UTERINE FIBROIS

SUBJECT: Nursing education

TOPIC: Uterine fibroid
MEDIUM: English
DATE: 10/05/2023
TIME: 11:AM
PLACE: S.S Agrawal college of nursing and research centre
NUMBER OF STUDENT: 05
METHOD OF TEACHING: Presentation,
AV. AIDS: Model, PPT, chart, flash card.
OBJECTIVES:
➢ General objective:
At end of the session group will be able to understand about uterine fibroid.
➢ Specific objective:
At the end of the session group will be able to…..

✓ Define uterine fibroid

✓ Explain histogenesis of uterine fibroids
✓ Discuss the Growth of Leiomyomas
✓ Explain types of uterine fibroids
✓ Explain pathology of uterine fibroids
✓ Discuss the degeneration of the uterine fibroid
✓ Described the Associated Changes in the Pelvic Organs
✓ State clinical feature of uterine fibroid
✓ Discuss complication of uterine fibroid
✓ Explain investigation of uterine fibroid
✓ Explain management of uterine fibroid.
Sr. time Specific Content Teaching A.V. Aids Evaluation
no objectives learning
activity
1. 2 min Define LEIOMYOMAS (Uterine fibroid) Explanation Ppt What is definition
uterine of uterine fibroid ?
fibroid Leiomyomas are the most common benign tumors of the
uterus and also the most common benign solid tumor in
female. Histologically, this tumor is composed of smooth
muscle and fibrous connective tissue, so named as uterine
leiomyoma, myoma or fibromyoma.

2. 5 min Explain the HISTOGENESIS Explanation Ppt How uterine

histogoly of fibroid is
uterine Origin occurred?
fibroid
The etiology still remains unclear. The prevailing
hypothesis is that, it arises from the neoplastic single
smooth muscle cell (myocyte) of the myometrium. Thus
each myoma is monoclonal. The stimulus for initial
neoplastic myocyte transformation is not known. The
following are implicated:

■Chromosomal abnormality: In about 40% of cases,

there is a varying type of chromosomal abnormality,
particularly the chromosome seven (17%) or twelve (12%)
(rearrangements, deletions). Somatic mutations in
myometrial cells may also be the cause for uncontrolled
cell proliferation.

■Role of polypeptide growth factors: Epidermal growth

factor (EGF), insulin-like growth factor-1 (IGF-1),
transforming growth factor-ẞ (TGF-β), stimulate the
 growth of leiomyoma either directly or via estrogen. A
positive family history is often present.

3 10 min Discuss the GROWTH OF LEIOMYOMA Explanation Chart How to grow

Growth of uterine fibroid?
Leiomyomas Leiomyoma-predominantly an Estrogen independent
Tumor

Both estrogen and progesterone receptors are found in

higher concentrations in myomas.

Myomas cells have higher levels of the enzyme

aromatase.

This increases the high local levels of estrogen.

Are rare before menarche and majority decreases in size

following menopause.

They often enlarge during pregnancy. Hypoestrogenic

conditions (GnRH agonist use) reduces the size of
myomas.

Hypercellularity of myomas (cellular leiomyomotas) are

less common (<5%).
Cellular myomas are often larger in size.

Clinical presentation is more close to a sarcoma

(leiomyosarcoma).
 However, most cellular leiomyomata have a benign
course
and prognosis.

Myoma cell contains more estrogen receptors than the

adjacent myometrium.

Frequent association of anovulation.

The growth potentiality is not squarely distributed amongst

the fibroids w which grow faster than the others. On the
whole, the rate of usually multiple, growth is slow and it
takes about the years for the fibroid to grow sufficiently
about 3-5 years - ovarian tumor grows in months).

However, the fibroid grows rapidly during pregnant to

malignant may also be due to degeneration of due to
malignant change. The newer low dose oral contraceptives
may reduce the size.

4 10 min Explain types TYPES: Explanation Ppt How many types

of uterine of uterine fibroid?
fibroids. ❖ Body
❖ Cervical

Body:

The fibroids are mostly located in the body of the uterus

and are usually multiple.

Interstitial or Intramural (75%)

Initially, the fibroids are intramural in position but
subsequently, some are pushed outward or inward.
Eventually, in about 70%, they persist in that position.

Sub peritoneal or Subserous (15%)

In this condition, the intramural myoma is pushed

outwards towards the peritoneal cavity. The fibroids are
either partially or completely covered by peritoneum.

When completely covered by peritoneum, it usually attains

a pedicle-called pedunculated subserous myoma.

