LEIOMYOMA

1. FIBROID UTERUS
Presented by: Dr Annabelle Sabu
Moderator: Dr J Narshetty

2. Introduction
• Fibroids(Myoma, Leiomyoma,Fibromyoma)
• Most common Monoclonal Benign tumors of
uterus arising in the smooth muscle cells of
myometrium.
• Contain large aggregation of extracellular matrix
consisting of collagen, elastin, fibronectin and
proteoglycan.
• Each fibroid is derived from smooth muscle cells
rests,either from vessel wall or uterine
musculature

3. Etiology
• Precise cause of Fibroids is not known.
• (A) Genetic
Fibroids are monoclonal .
40% have chromosomal abnormalities:
(a) translocations between chromosomes 12 and 14
(b)deletions of chromosome 7
(c) Trisomy of chromosome 12 in large tumors.
60% may have yet undetected mutations

4. Etiology
• Genetic  more than 100 genes were found
to regulate cell growth, proliferation,
differentiation and mitogenesis.
• Genetic differences between fibroid and
Leiomyosarcomas indicate that
Leiomyosarcomas do not result due to
malignant changes in fibroids .

5. Etiology
• (B) Hormones 
• Both increase in number and responsiveness of receptors for
estrogen and progesterone appear to promote fibroid
growth, as
1. These are rarely found before puberty,
2. Develop and increase during reproductive period of life and
also during pregnancy,
3. Regress after menopause/ bilateral oophorectomy.
• Found more with hyper estrogenic states like obesity,
increases after SERM therapy in menopausal women,
endometriosis, Cancer endometrium, anovulatory infertility
and early menarche.

6. Etiology
Hormones
• Estrogen induces increased expression of progesterone
receptors thus promoting oncogenic effect of
progesterone.
• Highest mitotic counts are found in fibroid cells when
progesterone concentration is also high.
• GnRH agonist decrease the size of fibroid.
• Concurrent Progesterone and GnRH therapy prevent
regression in size of fibroid.
• Anti progesterone RU486 reduces the growth of
fibroids.

7. Etiology
(C) Growth Factor
• Growth factors, proteins polypeptides promote
growth of fibroids by increasing extracellular
matrix.
• Many growth factors are participating in
proliferation and growth of cells of fibroid 
Tumor Growth Factor-Beta, Basic-Fibroblast
Growth Factor,increased DNA synthesis,
Epidermal Growth factor, Platelet Derived Growth
Factor, Insulin like growth factor, PRL,Vascular
endothelial growth factor etc

8. Locations
• Uterine Body-Intramural or interstitial75%,
submucous15% (sesile /Pedunculated,
subserous 10%( pedunculatd – torsion/
parasitic).
• Cervical <5% primary cervical.
• Ligamenary-Round ligament,utero
ovarian,utero sacral ligament.
• Extrauterine –vagina,vulval

9. • Intravenous leiomyomatosis-polypoid
projections of smooth muscle tumours into
the veins of the parametrium and broad
ligaments.
– Worm-like cords of benign fibrous tissue when
pulled out of the veins.
– Fragments of tumour emboli-obstruction of blood
flow from the atrium and sudden death.
• Disseminated intraperitoneal
leiomyomatosis-
• Large areas of subperitoneal surfaces-
pregnancy and oral contraceptives.

12. Pathology
Gross 
• A typical myoma is a well circumscribed tumor with a
pseudo-capsule. Cut surface is pinkish white and has a
whorled appearance.
• Capsule consists of connective tissue which fixes tumor
with myometrium.
• Vessels that supply Blood to tumor lie in capsule and
send radial branch to the tumor Hence central part of
tumor is comparatively less vascular.
• Calcification at the periphery and spreads inwards along
the vessels(‘Womb-stones’ in graveyards).

