫ Spasmodic type is associated with extrusion of
polyp and is expulsion from the uterine cavity.
⚫ INFERTILITY –
⚫ Infertility may be a major complaint.
⚫ The cause may be uterine, tubal, ovarian,
peritioneal.

34. SYMPTOMS
⚫ PREGNANCY RELATED PROBLEMS –
⚫ Abortion, preterm labour, IUGR.
⚫ PAIN –
⚫ Fibroids are usually painless, but it may be due to some
complications of the tumor or due to associated pelvic
pathology.
⚫ Due to tumour –
⚫ Degeneration
⚫ Torsion of subserous pedunculated fibroid
⚫ Extrusion of polyp
⚫ Assosiated pathology –
⚫ Endometriosis
⚫ PID

35. ⚫ PRESSURE SYMPTOMS
⚫ If large may distort or obstruct other organs like
ureters, bladder or rectum urinary symptoms,
hydroureter, constipation, pelvic venous congestion
& LL edema
⚫ Rarely a posterior fundal tumor extreme
retroflexion of the uterus distorting the bladder
base urinary retention
⚫ Parasitic tumor may cause bowel obstruction
⚫ Cervical tumors causes vaginal discharge,
bleeding, dyspareunia or infertility
SYMPTOMS

36. COMPLICATIONS

37. COMPLICATIONS IN PREGNANCY
⚫ 2/3of women with fibroids &
unexplained infertility conceive
after myomectomy
⚫ Red degeneration
⚫ In the 2nd or 3rd trimester of
pregnancy rapid in size
vascular deprivation
degeneration
⚫ Causes pain & tenderness
⚫ May initiate preterm labor
⚫ After the acute phase pregnancy
will continue to term

38. COMPLICATIONS IN PREGNANCY
DURING LABOR
⚫Uterine inertia
⚫Malpresentation
⚫Obstruction of the birth canal
⚫Cervical or isthmeic myoma necessitate CS
⚫PPH

39. COMPLICATIONS IN NONPREGNANT WOMEN
⚫Heavy bleeding with anemia is the most common
⚫Urinary or bowel obstruction from large parasitic
myoma is much less common
⚫Malignant transformation is rare
⚫Ureteral injury or ligation is a recognized
complication of surgery for myoma
⚫Postmenopausal women on hormonal therapy
must be followed up with pelvic exam or USG
every 6 months.

40. MANAGEMENT OF FIBROID

41. EXAMINATION
⚫ Most myoma are discovered on routine bimanual pelvic
exam or abdominal examination
⚫ Retroflexed retroverted uterus obscure the palpation
of myomas
LABORATORY FINDINGS
⚫ Anemia
⚫ Depletion of iron reserve
⚫ Rarely erythrocytosis pressure on the ureters back
pressure on the kidneys erythropoietin
⚫ Acute degeneration & infection ESR, leucocytosis, &
fever

42. IMAGING
⚫ Pelvic USG is very helpful in confirming the Dx &
excluding pregnancy / Particularly in obese .
⚫ Saline hysterosonography can identify submucous myoma that
may be missed on USG
⚫ HSG will show intrauterine leiomyoma
⚫ MRI highly accurate in delineating the size, location & no. of
myomas , but not always necessary
⚫ IVP will show ureteral dilatation or deviation & urinary
Anomalies.
HYSTROSCOPY for identification & removal of submucous
myomas

43. DIFFERENTIAL DIAGNOSIS
⚫ Usually easily diagnosed
⚫ Exclude pregnancy
⚫ Exclude other pelvic masses
-Ovarian Ca
-Tubo-ovarian abscess
-Endometriosis
-Adenexa, omentum or bowel adherent to the uterus
Exclude other causes of uterine enlargement:
-Adenomyosis
-Myometrial hypertrophy
-Congenital anomalies
-Endometrial Ca

44. DIFFERENTIAL DIAGNOSIS
Exclude other causes of abnormal bleeding
⚫ Endometrial hyperplasia
⚫ Endometrial or tubal Ca
⚫ Uterine sarcoma
⚫ Ovarian Ca
⚫ Polyps
⚫ Adenomyosis
⚫ DUB
⚫ Endometriosis
⚫ Exogenouse estrogens
Endometrial biopsy or D&C is essential in the evaluation of
abnormal bleeding to exclude endometrial Ca

45. TREATMENT

46. TREATMENT
DEPENDS ON:
⚫Age
⚫Parity
⚫Pregnancy status
⚫Desire for future pregnancy
⚫General health
⚫Symptoms
⚫Size
⚫Location

