Fibroids

Dr F Hove
 benign smooth muscle tumors of the
uterus
 The most common uterine tumor
 About 20% to 80% of women develop
fibroids by the age of 50
 Occurring in about 30% of women
above the age of 30 years.
Risk Factors
 Age:
◦ 30-40 years.
◦ Rare before 30 or after 40 years
 Parity:
◦ Common in nulliparas, patients with low parity.
◦ It is rare in multiparas.
 Race:
◦ 3-9 times more common in black race
 Family history:
◦ Usually positive.
Fibroids are more common in obese women.
Smoking lowers the risk
Current use of oral or injectable contraception is associated
with a two thirds reduced risk.
Pathogenesis
 The cause of remain unknown.
 arises from a single neoplastic cell within
the smooth muscle of the myometrium.
 estrogen and progesterone have a
mitogenic effect
 sex steroids promote development of
leiomyomas by stimulating inappropriate
expression of growth factors.
 progesterone that influences the
proliferation of leiomyoma more than
estrogen.
classification
Fibroids

Uterine Extrauterine
[99%] [1%]

Corporeal Cervical
Genital Extragenital
[95%] [4%]

Interstitial Parasitic
[60%] Fibroid

Submucous
Others
[ 20%]

Subserous
[15%]
Chracteristics
 Size
◦ from microscopic to very huge size filling the whole abdominal cavity
 Shape
◦ Spherical, flattened, or pointed according to the type.
 Cut section:
◦ On cut section,, whorly in appearance, and more pale than the surrounding
uterine muscle.
 Consistency:
◦ firmer than the surrounding myometrium.
◦ Soft fibroid occurs in pregnancy, cystic changes, vascular, inflammatory, and
malignant changes.
◦ Hard fibroid occurs in calcification.
 Capsule:
◦ Is a pseudo-capsule formed by compressed normal surrounding muscle fibres.
◦ the blood supply comes through it,
◦ it is the plain of cleavage during myomectomy
◦ its presence differentiate the myoma from adenomyosis.
 Blood supply:
◦ Nourishes the myoma from the periphery,
◦ The tumor itself is relatively avascular.
presentation
 Asymptomatic:
◦ Accidentally discovered during examination.
◦ It is the commonest presentation, especially in subserous and
interstitial fibroids.
 Vaginal bleeding: It is the commonest symptom,
◦ Menorrhagia or polymenorrhea: (commonest): This occurs due
to:.
 Swelling:
◦ Either abdominal swelling due to large fibroid or vaginal swelling
due to a polyp.
 Infertility
 Pain: uncommon
 Pressure symptoms
examination
 General examination:
◦ signs of chronic anemia.
 Abdominal examination:
◦ large pelvi-abdominal swelling in huge
fibroids.
 Pelvic examination:
◦ symmetrically or asymmetrically enlarged
uterus.
 Speculum examination
◦ fibroid polyp.
investigations
 Ultrasound
◦ Frequently misdiagnosed with this modality
◦ “Multiple small fibroids” is usually irrelevant
◦ Heterogenous echolucency is normal in a parous uterus
◦ Adenomyosis can look the same
◦ Size and location important
◦ Can be a “contraction wave” in pregnancy
 MRI better than CT Imaging
 Laparoscopy and Hysteroscopy
 Saline hysterography
◦ Useful for pedunculated submucous fibroids
management
 Conservative Management
◦ small asymptomatic fibroid,
◦ fibroid in pregnancy or puerperium.
Surgical Management
Medical Management
radiological
Medical Managment
 NSAIDs can be used to reduce
painful menstrual periods.
 Oral contraceptive pills may be
prescribed to reduce uterine bleeding
and cramps
 Anemia may be treated with iron
supplementation.
 Levonorgestrel intrauterine devices
are effective in limiting menstrual
blood flow
 Gonadotropin-releasing hormone
analogs cause temporary regression
of fibroids by decreasing estrogen
levels
 Danazol is an effective treatment to
shrink fibroids and control symptoms.
 Ulipristal acetate is a synthetic
selective progesterone receptor
modulator (SPRM)
Surgical management
• Indications:
• Symptomatic cases or uterus larger
than 12 weeks size.
• Suspected malignancy (rapidly
enlarging or post-menopausal
growth).
• Multiple huge fibroids liable to
complications.
• Infertility.
myomectomy
 Abdominal Myomectomy
 Vaginal Myomectomy
 Endoscopic Myomectomy
◦ Hysteroscopic
◦ Laparoscopic
 Myomectomy aims at
◦ removal of all the myomas,
◦ with conservation of a functioning uterus to
preserve the reproductive function.
 Generallythe morbidity is higher than
those with hysterectomy.
◦ It is associated with much blood loss
◦ Liability of recurrence of fibroid
Hysterectomy
 Patient around 40 years, and completed
her family.
 The number or site contraindicate
myomectomy
 Severe bleeding during myomectomy.
 Major damage of the uterus by
myomectomy which affects its function
for pregnancy.
 Recurrent fibroids.
 Suspicious of malignancy
Alterna tive thera py
 Radiofrequency ablation is a minimally invasive
treatments for fibroids
 In this technique the fibroid is shrunk by inserting a needle-
needle-like device into the fibroid through the abdomen and
and heating it with radio-frequency (RF) electrical energy to
energy to cause necrosis of cells.
 The treatment is a potential option for women who have
fibroids, have completed child-bearing and want to avoid a
avoid a hysterectomy.

 Magnetic resonance guided focused ultrasound, is a

a non-invasive intervention (requiring no incision) that uses
high intensity focused ultrasound waves to destroy tissue
 Uterine artery embolization (UAE) is a noninvasive
procedure that blocks of blood flow to fibroids and thus can
treat them
Fibroids and pregnancy
 In most women there is no effect
 80% remain unchanged in size
 Rarely rapid growth and red degeneration
 Increased risk of bleeding and threatened
preterm delivery
◦ But most deliver at term
 Fibroid in the lower segment can interfere with
vaginal birth
 Myomectomy at the time of Caesarean is not
wise
◦ 30% require emergency hysterectomy