17. Microscopic
• Whorled (fascicular) pattern of smooth muscle bundles
separated by well vascularized connective tissue.
• Smooth muscle cells are elongated with eosinophilic or
occasional fibrillar cytoplasm and distinct cell membranes

18. Typical histopathology of fibrod

19. Risk Factors
• Age –
• Endogenous Hormonal factors
• Family History—1st degree relatives have 2.5 times
more risk
• Ethnicity—
• -Body weight—Risk of fibroid increase by 21%
with each 10 kg increase in body weight.
• Diet—diet rich in red meat, ham, beef: increase
the risk of fibroids
-diet with green leafy vegetables decrease the
risk.

20. Risk Factors
• Exercise –regular exercise (7hrs/week)=low risk
• OCS --- no definite relationship.
• Menopausal Hormone Therapy—variable reports
increase when progesterones were added.
• Pregnancy—pre-existing fibroids may enlarge,
undergo red degeneration. Increased parity is
associated with lower incidence and number of
clinically apparent fibroids.
• Smoking----decrease bioavailability of estrogen.
• Tissue injury—may increase the incidence probably
by increasing local production of tissue growth
factors.

21. Symptoms
• Asymptomatic  Fibroid size<5cm / uterine size
<12 cm(42%)
• Abnormal uterine bleeding  menorrhagia > 64%
Meno metrorrhagia present in cases of infected /
ulcerated fibroid.
• Pain Dysmenorrhoea,
– Degenerated fibroid-Pelvic pain
– Torsion-Acute abdomen.

22. • Urinary symptoms  pressure and obstructive
effect on urinary tract
• Secondary symptoms  progressive anaemia due
to chronic blood loss -- CHF, ill-health, loss of
appetite and work capacity.
• Polycythemia due to erythropoiten production.
• Abdominal Lump.

23. Natural History of Fibroids
• Most fibroid grow slowly - 9% growth rate over 12
months, more depending on growth factors rather
than hormones.
• Rapid uterine fibroid growth in premenopausal age
almost never indicate sarcomatous change.
• O.25% women with pre-exisiting fibroid-- pain and
bleeding in their postmenopausal age-- sarcomatous
changes.
• Fibroids may become calcified in menopausal women
or develop variety of degenerative changes.

24. Degenerative Changes
• Hyaline degeneration
• Fatty degeneration
• Red degeneration (Aseptic
Necrobiosis)  in pregnancy,
postpartum
• Saponification
• Cystic degeneration
• Calcification

25. Complications of fibroid
• Hemorrhagic, torsion
• Sarcomatous changes
• Infection/ulceration of pedunculated fibroid
• Association with endometrial Ca, endometriosis,
follicular enlargement of ovaries.
• Inversion of uterus
• Subserosal fibroid sessile  pedunculated 
torsion  acute abdominal pain.
Detached  wandering fibroid  get attached to
other peritoneal structure  parasite Fibroid.

26. CYSTIC DEGENERATION

27. HAEMORRHAGE & CALCIFICATION

28. CALCIFICATION OF FIBROID - RADIOGRAPH

29. RED DEGENERATION OF FIBROID - NECROBIOSIS

30. SARCOMATOUS CHANGE

31. FIBROID WITH ENDOMETRIAL CARCINOMA

32. Diagnosis
• PA Examination—fibroid with uterus larger than
12-14 wks. of gestation are well palpable per
abdomen .
• Surface is irregular nodular, bossed, firm.
• Uterine soufflé due to increased blood supply to
uterus may be audible, it has to be differentiated
from umbilical soufflé.

33. Diagnosis
Pelvic Examination 
• Enlarged uterus
• Associated cystic enlargement of ovary may be
noted.
• Enlarged uterus is firm and non-tender, freely
mobile.
• Enlarged uterus and cervix move together.

