This document defines uterine fibroids as benign tumors of smooth muscle origin that develop in the uterus. Fibroids are most common in women ages 35-45 and regress after menopause. While the exact causes are unknown, factors like genetics, hormones, and growth factors may contribute to their development. Fibroids can vary in size and location within the uterus. Common symptoms include abnormal uterine bleeding, pain, and infertility. Diagnosis involves physical examination and ultrasound imaging. Potential complications relate to bleeding, pregnancy outcomes, and pressure on surrounding organs. Treatment options range from conservative approaches like hormonal therapy to surgical procedures like hysterectomy or myomectomy depending on factors like symptoms and desire for future fertility.

1. UTERINE FIBROIDS Masingi UH

2. LAYOUT
Definition
Aetiology
Pathology
Complications
Clinical features
Diagnosis
Treatment

3. INTRODUCTION
Fibroid is a benign(non-concerous) tumour of Müllerian duct origin,
composed of smooth muscle interlaced with fibrous strands.
The tumour can be referred to as leiomyomata, fibromyoma or
myoma
Fibroids are commonly found on the myometrium and can range from
microscopic lesions to big masses that can weigh up to 45kg
Fibroids do not present clinical problems before puberty and should
not grow after menopause

4. INCIDENCE
Occur in 5–25 percent of women over the age of 35 years.
Rare before puberty.
Their peak incidence is between 35 and 45 years of age and they
regress postmenopausally.

5. AETIOLOGY
Not fully understood
May arise from mature myometrial cells, immature muscle in the
myometrium or from embryonic cells in the walls of uterine vessels
Individual fibroids are unicellular in origin
genetics: translocation of chromosome 12 and 14,deletion of chromosome
7, trisomy of chromosome 12.
Rarely growth factors, protein polypeptides produced locally by smooth
muscles and fibroblast promotes its growth by increasing the extracellular
matrix
Growth of fibroids is also linked to influence of hormones like oestrogen and
progesterone
 This is supported by the acceleration of fibroid growth during pregnancy and
hyper estrogenic state(CA endometrium, obesity, emdometriosis) and regression
postmenopausally
 A fibroid uterus has more oestrogen, prostaglandin and progesterone receptors
than a normal uterus

6. TYPES/LOCATION
Site:
Pedunculated
Sub-serous
Intramural
Submucous
Cervical
Prolapsed

7. RISK FACTORS
Early mernache(early estrogen expusure)
Obesity (increased conversion of androgen to estrogen)
Family history-1st degree relative
Polycystic ovarian tumour- due to unopposed oestrogen secondary to
anovulation
Age-increases with reproductive age
Hyper-estrogenic states
diet

8. PATHOLOGY
Macroscopically round tomour,
firm in consistency and whitish in
colour.
When cut it pouts out the
psuedocapsule, it has typical
whorled pattern
Microscopically composed of a
mixture of smooth muscles and
fibrous tissue.
Have a thin outer CT-
psuedocapsule
Blood supply is from peripheral

9. PATHOPHYSIOLOGY
Fibroids begin as a single or multiple seedlings in the myometrium
and grow gradually
Initially growth is in the myometrium(intramural)
Some grow inwards towards the uterine cavity and become
submucosal fibroids, this one can become polyps which sometimes
protrude through the cervical os
Others grow outwards towards the outer surface to become
subserosal and serosal fibroids

10. TYPES OF DEGENERATION
Hyaline and cystic degeneration and calcification
 This occurs in 10% of fibroids, where the tumour outgrows its blood supply
 This leads to avascular necrosis at the centre
 Hyaline degeneration(smooth muscles replaced by fibrous CT) occurs initially at the
centre, extensive hyalinisation leads to liquefaction and cystic degeneration
 In long standing tumors calcium phosphates and carbonates deposit into the
hyalinised portions, this gives rise to stone-hard calcified fibroids that can be easily
identified on radiography
Necrobiosis or red degeneration
 rare and usually occurs as a complication of pregnancy
 Caused by the gravid uterus obstructing venous return which will lead to
intravenous pressure causing rapture of capillaries and extravasation of blood into
the tomour(red appearance)
 In non-pregnant uterus it may be induced by administration of oestrogen or
progesterone

11. TYPES OF DEGENERATION
Sarcomatous degeneration:
 sarcomatous change will occur in 0.2–0.5% of leiomyomata.
 The rapid growth of a leiomyoma and the development of pain should alert the
clinician to the fact that sarcomatous change may be taking place
 Leiomyosarcomata occurs in older women and postmenopausal
 Likely Not to be dependent on hormones
metastasising uterine leiomyoma:
 Metastasising leiomyomata are to all intents and purposes indistinguishable from
benign leiomyomata, except that they spread to other pelvic organs, the omentum
and the lungs.
 Have interlacing bundles like benign leiomyomata