47. MANAGEMENT
BODY CERVIX
ASYMPTOMATIC SYMPTOMA
TIC
SURGICAL
 Size <12 weeks.
Diagnosis certain.
REGULAR
SUPERVISION
 Size >12weeks.
MEDICAL
Diagnosis uncertain.
Unexplained infertility.
H/o abortion.
Pedunculated SURGERY
 Size increases.
Symptoms appear.
oSize stationary.
oSymptom less.
SURGERY FOLLOW UP

48. SYMPTOMATIC
MEDICAL SURGICAL
INDICATIONS
1.Symptomatic pt.
2.Perimenopausal
female
3.Women desiring
children & retaining
uterus.
4.For correction of
anemia before surgery.
5.To decrease size &
vascularity of tumors.
TREATMENT
Treat anaemia- Haematinics.
Fibrinolytics- Tranexemic acid.
Antiprogesterone-
Mifepristone ( RU 486)
- Danazol.
Gnrhagonist- Goserlin, Luporelin
Naferelin, Buserelin.
Gnrhantagonist- Cetrorelix, Ganirelix.
Pg synthetase inh- NSAID’s.
Progesterone releasing IUD.

49. SURGICAL OPTIONS
MYOMECTOMY HYSTERECTOMY
MYOLYSIS EMBOLOTHERAPY
ENDOSCOPY
LAPAROTOMY
LAPROSCOPIC
MYOMECTOMY
HYSTEROSCOPIC
RESECTION OF
SUBMUCOUS MYOMA
1. Electrocautery
2. Laser.
3. Cryo

50. CERVIX
SUPRAVAGINAL VAGINAL
Myomectomy Hysterectomy
Polypectomy
Myomectomy

51. MANAGEMENT OF UTERINE FIBROID
⚫No treatment is required for asymptomatic small
fibroid, unless if cause 12 week uterine enlargement
or is the cause of infertility.
⚫For excessive heavy cycle.
⚫Progesterone only therapy:
⚫Oral
⚫Progesterone only pills.
⚫LNG releasing IUD.

52. ⚫Combined oral contraceptive pills: used cyclically to
reduce menstrual blood loss or continueously to
eliminate the cycle.
⚫Dysmenorrhoea is also improved.
MANAGEMENT OF UTERINE FIBROID

53. EMERGENCY MEASURES
⚫Blood transfusion/ PRBC to correct anemia.
⚫Emergrncy surgery indicatd for:
- infected myoma
-acute torsion
-intestinal obstruction
⚫Myomectomy is contraindicated during pregnancy.

54. SPECIFIC MEASURES
⚫ Most cases asymptomatic no treatment
⚫ Postmenopausal no treatment
⚫ Other causes of pelvic mass must be excluded
⚫ Initial follow up every 6 months to determine the rate of
growth of the myoma
⚫ Surgery is contraindicated in pregnancy
⚫ The only indication for myomectomy in pregnancy is
torsion of a pedunculated fibroid
⚫ Myomectomy is not recommended during CS
⚫ Pregnant women with previous multiple myomectomy /
especially if the cavity was entered 🡆 should be delivered by
CS to risk of scar rupture in labor

55. SUPPORTIVE MEASURES
⚫PAP smear & endometrial sampling for all Pt with
irregular bleeding
⚫Before surgery
-Correct Hb
-Prophylactic antibiotics
-Mechanical & antibiotic bowel preparation if
difficult surgery is anticipated
⚫Prophylactic heparin postoperative

56. SURGICAL MEASURES

57. Operative treatment
Myomectomy :
Indications
 Women who wish to maintain fertility
 SM fibroid distorting the uterine cavity
 Fibroids > 5 CM
 Multiple fibroids

58. Open myomectomy
The route of choice for :
Large SS or IM fibroids >7 cm
Mulitple fibroids >5 cm
When entry in to uterine cavity is expected

59. Hystroscopic myomectomy
⚫The route of choice for SM fibroids.
for removing SM fibroids >2 cm

60. Laproscopic myomectomy
Mostly done in subserosal type.
Remove the mass through a small abdominal
incision.

61. Hysterectomy
⚫Old age
⚫Completed her family
⚫Multiple fibroids

62. Non invasive procedures
1.Uterine artery embolization
The ideal patient for UAE :
 Pre-menopausal pt not desiring fertility.
 Post-menopausal pt with failure of spontaneous regression.
 Patient has failed medical management.
 Absolute contraindication to surgery.

63. 2. MRGFUS :
Non invasive procedure
Focused ultrasound wave converted in pathology to
heat under guide of MRI.
Slection criteria:
 4-10 cm
 family completed
 perimenopausal
Non invasive procedures