On rare occasion, the pedicle may be torn through; the

fibroid gets its nourishment from the omental or
mesenteric adhesions and is called 'wandering' or 'parasitic'
fibroid. Sometimes, fat percumaral fibroid may be pushed
out in between the In of broad ligament and is called broad
ligament myoma (false or pseudo).
These myomas are difficult to differentiate from a solid
ovarian tumor. These myoma may cause hydroureter.
Leiomyomas may cause pseudo- Meig's syndrome
Submucous (5%)

The intramural fibroid when pushed toward the uterine

cavity, and is lying underneath the endometrium, it is
called submucous fibroid. Submucous fibroid can make
the uterine cavity irregular and distorted.

Pedunculated submucous fibroid may come out through

the cervix
It may be infected or ulcerated to cause metrorrhagia.
Although, this variety is least common (about 5%) but it
produces maximum symptoms including infertility man
miscarriage.

Cervical

Cervical fibroid is rare (1-2%). In the supravaginal part of

the cervix, it may be interstitial or subperitoneal variety
and rarely polypoidal. Depending upon the position, it may
be anterior, posterior, lateral or central. Interstitial growths
may displace the cervix or expand it so much that the
external os is difficult to recognize. All these disturb the
pelvic anatomy, especially the ureter.
In the vaginal cervix, the fibroid is usually pedunculated
and rarely sessile.

BODY OR CORPOREAL FIBROIDS

PATHOLOGY

Naked Eye Appearance

The uterus is enlarged; the shape is distorted by multiple

nodular growth of varying sizes. Occasionally, there may
be uniform enlargement of the uterus by a single fibroid.
The feel is firm.
Cut surface of the tumor is smooth and whitish. The cut
section, in the absence of degenerative changes, shows
features of whorled appearance and trabeculation. These
are due to the intermingling of fibrous tissues with the
muscle bundles.
 The false capsule is formed by the compressed adjacent
myometrium. They have more parallel arrangement and
are pinkish in color in contrast to whitish appearance of the
tumor.

The capsule is separated from the growth by a thin loose

areolar tissue. The blood vessels run through this plane to
supply the tumor. It is through this plane that the tumor is
shelled out during myomectomy operation.
The periphery of the tumor is more vascular and have more
growth potentiality. The center of the tumor is least
vascular and likely to degenerate. It is due to contraction
of the false capsule that makes the cut surface of the tumor
to bulge out.

Microscopic Appearance

The tumor consists of smooth muscles and fibrous

connective tissues of varying proportion. Originally, it
consists of only muscle element but later on, fibrous tissues
intermingle with the muscle bundles. As such, the
nomenclature of 'fibroids' although commonly used, is
inappropriate and should better be called either myomata
or fibromyomata.

4. 10 min Discuss the SECONDARY CHANGES IN UTERINE Explanation Flash card What types of
degeneration FIBROID degeneration is
of the uterine occurred?
fibroid? DEGENERATIONS
The arterial supply of myomas is less compared to a same
sized area of normal myometrium. Degenerations occur as
the tumor out grows its blood supply.

Hyaline degeneration is the most common (65%) type of

degeneration affecting all sizes of fibroids except the tiny
one. It is common especially in tumors having more
connective tissues. The central part of the tumor which is
least vascular is the common site.

Naked eye examination on the cut surface shows irregular

homogeneous areas with loss of whorl-like appearance.

Microscopic examination reveals hyaline changes of both

the muscles and fibrous tissues.

Cellular details are lost.

Cystic degeneration usually occurs following menopause

and is common in interstitial fibroids. It is formed by
liquefaction of the areas with hyaline changes. The cystic
spaces are lined by irregular ragged walls. The core big
fibroid may be confused with an ovarian cyst or pregnancy.

Fatty degeneration is usually found at or after menopause.

Fat globules are deposited mainly in the muscle cells.

Calcific degeneration (10%) usually involves the

subserous fibroids with small pedicle or myomas of
postmenopausal women. It is usually preceded by fatty
degeneration. There is precipitation of calcium carbonate
or phosphate within the tumor.
When whole of the tumor is converted into a calcified
mass, it is called "womb stone".

Red degeneration (carneous degeneration) occurs in a large

fibroid mainly during second half of pregnancy and
puerperium (5-10%).

Partial recovery is possible and as such called necrobiosis.

The cause is not known but is probably vascular in origin.
Infection does not play any part.

Naked eye appearance of the tumor shows dark areas with

cut section revealing raw-beef appearance often containing
cystic spaces. The odor is often fishy due to fatty acids.

Color is due to the presence of hemolyzed red cells and

hemoglobin.

Microscopically, evidences of necrosis are present.

