This presentation describes Uterine fibroid Definition Incidence Etiology Risk factors Clinical manifestation Red degeneration Complications of fibroids Management and the new modalities in treatment

1. UTERINE LEIOMYOMA
DONE BY
MOHAMMED SAADI
UTERINE FIBROIDS

2. Objectives:-
 Definition
 Incidence
 Etiology
 Risk factors
 Clinical manifestation
 Red degeneration
 Complications of fibroids
 Management

3. LEIOMYOMA
What is a leiomyoma?
It is a benign neoplasm of the muscular wall of the uterus
composed primarily of smooth muscle .
Although they can grow to huge size their malignant potential
is minimal.
Incidence:
They are the most common pelvic tumors
It is found in 25% of white women & 50% of black
Women.
More than 45% of women have leiomyomas by the fifth
decade of life.
They are primary indication for about 200000
Hysterectomies in united state each year

4. ETIOLOGY
 Unknown
 Each individual myoma is unicellular in origin
 Estogens no evidence that it is a causative factor , it has
been implicated in growth of myomas
 Myomas contain estrogen receptors in higher
concentration than surrounding myometrium
 Myomas may increase in size with estrogen therapy & in
pregnancy & decrease after menopause
 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.
 Reduced incidence with
COCP and DMPA user.

6. 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

7. MICROSCOPIC STRUCTURE
 Whorled appearance nonstriated muscle fibers
arranged in bundles running in different directions
 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

9. CLASSIFICATION
 Submucous leiomyoma
 Pedunculated
submucous
 Intramural or interstitial
 Subserous or
subperitoneal
 Pedunculated abdominal
 Parasitic
 Intraligmentary
 Cervical

10. SECONDARY CHANGES

12. 1-BENIGN DEGENERATION
 Atrophic.
 Hyaline  yellow, soft gelatinous areas
 Cystic liquefaction follows extreme hyalinization
 Calcific circulatory deprivation precipitation of ca
carbonate & phosphate
 Septic circulatory deprivation necrosis  inection
 Myxomatous (fatty) uncommon, follows hyaline or
cystic degenration

13. Red Degeneration of Fibroid

14. 1-BENIGN DEGENRATION
Red (carneous) degeneration
 Commonly occurs during pregnancy
 Edema & hypertrophy impede blood supply aseptic
degenration & infarction with venous thrombosis &
hemorrhage
 Painful but self-limiting
 May result in preterm labor & rarely DIC
2-MALIGNANT TRANSFORMATION is rare:
 Transformation to leiomyosarcomas occurs in 0.1-0.5%

15. Pregnency and Fibroid

16. Pregnency and Fibroid

17. CLINICAL FINDINGS

18. 1-SYMPTOMS
 Symptomatic in only 30% of Patient.
 Symptoms depend on location, size, changes &
pregnancy status
1-Abnormal uterine bleeding
 The most common 30%
 Heavy / prolonged bleeding (menorrhagia)  iron
deficiency anemia

19. 1-Abnormal uterine bleeding
 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
intermenstrtual bleeding

20. 2-PAIN
 Vascular occlusion  necrosis, infection
 Torsion of a pedunculated fibroid acute pain
 Myometrial contractions to expel the myoma
 Red degenration acute pain
 Heaviness fullness in the pelvic area
 Feeling a mass
 If the tumor gets impacted in the pelvis pressure
on nerves back pain radiating to the lower
extremities
 Dysparunea if it is protruding to vagina

21. 3-PRESSURE EFFECTS
 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 serosanguineous vaginal discharge,
bleeding, dyspareunia or infertility

22. 4-INFERTILITY
 The relationship is uncertain
 27-40% of women with multiple fibroids are infertile
 but other causes of infertility are present
 Endocavitary tumors affect fertility more
5- SPONTANEOUS ABORTIONS
  incidence before myomectomy 40%
after myomectomy 20%
 More with intracavitary tumors

23. COMPLICATIONS

24. 1-COMPLICATIONS IN PREGNANCY
 ≥ 2/3 of 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
 Managed conservatively with
bedrest & narcotics + tocolytics if
indicated
 After the acute phase pregnancy
will continue to term

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

26. 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
 No evidence that COCP  the size of myomas
 Postmenopausal women on HRT must be followed
up with pelvic exam or U/S every 6 M

27. Dx of Fibroid

28. EXAMINTION
 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

29. IMAGING
 Pelvic U/S is very helpful in confirming the Dx & excluding
pregnancy / Particularly in obese .
 Saline hysterosonography can identify submucous myoma that
may be missed on U/S
 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

30. 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

31. 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

32. TREATMENT

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

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

35. SYMPTTOMATIC
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.

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

37. 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
 Injected MPA.
 Progesterone only pills.
 LNG releasing IUD.

38.  COCP:used cyclically to reduce menstrual blood loss
or continueously to eliminate the cycle
 Dysmenorrhoea is also improved

39. GNRH AGONISTS
RX results in:
1- size of the myomas 50% maximum
2- This shrinkage is achieved in 3months of RX
3-Amenorrhea & hypoestrogenic side-effects occur
4-Osteopososis may occur if Rx last > 6M
It is indicated for
1- bleeding from myoma except for the polypoid
submucous type
2-Preoperative to  size  allow for vaginal hysterectomy
myomectomy
laparoscopic myomectomy

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

41. B-SPECIFIC MEASURES
 Most cases asymptomatic  no treatment
 Postmenopausal  no treatment
 Other causes of pelvic mass must be excluded
 The Dx must be certain
 Initial follow up every 6 M  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

42. C-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

43. D-SURGICAL MEASURES

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

45. 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

46. Hystroscopic myomectomy
 The route of choice for SM fibroids.
for removing SM fibroids >2 cm

47. Laproscopic myomectomy
Mostly done in subserosal type.
remove the mass through a small abdominal
incision .

48. hysterectomy
 Old age
 Completed her family
 Multiple fibroids

49. 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.

51. 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

52. References
1. Ash Monga and Stephen Dobbs. Fibroid.Gynecology By
Ten Teachers.(2011)19th edition.
2. Sally Collins, Sabaratnam Arulkumaran, Kevin Hayes,
Simon Jackson, Lawrence Impey.Fibroid. Oxford
Handbook of Obstetrics and Gynaecology. (2013)3rd
edition.
3. Uterine Fibroid. Williams Gynecology.(2008).
4. Hiralar konar. Benign condicions of uterus(Fibroid).
Dc dutta’s textbook of gynecology.(2013) 6th edition.
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