Uterine fibroids by oouth unit b medical students o&g

1. UTERINE FIBROIDS
UNIT C PRESENTATION

2. • Mrs AA is a 42 year old woman who has a large abdominal mass but
no symptoms of heavy period. The smear history is normal.She has
two children but still wishes to retain her fertility as she is planning a
third. She is married, a non smoker and otherwise fit and well. On
examination, the abdomen is distended and there is a pelvic mass
consistent with that of a 20 weeks size pregnancy. Vaginal
examination confirms this and ultrasound scan shows two large
fibroids that are intramyometrial but also subserous.

3. •INTRODUCTION
•EPIDEMIOLOGY
•AETIOLOGYRISK FACTORS
•PATHOLOGY
•CLINICAL FEATURES
•MANAGEMENT
•CONCLUSION
•REFERENCES

4. Introduction
DEFINITION
• Uterine fibroids are benign proliferation of smooth muscle cells of the
uterus
• It is synonymous to fibromyomata, myomata, leiomyomata
• It is the commonest benign tumour of the female genital tract

5. Epidemiology
• Quite high in Nigerian women and the blacks over the age of 25yrs
• Over 80% of the women over the age of 25yrs have fibroids if only of
the size of a seedling
• 3-9 times more commoner in blacks than Caucasian

6. Aetiology
Aetiology is unknown but there are associated risk factors which
include
• Nulliparity
• Africa racial origin
• Obesity
• Positive family history
• Smoking decreases chances of occurrence
• The role of ovarian steroid hormone as etiological factors is now
recognized

7. Cont’d
• Somatic mutation in myometrial cells resulting in progressive loss
of growth regulation
Genetic predispositions
• Clues : ethnic predisposition studies, twin studies and familial
aggregation studies.
• cytogenetic aberrations on chromosome 12, 6, 3 and 7, a ring
chromosome 1.
translocation on chromosomes 12 and 14
[t(12;14)] associated with large fibroids
[del(7)q22q32)] with smaller fibroids

8. Pathology
GROSS PATHOLOGY
• Size
• solitary or multiple
• sessile or pedunculated
• They are rounded in shape especially when confined to the
myometrium
• There is usually a line of cleavage between fibroid and the
myometrium which makes it possible to shell it out at operation
• The cut surface presents white appearance with the characteristic
whorled pattern

9. PATHOLOGY
MICROSCOPY
• Microscopically, tumor cells resemble normal cells (elongated, spindle
shaped, with a cigar-shaped nucleus) and form bundles arranged in a
concentric pattern with different directions (whorled).
• Some fibrous connective tissue may be interspersed between the
muscle bundles.
• These cells are uniform in size and shape, with scarce mitoses.
• There are three benign variants: bizarre (atypical); cellular; and
mitotically active.

10. Sites
• Subserous: when it is beneath the serous covering. Sometimes this
may possess a stalk and may be referred to as pedunculated fibroid
• Interstitial or intramural: when it is within the substance of the
myometrial tissue
• Submucous: when it is beneath the mucous or endometrial lining.
Sometimes this may also develop a stalk and become a fibroid polyp
• Cervical: when it is situated in the cervix. The incidence of cervical
fibroid is quoted as 1-2% of all cases of fibroid
• Broad ligament (intraligamentary): when a subserous fibroid burrows
into the Broad ligament

15. Degenerative changes
• Hyaline degeneration ⅔ of fibriod: it occurs when the fibroid
gradually outgrows its blood supply, and may progress to central
necrosis, leaving cystic spaces.
• Cystic degeneration: this may follow hyaline degeneration. The
hyaline tissue liquefies and forms cystic areas thus making the whole
tumour become soft and cystic.
• Fatty degeneration: this may occur when fat is deposited in a fibroid
and the tumour then assumes a yellowish appearance

16. Degenerative changes
• Red degeneration (Necrobiosis): it follows an acute disruption of the
blood supply to the fibroid during active growth, classically during the
mid-second trimester of pregnancy
• Calcification: fibroids may become calcified and this visible on an X-
ray. This degeneration may occur post-menopausally or secondary to
necrosis
• Sarcomatous change 0.2-0.5%
• Atrophy