34. Imaging
• For symptomatic women, consideration of
conservative therapy, non invasive procedure or
surgery often depends on an accurate assessment of
the size, number and position of fibroids.
• TVS Saline infusion USG, Hysteroscopy, MRI can be
done. Sub mucous fibroids were best identified by
MRI (100%sensitivity, 91% specificity )
• MRI allows mapping: evaluation of number, size
location and proximity to bladder, rectum, tubal
opening in uterine cavity and endometrium, thus
helping in planning surgery.

35. Imaging
• Sonography is the most readily available and
least costly to differentiate fibroids from other
pelvic pathology . It is reasonably reliable for
evaluation of uterus with < 375 cc volume and
4 or fewer fibroids.
• 3D USG is done for exact location of the fibroid.

36. MRI Image showing multiple fibroids

38. USG SALINE SONO-SALPINGOGRAPHY

39. Fertility and Fibroids
1. Submucous fibroids-decrease fertility and
removal increases fertility.
2. Sub serous and intramural fibroid do not effect
fertility but their removal may increase fertility
depending on their location.

40. Fibroid and Pregnancy
Prevalence: 18% based on 1st trimester USG
• Most of fibroids do not increase significantly in
pregnancy.
• Red degeneration of fibroids occurs in 5% cases.
– Purple red color and fishy odour.
– Patient develops pain, fever, local tenderness of fibroid, raised
ESR.
Rx: Bed rest, analgesics and plenty of fluids
• Fetal injury attributed to mechanical
compression by fibroid(0.2%)

41. Influence of fibroids on pregnancy
• Abortions
• Malpresentation
• IUGR
• PROM, Premature onset of labour
• Uterine inertia
• Prolonged labor
• Obstructed labor due to cervical fibroid or incarcerated
fibroid
• APH, Atonic PPH
• Inversion of uterus, sub involution of uterus. Rupture
of Myomectomy scar.

43. Rupture of Myomectomy scar during
pregnancy
• A retrospective study of 412 women who had
abdominal myomectomies reported only one
woman with uterine rupture. (0.2%)
• However trial of labour can be given.

44. Differential Diagnosis
• Pregnancy/ fibroid with pregnancy
• Full Bladder
• Haematometra/Pyometra
• Adenomyosis
• Bicornuate Uterus
• T.O.Mass
• Ch.Ectopic Pregnancy
• Pelvic Endometriosis/Chocolate cyst
• Endometrial Carcinoma/uterine sarcoma
• Ovarian Neoplasms/para- ovarian Cysts.
• Pelvic Kidney.

45. TREATMENT

46. Watchful Waiting
• 3-7%-untreated fibroids in premenopausal women
regress over 6m to 3yrs
• Shrinkage of fibroids and relief-Menopause
– Those approaching menopause may wait for onset of
menopause

47. Medical Therapy
• GnRH Agonist Down regulation and desensitisation of
GnRH receptors.
• Monthly GnRH Agonist given for 6 months
reduced fibroid volume by 30%
• Reduction in uterine size within 1st 3months of
Rx.

49. Medical Treatment
GnRH –Antagonist Classical competitive
blockage mechanism.
Immediate suppression of endogenous GnRh
by daily SC injection 0f Ganirelix results in
30% reduction in fibroid volume within
3wks.
Patient develops Hypo estrogenic symptoms.
Availability of long acting compounds might
be considered for medical treatment prior to
surgery.

50. Medical Treatment
• Estrogen Receptor Antagonist(Fulvestrant)
• Selective Estrogen Receptor Modulators
– Tamoxifen
– Raloxifene
• Selective Progesterone Receptor Modulators
– Mifepristone-Pure antagonist-5-10mg/day
– Ulipristal Acetate-Mixed agonist and antagonist-5mg/day
– For 3months
• Aromatase Inhibitors
– Letrozole

51. Medical Treatment
• Progesterone releasing IUCD Mirena-
Levonorgestrel releasing IUCD –for women of
child bearing age with fibroid associated
menorrhagia and wanting contraception.
• 85% of such women returned to their normal
bleeding within 3 months
• 40% developed reversible amenorrhea at the
end of 1.5-2years .

