Medical management of fibroids involves hormonal treatments to control menorrhagia and improve hemoglobin levels before surgery. The objectives are to improve menorrhagia, correct anemia, minimize fibroid size to facilitate surgery, and serve as an alternative to surgery for some patients. Drugs used include iron supplements, NSAIDs, GnRH agonists/antagonists, danazol, and mifepristone. Surgical options include myomectomy to remove fibroids while preserving the uterus, hysterectomy to remove the uterus, and uterine artery embolization to reduce fibroid size and bleeding. The choice depends on desire for future fertility and uterine preservation.

3. Medical management of fibroids
 Fibroid growth is hormone dependent
 Medical treatments mainly involve hormonal
Manipulations
AIM : to control Menorrhagia , Improve
Haemoglobin before surgery
 Iron Therapy for anaemia
 Drugs used to control Menorrhagia :-
Anti fibrinolytic agents
GnRH therapy
Danazol
Clomiphene Citrate
Mirena IUCD
NSAIDs

4. The objectives of medical
treatment are-
 To improve menorrhagia and to correct anemia before
surgery .
 To minimize the size and vascularity of the tumor in
order to facilitate surgery .
 In selected cases of infertility to facilitate
hysteroscopic or laparoscopic surgery .
 As an alternative to surgery in perimenopausal women
or woman with high-risk factors for surgery .

5. DRUGS USED TO MINIMISE
BLOOD LOSS
LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM (LNG-IUS)

6. ANTIPROGESTERONE
 Mifepristone (RU486) is very effective to reduce
fibroid size and also menorrhagia. It may produce
amenorrhea. A daily dose of 25-30 mg is
recommended for 3 months . Long term therapy is
avoided as it causes Endometrial hyperplasia.
Asoprisnil is used with success,it is a selective
progesterone receptor modulator & it does not
cause endometrial hyperplasia.

7. DANAZOL
It administered daily in divided doses
ranging from 200-400 mg for 3 months
minimizes blood loss or even produce
amenorrhea by its antigonadotropin &
androgen agonist actions.

8. GnRH AGONISTS
 Drugs commonly used are- goserelin ,
luporelin , buserelin or nafarelin .
Mechanism of action is sustained pituitary
down regulation and suppression of ovarian
function. Optimal duration of therapy is 3
months.

9. GnRH ANTAGONISTS
Cetrorelix or ganirelix causes
immediate suppression of pituitary and
the ovaries .onset of amenorrhea is
rapid.

10. Advantage of GnRH Analogue

11. Disadvantage of GnRH Analogue

12. PROSTAGLANDIN SYNTHETASE
INHIBITORS
 These are used to relieve pain due to associated
endometriosis or degeneration of the fibroid. They
cannot improve menorrhagia due to fibroids.

13. LEVONORGESTREL-RELEASING
INTRAUTERINE SYSTEM (LNG-IUS)
 It reduces blood loss and uterine size. However, this is
not recommended when the uterine size is >12 weeks
or there is distortion of uterine cavity.

14. Benefits of medical t/t
Pfannenstiel’s incision can be given during total
hystrectomy
Vaginal hystrectomy can be done
Hysteroscopic guided resection can be done

15. Demerits of medical t/t
Expensive
Regrowth after stopping therapy
Difficulty in establishing the surgical plane
between fibroid and surrounding tissue due to
thinning of capsule
Menopausal signs and symptoms

16. Desire future fertility…
 Myomectomy
 Laparotomy – larger fibroids
 Laparoscopic – pedunculated or subserosal fibroids
 Hysteroscopic – submucosal fibroids, >50% in cavity
Desire uterine preservation but not fertility…
 Endometrial ablation
 Uterine artery emboloization (UAE)
No desire for uterine preservation or fertility…
 Hysterectomy (definitive)
 Laparotomy (TAH) – larger fibroids
 Laparascopic (TVH, TLH) – smaller fibroids
Surgical Management

17. MYOMECTOMY
Removal of fibroids leaving behind the uterus
Indications
 Infertile woman
 Woman desirous of child bearing
 Solitary or few fibroids
Pre operative requisites
 Hb should be restored
 Consent for Hysterectomy in difficult unforeseen
circumstances
 Endometrial cancer ruled out by d & c
 Perform in preoovulatory menstrual cycle to reduce blood loss