Vessels are thrombosed but extravasation of blood is

unlikely.

Atrophy: Atrophic changes occur following menopause

due to loss of support from estrogen. There is reduction in
the size of the tumor. Similar reduction also occurs
following pregnancy enlargement.
Necrosis: Circulatory inadequacy may lead to central
necrosis of the tumor. This is present in submucous polyp
or pedunculated subserous fibroid.
Infection: The infection gains access to the tumor core
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.

5 5 min Described the Associated Changes in the Pelvic Organs Explanation Chart How many organs
Associated are affected?
Changes in Uterus: The shape is distorted; usually asymmetrical but
the Pelvic at times, uniform. Myohyperplasia is almost a constant
Organs finding. It may be due to hyperestrinism or work
hypertrophy in an attempt to expel the fibroid.

The endometrium may be of normal type. In others, there

are features of anovulation with evidences of hyperplasia.
There is dilatation and congestion of the myometrial and
endometrial venous plexuses.

The endometrium as a result becomes thick, congested,

and edematous. The endometrium overlying the
submucous fibroid may be thin and necrotic with
evidences of infection.

The uterine cavity may be elongated and distorted in

intramural and submucous varieties.

Uterine tubes: The frequent tubal infection (about 15%)

detected in association with fibroid seems coincidental.

Ovaries: The ovaries may be enlarged, congested, and

studded with multiple cysts. The cause may be due to
hyperestrinism.
 Ureter: There may be displacement of the anatomy of the
ureter in broad ligament fibroid. The compression effect
results in hydroureter and or hydronephrosis.

Endometriosis: There is increased association of pelvic

endometriosis and adenomyosis (30%). Endometrial
carcinoma: The incidence remains unaffected.

6 5min State clinical CLINICAL FEATURES Explanation Flash card What are the
feature of clinical feature of
uterine Asymptomatic – 75% uterine fibroid?
fibroid. Abnormal uterine bleeding – 30%
- Menorrhagia, metrorrhgia
Dysmenorrhea
Dyspareunia
Subfertility
Pressure symptoms (bladder, ureter, rectum)
Recurrent pregnancy loss
Lower abdominal and pelvic pain
Abdominal enlargement

7 5 min Discuss COMLICATION Explanation Flash card What are the

complication complication of
of uterine Degeneration: uterine fibroid?
fibroid. - Hyaline (65%)
- Cystic
- Fatty
- Calcification
- Red
- Necrosis
Necrosis
Infection
 Sarcomatous change
Hemorrhage
- Intra capsular
- Rupture surface vein of subserous fibroid
Polycythemia due to
- Erythropoietic
- Altered Erythropoietic function of the kidney
through uterine pressure
Persistent menorrhagia
Severe intra peritoneal hemorrhage
Sarcoma

8 7min Explain INVESTIGATION Explanation Ppt What are the

investigation investigation done
of uterine To confirm diagnosis: to find out uterine
fibroid. fibroid?
- Ultrasound and color doppler
- Saline infusion sonography
- Hysteroscopy
- HSC
- MRI
- Laparoscopy
- Uterine curettage

9 10 min Explain MANAGEMENT Explanation Ppt How to manage

management uterine fibroid?
of uterine Asymptomatic management
fibroid. - Observation
- Surgery
Symptomatic management
1. Medical management
To minimize blood loss
 - Antiprogesterone
- Selective progesterone receptor modulator
- Danazol
- GnRH agonist
- GnRH antagonist
Nonhormonal management
- Tranexamic acid
- Aromatase inhibitors
- Prostaglandin synthetase inhibitor
2. Surgical management
Myomectomy
- Laparotomy
- Laparoscopy
- Hysteroscopy
- Robotic
Embolotherapy
Laparoscopic uterine artery ligation
Myolysis
Endometrial ablation
Hysterectomy
 SUMMARY
At the end of the session I summarise the topic of uterine fibroid including definition,
histology, types, secondary changes, associate changes of pelvic organs, clinical feature,
complications, investigation and management.

BIBLIOGRAPHY
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agency ,New delhi.
2) Buckly Kathleen and Kulb Nancy, “High Risk Maternity Nursing
Manual”,2ndedition;1993, Williams and Wilkins publication, Maryland.
3) Mudaliar and Menon’s, “Clinical obstetrics” ,9thedition ;1997, published by orient
Longman, Chennai.
4) Myles, “Text book for Midwives”,15thedition;2009, published by Churchill livinstone
China.
5) Parulkar Shashikant, “Text book for Midwives”,2nd edition;1995, Voramedical
publication, Bombay,