12. CLINICAL FEATURES
Abnormal uterine bleeding-menorrhagia/polymenorrhoea/metrorrhagia
polymeno
Infertility/recurrent miscarraiges- Submucous and intramural may be
responsible for an unfavourable intrauterine environment, resulting in
recurrent abortions and infertility. Intramural and submucous tumours in the
cornua of the uterus may cause infertility due to occlusion.
Abdominal mass
Pain((torsion/myometrial contractions/heaviness/dyspareuria/pressure on
nerves)
Vaginal discharge
Uterine inversion
Pressure effects on bowel and urinary tract(Constipation and/or urinary
retention)

13. DIAGNOSIS
PHYSICAL EXAMINATION(PALPATION) AND ULTRASOUND CAN BE DONE to demonstrate
the myomata and determine the size of the fetus at the same time.
Bimanual: Non-tender mobile lobular pelvic mass
Vaginal Exam: Anterior placement of the cervix towards the pubic symphysis
A calcified fibroid will be seen on radiography
Abdominal/transvaginal/pelvic Ultrasound can also be used to diagnose a fibroid
Laparoscopy
Hysterosalpingography
Endometrial biopsy
The effects of fibriods on the pregnancy depend on the site, size and number.
Myomata of more than 3 cm are associated with increased risk of abortion, pre-term
labour, fetal malpresentations, abruptio placentae, postpartum haemorrhage and pelvic
pain.
Tumours of less than 3 cm have no clinical significance.
However the growth of myomata during pregnancy cannot be accurately predicted.

14. COMPLICATION
Complications of fibroids unrelated to pregnancy
 Anaemia: excessive endometrial bleeding
 Infection: submucous leiomyoma may become infected in the postpartum or
puerperal period. Leiomyomata and PID are commonly associated.
 Torsion: Is a rare complication involving pedunculated leiomyoma. It is part of a
differential diagnosis of an acute abdomen
 Ascites: Altered permeability of pseudocapsule is said to allow transudation of
fluid from the tumour to the peritoneal cavity.

15. COMPLICATION RELATED TO
PREGNANCY
The enlarging uterus may be mistaken for foetal parts
First trimester
 Large for date pregnancy, localised pain secondary to necrobiosis
 Submucosal and large intramural fibroids may cause recurrent miscarriage.
Second trimester
 Necrobiosis and recurrent miscarriage may occur in the second trimester.
Third trimester
 Premature rupture of membranes and premature labour may occur
 Abruptio placentae is a late complication if the placenta implants on a fibroid
 Infrequently, intrauterine growth retardation.
 Higher incidence of caesarean sections due to the abnormal position of the foetus

16. COMPLICATION RELATED TO
PREGNANCY
Intrapartum
Labour complications: include uterine inertia, fetal malpresentation
and
obstruction of the birth canal
During Caesarean section, large leiomyomata in the lower uterine
segment
may make a lower segment incision hazardous, thus indicating a
classical
upper segment approach.
Postpartum
Leiomyomata may interfere with contraction(uterine atony and
retraction, resulting in postpartum haemorrhage.

17. TREATMENT
Conservative treatment
 If the fibroid is small and symptomless
 Patients on conservative treatment should be seen at 3 monthly intervals to assess
the tumour
 Gonadotrophin-releasing hormone agonist-monthy for 3-6months
 NSAIDS (Ibuprofen), Tranexamic Acid
 Depo Provera
 Mirena: <3cm fibroid that does not distort the anatomy
 Oral Contrceptives-treat menorrhagia
 Zoladex
 Anti-progesterones: Mifepristone
 Uterine artery embolisation
 Magnetic resonance-guided focused ultrasound surgery
Surgery
The surgical procedures usually performed for leiomyomata are
abdominal hysterectomy, myomectomy (via laparatomy,laparascopy or
histoscopy) or hysteroscopic resection of submucous myomas

18. TREATMENT
Surgery should be considered under the following conditions:
leiomyoma larger than the size of the uterus, equivalent to a 14
weeks’ gestation
leiomyoma that distorts the uterine cavity in a patient who wishes to
have more children, provided that there are no other causes of
infertility
When the leiomyoma is situated in the lower part of the uterus, which
may complicate labour
When there is doubt about the nature of the leiomyoma
In the presence of complications i.e severe menorrhagia, pain or
pressure on neighbouring organs
Sudden enlargement of a myoma

19. MANAGEMENT SUMMARY

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