KABWE CENTRAL HOSPITAL

OBGYN
“UTERINE FIBROIDS”
Wisdom’s Lecture Notes

Banda Wisdom Chilufya

DEFINATION
• Uterine fibroids are well circumscribed
benign tumors
• It the commonest tumor of the female
genital tract being present in al least in
30% of women over the age of 30
• The peak age of presentation is between
35 and 45 years
Pathology

• A leiomyoma or fibroid is derived mainly from

smooth muscle contain a variable amount of fibrous
tissue.
• Although well circumscribed fibroids have no true
capsule a layer of compressed uterine muscles
surrounding each neoplasm form a pseudo
capsule.
• Fibroids may occur single but they are more often
multiple
Who gets fibroids

• 20 - 30 % of women over 30 yrs have them

• early menarche
• overweight
• nulliparas
• sedentary life
• HRT -recurrence after shrinkage
According to their location fibroids are divided to

• (1) Subserousal
– Project from the uterus into the peritoneal cavity
– Sometimes pedunculated
– Least likely to cause symptoms
– pedunculated fibroid may lose their attachment and gain
a secondary blood supply usually from the omentum and
called parasitic fibroid
• (2) Submucous (~5% of all fibroids)
– Project into the uterine cavity
– Sometimes become pedunculated to form a fibroid polyp
– Most likely to cause symptoms
(3) Intramural
– Most common
– Occupy central portion of uterine muscle
– Usually multiple
(4) Cervical fibroid
-developing from the musculature of the cervix.
(5) intraligmentous
-grow laterally between the two leaves of the broad
ligament.
Complications of fibroids

• (1) degeneration
• -occurs because of interference with the blood
supply of the tumor. The tumor becomes
painful, tender, soft and enlarged
• 1) hyaline degeneration
• -present to some degree in most moderate
to large size fibroids. Some of the tissue are
replaced by structureless homogeneous
substance
• 2) cystic degeneration
• - the hyaline material liquefies leaving ragged
cavities filled with colourless or blood stained
fluid
• 3) fatty degeneration
• 4) calcification
• -usually follow fatty degeneration. More
common in subserous fibroids and more
common after the menopause
• 5) red degeneration
-mostly seen during pregnancy and puerperium
typically at about mid pregnancy
- it is due to infarction of the centre of the tumor.
- the fibroid suddenly becomes painful, tender and
enlarged.
- the patient becomes ill with vomiting and slight
fever. Treatment is conservative (analgesia)
• 6) sarcomatous degeneration (malignant change)
• - occur in under 0.5% of cases
• - the fibroids may grow suddenly and becomes
painful and tender
• (7) infection
• -submucous myoma nearly always becomes
ulcerated and infected at its lower pole
• - infection of fibroid of other site usually precedes
necrosis, it occur following abortion or labour.
• (8) torsion
• -occur in polyps and pedunculated fibroids
• (9) polycythaemia
• - is rare complication
• -usually with large intraligamentous fibroid
• - the explanation is either the tumor itself produces
erythropoietin or it press on the kidney to produce
erythropoietin
Effect of pregnancy on fibroid

• -- during pregnancy fibroids often enlarge and

become soft
• -- they are more liable to become complicated by
red degeneration
• -- torsion of pedunculated fibroid may occur
antepartum but is more likely to occur early in the
puerperium when there is rapid uterine involution
and laxity of the abdominal wall
Effect of fibroid on pregnancy

• -- subfertility
• --abortion and preterm labour
• --mal presentation
• --rarely obstructed labour
• -- post partum haemorrhage
• --delayed involution of the uterus
Symptoms of fibroids :

• None ,small
• Prolonged heavy cycles -menorrhagia in 25% of
women - leads to anaemia
• Pain : abdominal or backache
• Distention & heaviness by large fibroids
• Frequency or urgency
• Pressure on ureters - blockage
• Pressure on rectum- constipation
 Investigation of Fibroids
• (1) Ultrasound
– With expertise and the use of vaginal probe it is possible to get
an accuracy of 80%
• (2) MRI
• - allow for better differentiation between an
ovarian mass & a fibroid uterus
• (3) laparoscopy
• - Direct visualization can be important
• (4) Hysteroscopy
• -important in the assessment of infertility and
recurrent miscarriage
Treatment options of fibroids

• (1) conservitive
indication
-when the tumors are small, the diagnosis is certain,
and there are no symptoms
• - during pregnancy
• - near the menopause when there are no
symptoms and the tumor is not enlarging
(2) Surgical treatment

• Surgical treatment is indicated

• 1) the fibroid are causing symptoms
• 2) fibroid are growing rapidly
• 3) they are larger than the size of 16 weeks
pregnancy
• 4) the diagnosis is in doubt
• 5) they are likely to complicate a future pregnancy
1) Hesterectomy

• Is the definitive treatment of fibroids

• With this procedure recurrence of fibroids is
therefore avoided
• Usually through the abdominal route however the
vaginal approach can be attempted in selected
cases
2) Myomectomy

• Advocated in young women wishing to conserve

their fertility
• Recurrence rate can be as high as 10%
• Postoperative morbidity ( bleeding, adhesive
intestinal obstruction) is higher than with
hysterectomy
Medical treatment of fibroids

• 1) Gn RH analogues
• -- can reduce the size of fibroid by 50% within
three months
• -- on cessation of treatment the base line volume
return within 6 months
• -- because of the risk of osteoporosis such
treatment cannot reasonably be continued for more
than 6 months
Treatment -cont.

• Gn RH agonists –eg goselerin acetate (zoladex),

nafarelin, block release of LH&FSH and eventually
reduce oestrogen production
• Androgens : Danazol -may cause androgenic features
 Indications of medical treatment

• 1- can be used while the patient is waiting for

surgical treatment, they reduce size, reduce
anemia and the need for blood transfusion and
reduce intraoperative blood loss.
• 2- GnRH may allow shrinkage such that a vaginal
hystrectomy can be done
• 3- around the menopause GnRH may provide
symptomatic relief until natural menopause occur
• The antiprogesterone mifepristone has also been
shown to decrease the size of the uterine fibroid
and their blood flow similarly to GnRH analogues