17. Clinical Features
• Asymptomatic: most fibroids are usually asymptomatic especially if they
are small
• Symptomatic: symptoms peak in the perimenopausal years and declines
after the menopause. These symptoms include:
• Menorrhagia- this more common with the submucous type.
This can be due to
• increase endometrial surface area
• Endometrial hyperplasia
• Congestion and dilatation of the venous plexus
• Imbalance in the prostaglandin productions as fibroids have been
shown to release a prostacyclin
• Disturbance in the uterine contractility

18. Clinica features
• Abdominal mass- the woman may complain of a swelling in abdomen
or increased abdominal girth if the tumour is a big one
• Irregular bleeding- the menstrual pattern may become irregular and
the bleeding heavy in the presence of fibroid polyp or when a
submucous fibroid becomes ulcerated
• Abdominal pain- causes include red degeneration, torsion, malignant
change, infection of fibroid, compression of pelvic nerves

19. Clinical features
• Pressure symptoms- a large fibroid may compress the surrounding organs
and present corresponding symptoms:
• Bladder- when the bladder is compressed there may be frequency of
micturition or retention of urine
• Rectum- compression of the organs may result in constipation or dyspepsia
• Lymphatics- oedema of the legs is the result of compression of the
lymphatics by fibroid
• Veins- varicosity of the veins in the legs is the result of compression of
veins like the iliac veins
• Nerves- occasionally, pressure on the sacral plexus may cause pain

20. MANAGEMENT
• History taking
• Examination : General examination
• Pallor
• Oedema and varicose veins on the leg
• Abdominal examination
• Findings include:
Firm in consistency and surface is irregular in case of multiple fibroids
• Tenderness may be elicited only if the tumour is undergoing red or
sarcomatous degenerative changes
• Bimanual examination will confirm that that the mass is uterine.

21. Investigations
• Investigations include the following:
Full blood count
Abdominal ultrasound
Diagnostic curettage
Hysterosalpingography
Hysteroscopy

22. INVESTIGATION (Cont’d)
Intravenous urography (IVU)- it is mandatory in a case of large uterine
fibroid for the following reasons:
Presence of hydronephrosis and hydroureter
IVU will show the course of the ureters which is a great advantage to
the surgeon.
Plain X-ray of abdomen: a soft tissue mass may indicate a fibroid
tumour. This may be more diagnostic if areas of calcification are
shown within the tissue mass

23. TREATMENT
• Treatment options depends on:
• Size of the fibroid
• Presenting symptoms
• Reproductive wishes of the woman
• Surgical fitness
• Desire to retain the uterus

24. • Treatment is not required if a fibroid is asymptomatic.
• However fibroids that enlarge the uterus to about 12 weeks
pregnancy size, whether symptomless or not, should preferably be
removed.

25. • Treatment can be
• Medical management
• Surgical management

26. Medical management
INDICATIONS FOR MEDICAL MANAGEMENT
• To control menorrhagia
• For patient that are not ready for surgery
• Unfit for surgery
• To reduce tumour size before surgery
• Perimenopausal patient

27. DRUGS
Gonadotropin releasing hormone analogues: Goserelin, buserelin,
zaferelin, naferelin and leuprolide
• Danazol
• Antiprogestrogen: Mifepristone,
To treat menorrhagia
• Antifibrinolytic: Tranexemic acid
• NSAIDS: mefenamic acid

28. ADVANTAGES
• Shrinks the fibroid before surgery
• Reduce compression symptoms
• Reduce blood loss during surgery
• Allow use of pfannenstiel incision
DISADVANTAGES
• Cost of drugs
• Rebound recurrence
• Loss of cleavage plane
• Prolong use is associated with post menopausal PG

29. SURGICAL MANAGEMENT
• Hysterectomy
• Myomectomy
• Laparoscopic myolysis
• Uterine artery embolisation

30. SURGICAL MANAGEMENT
• Myomectomy
• This is the treatment of choice when patient is desirous of pregnancy.
Indications for myomectomy
• In child bearing age to preserve the uterus.
• Pain
• Pressure effect
• Abnormal bleeding.
• Infertility after other cause have been ruled out – in patients with
unexplained infertility and uterine fibroids, about 20-40% are known to have
conceived after myomectomy.
• Uterine size greater than or equal to 20 weeks.