18. INDICATION OF MYOMECTOMY
1

19. PRE-REQUISITES TO MYOMECTOMY

20. CONTRAINDICATIONS OF
MYOMECTOMY

21. Technique
 Incision - Pfannelstiel incision (uterus <16 -20 weeks
&mobile)
- Vertical paramedian incision (large uterus, fixed
uterus with adhesions, associated PID and endometriosis)
Incision over the anterior abdominal wall

22. Types of Incisions
Vertical Incision
Pfannenstiel Incision

23. Hemorrhage
Controlled by Bonney’s myomectomy clamp
Ovarian vessels occluded by sponge forceps
Rubber tourniquet when myomectomy clamp
cannot be applied
 Capsule incised and fibroid enucleated with help
of myomectomy screw
 Following enucleation haemostasis secured ,
cavity obliterated by several catgut sutures

24. myoma screw Boneys clamp

25. COMPLICATIONS
Primary , Secondary and Reactionary
Haemorrhage
Trauma to bladder , ureter , bowel
Infection
Adhesions
Recurrence of fibroid
Persistence of menorrhagia

26. Types of Myomectomy
Abdominal
Laproscopic
Hysteroscopic
- Removes fibroid through cervix without making
incision
- Submucous fibroid excised by cautery , laser or
resectoscope
 Vaginal (sub mucous fibroid)

27. Laproscopic Myomectomy
Done in
Pedunculated fibroid
Sub serous fibroid < 10 cm
< 4 in number
 Use of unipolar or bipolar cautery or laser
 Fibroma is retrieved through posterior colpotomy
, mini laprotomy , morcellation
Disadvantages
 More bleeding
 Post operative adhesions
 Scar rupture
 Not safe in infertile woman

28. Laparoscopic Myomectomy

30. Hysteroscopic Myomectomy

31. UTERINE ARTERY EMBOLIZATION
 Done pre operatively to reduce vascularity and size of
fibroid
Relief from - Menorrhagia
Pressure symptoms
 Indication - Menorrhagia in multiparous
woman
 Contra indication
Sub serous pedunculated fibroid
 Technique
Done under local sedation
Bilateral UAE through percutaneous
femoral catheterization using polyvinyl
alcohol , gel foam or metal coils

32. Embolization

33. Complications
 Fever
 Infection
 Vaginal discharge and bleeding
 Ischaemic pain
 Pulmonary embolism
 Ovarian failure
 Premature menopause
Advantages
 No major surgery
 No intra operative bleeding
 Short hospital stay

34. HYSTERECTOMY
 Removal of uterus
Indications
 Age >40 years
 Multiparous
 Malignancy
 Uncontrolled haemorrhage during myomectomy
Types
 Abdominal
 Vaginal
 Laproscopic

35. Abdominal Hysterectomy
 Radical Hysterectomy (Complete Removal of
Uterus , cervix , upper vagina and
parametrium)
 Total Hysterectomy(removal of uterus and cervix
without oopherectomy)
 Subtotal Hysterectomy (removal of uterus leaving
cervix in situ)
 Pan Hysterectomy (when ovaries are also
removed)
 Extended and Wertheim’s Hysterectomy

36.  Partial Hysterectomy
 Removes 2/3 of uterus
 Total Hysterectomy
 Removes uterus and
cervix
 Radical Hysterecomty
 Removes uterus, cervix,
and vagina

37. Vaginal Hysterectomy
Done in
 <14 weeks
 Uterus mobile
 No previous surgery
 Uterus size if more than 12 weeks provided uterus is not fixed
by adhesions ,adnexal inflammatory mass or endometriosis by
performing -
 Bi section of uterus removing each half separately
 Myomectomy and enucleation of fibroid first
 Morcellation

38. Complications
 Primary secondary and reactionary haemorrhage
 Trauma to bladder ureter and bowel
 Sepsis
 Anesthetic complications
 Paralytic ileus and intestinal obstruction
 Thrombosis and pulmonary embolism
 Burst abdomen and scar hernia
 Post operative infections
 Abdominal adhesions

39. SEQUELAE OF HYSTERECTOMY
 Dyspareunia and ovarian adhesions to vaginal wall
 Chronic pelvic pain
 residual ovarian syndrome and atrophy
 Vault prolapse
 Ovarian cancer in 1% if ovaries are left behind
 Prolapse of fallopian tube

40. 0THER MODALITIES
Laparoscopic assisted vaginal hysterectomy
Laparoscopic myolysis
• MRI guided percutaneous laser ablation
MRI guided focussed ultra sound (FUS)
surgery

43. Uterine Morcellation