52. Surgical Treatment
• Myomectomy  Laparotomy , Laparoscopy,
Hysteroscopy.
• Hysterectomy  Abdominal, Non descent
Vaginal
• Uterine Artery occulsion  Embolization

54. Preoperative management
• Severe anemia can be rapidly corrected by :
– Auto transfusion / donor blood transfusion
• Control of bleedingGnRH agonist therapy
• Control of associated medical problems like
hypertension, CHF, Asthma, UTI, kidney or liver
illness.

55. Myomectomy
• Safe alternate to hysterectomy for young women
who have large fibroid and want to retain uterus
, fertility
• “The restoration and maintenance of
physiological function is or should be the ultimate
goal of surgery”-Victor Bonney -1931

56. Myomectomy Indications
• Infertility caused by cornual fibroid blocking
tube.
• Habitual abortion due to sub mucous fibroid.
• Pedunculated fibroid likely to undergo torsion.
• Fibroid (ut size> 12 weeks)
• Broad ligament fibroid pressing on ureter.
• Fibroid pressing over bladder causing retention of
urine / infection.
• Rapidly growing uterine fibroid in post
menopausal women.

57. OPEN MYOMECTOMY

58. LAPROSCOPIC MYOMECTOMY STEPS

59. Hysteroscopic Myoma -resection
• Submucous fibroid < 1/3rd buried in
myometrium to avoid uterine perforation.
• It can be excised either by electric cautery ,
laser or resectoscope.
• It is best done under laparoscopic guidance
line to avoid myometrial perforation.

60. Uterine Artery Embolization(UAE)
• Ravina (1991) first performed it to reduce blood
supply to fibroid, results in reduction in size,
further growth of fibroid reduced and minimum
menstrual blood loss.
– Menorrhagia reduced in 80-90 %
– Pressure symptoms reduced in 40-70%
– Volume decreased by 50% at the end of 3 months.

63. Results and complications of UAE
• Vascularity and size reduced by 40% at 6
weeks and 75% at the end of 1 year.
• Symptoms are relieved in 70% women.
Post operative complications  fever and
infection, vaginal discharge and bleeding ,
unbearable ischaemic pain, pulmonary
embolism, premature ovarian failure if
accidental occlusion of ovarian vessels occur,
fertility rate is reduced due to adhesions, failure
due to incomplete coagulation caused by arterial
spasm or tortuosity of blood vessel.

64. Hysterectomy
Indication  Women over 40 years of age ,
multiparous women, complicated fibroids,
unforeseen difficulties during myomectomy.

65. Newer techniques
• MRI guided per cutaneous laser ablation using
High Intensity focused Ultrasound (HIFU) has
been recently attempted –results are awaited.
• Laparoscopic myolysis  optimal surgery in
multiparous women by using Nd : YAG laser, cryo-
probe or diathermy to coagulate subserous
fibroid . The contraindication are similar to UAE.
Not recommended in those who wish future fertility
• Cervical fibroids preoperative GnRH will shrink
the fibroid. Fibroid enucleation will be easy to
perform myomectomy / hysterectomy, thus
reducing ureteric and bladder injury.

66. • Uterine Artery Occlusion:
Trans vaginal approach.Guided by Doppler
ultrasound auditory signals.
Results not known.
• Magnetic resonance-Guided Focused USG:
• Ultrasound energy can be focused to create
sufficient heat at a focal point so that protein
is denatured and cell death occurs.
• Concurrent MRI precisely targets tissue and
monitoring is done by assessing temp of
treated tissue.
• Not recommended for those wishing future
fertility.

69. Sarcoma Of the Uterus
• Post menopausal growth or onset of
symptoms-high index of suspicion.
• Intramural type-Most common.
– Spindle celled-Leiomyosarcoma
• MOST RECENT STUDIES: Women undergoing
sx for fibroid: 0.25% risk

70. THANK YOU