uterinefibroid gynaecology easy base of understanding
1. DEPARTEMNT OF GYNAECOLOGY AND
OBSTERTICS
UTERINE
FIBROIDS
DR. D. Y. PATIL HOMOEOPATHIC MEDICAL
COLLEGE AND RESEARCH CENTRE
- DR. RADHIKA KHANDEWAL -
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
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
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.’
21.
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.
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.
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
37. 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
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.
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:
-
Adenomyosi
s
-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
47. MANAGEMEN
T
BODY CERVI
X
ASYMPTOMATIC SYMPTOMATIC
SURGICA
L
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.
SURGER
Y
FOLLOW UP
48. SYMPTOMATIC
MEDICA
L
SURGICA
L
INDICATION
S
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.
TREATMEN
T
•Treat anaemia-
Haematinics.
•Fibrinolytics- Tranexemic
acid.
•Antiprogesterone-
Mifepristone ( RU 486)
•- Danazol.
•Gnrh agonist- Goserlin, Luporelin
Naferelin, Buserelin.
•Gnrh antagonist- Cetrorelix, Ganirelix.
•Pg synthetase inh- NSAID’s.
•Progesterone releasing IUD.
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
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