31. • Because hemorrhage is the most serious complication of myomectomy,it is
important that conscious effort is made to minimize blood loss and its
effect on the patient.
• Preoperatively
• Patient should not be anaemic- pcv not less than 30%.this enhances the
patient”s ability to tolerate any blood loss.
• The timing of the surgery where possible should be in the proliferation
phase of the menstrual cycle when the uterus is less vascular.
• For huge fibroids, gnrh agonists to shrink the fibroid.
• Hemodilution with 2 litres of normal saline

32. • Intraoperatively
• Use of torniquette.
• Minimizing adhesions
• Use of single anteror incision,use of synthetic absorbable sutures
during uterine repair,antibiotic prophylaxis,gentle handling of
tissues,post operative peritoneal lavage.

33. Surgical management (cont’d)
• Hysterectomy .This is the definitive treatment of uterine fibroids.
• Abdominal hysterectomy with bilateral salpingo-oophorectomy is
offered to women with fibroids if they are:
Over 40 years
Have completed childbearing
Perimenopausal
• The procedure is not readily acceptable by our women of childbearing
age for reasons earlier stated

34. Surgical management (cont’d)
• Vaginal hysterectomy
•This operation can be carried out if fibroid is
associated with utero-vaginal prolapse provided the
fibroid is not bigger than 10-12 weeks pregnant size

35. Surgical Management (cont’d)
Polypectomy
This is an operation for the removal of fibroid polyp per vaginam
The stalk or pedicle is ligated as far as up as possible and then
excised distal to the ligature
In some cases, it may be necessary to first carry out dilatation of the
cervical canal.

36. MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND
• Is a non invasive outpatient, procedure that uses high intensity
focused ultrasound waves to ablate the fibroid tissue.

37. COMPLICATIONS OF FIBROIDS
• Degenerative changes
• Hyaline changes
• Red degeneration changes
• Cystic change
• Calcification
• Fatty
• Atrophic
• Sarcomatous
• Infection
• Pain
• Haemorrhage
• Infertility
• Torsion

38. Differential Diagnosis
• Ovarian tumour: this can be differentiated from fibroid
• Pregnancy
• Pelvic inflammatory disease
• Chronic ectopic pregnancy

39. FIBROID AND PREGNANCY
• During pregnancy, fibroids may reduce in size ,grow bigger or flatten out.
• It returns to pre-pregnancy size after the puerperium
• Red degeneration is a common complication in pregnancy especially during
the fifth to seventh months of pregnancy
• The woman usually presents with severe abdominal pain and low grade
pyrexia
• Management consists of bed rest and analgesics

40. FIBROID AND PREGNANCY (CONT’D)
• Other complications are:
• First trimester
Recurrent miscarriages.
• Third trimester
Placenta praevia
Premature labour
Miscarriage
Abnormal lie
Obstructed labour
Malpresentation
Malpositioning
• Postpartum hemorrhage

41. Prognosis
• The recurrence rate of fibroid, if treated by myomectomy, may be as
high as 10 percent especially as a few fibroid seedlings may escape
removal and these may grow to a big size over the next few years
• Some of our women have been known to come back with recurrence
within two or three years
• It is however interesting to note that the rate of fibroid growth cannot
be determined with certainty
• In some women, it grows rapidly while in others, it may be dormant
for years

42. CONCLUSION
• The important factor here is that Mrs AA is asymptomatic and
therefore there is no need for any specific treatment. The other
important feature is that she wishes to retain her fertility and
therefore hysterectomy is contraindicated. Myomectomy is not
necessary unless she has problems conceiving.She should be
counselled that there is a risk of bleeding and that hysterectomy is a
possibilty.

43. REFERENCES
• Gynaecology by Ten Teachers 19th edition.Edited by Ash Monga and
Stephen Dobbs.
• Textbook of Obstetrics and Gynaecology for Medical students. Second
edition.
• Uterine Fibroids by DR M.A LAMINA.
• Uterine fibroids by DR E.O JAGUN.
• Foundations of clincal gynaecology in the tropics. First edition by
PETER N. EBEIGBE.

44. •THANK YOU