Uterine Fibroid

Presented By
Dr. Sakila Murmu
 Introduction

 Most common benign tumor of female reprod

uctive system
 Benign neoplasm composed primarily of sm
ooth muscle and connectives tissue
 Incidence

Common in Nulliparous or in those havi

ng One Child Infertility
Prevalence is Highest between Women
of 30-45 years
Usually Asymptomatic
 Increased Risk Factors for Fibroid

• Nulliparity • High Fat Diet

• Obesity • Family History
• Increased BMI
• PCOS
• Hyperestrogenic Sta
te
• Black Women
 Reduced Risk Factors

• Multiparity
• Menopause
• Combined OCPs
• Smoking
 Histogenesis

 It arises from the Neoplastic Single Smooth M

uscle cell of the myometrium
 Chromosomal Abnormality  6th or 7th Chrom
osome (Rearrangements, Deletions)
 Epidermal Growth Factors (EGF), Insulin Like
Growth Factor-1 (IGF-1), Transforming Growth
Factor (TGF) stimulates the growth of Leiomyo
ma either Directly or via Estrogen.
 Growth

• It is predominately an ESTROGEN depen

dent tumour.
• Limited growth during Childbearing Period.
• Increased growth during Pregnancy.
• Frequent association of anovulation
• Do not occur before Menarche.
• Following Menopause there is cessation of
growth & No new growth occur
 Classification

According to the anatomical location：

 Body (Corporeal) 90%

 Cervical 10%
Anatomical Location Classification
 Classification

According to the relationship between m

yoma and uterine myometrium ：

 Interstitial / Intramural 75%

 Subserous / Subperitoneal 15%
 Submucous 5%
Classification
 Classification

multiple myoma
 Pathology

Gross Appearance：

 round, smooth, and usually firm

 false capsule formed by compressed adjacen
t myometrium.
 can be clearly demarcated from the surrounding myometrium
 Centre of the tumour is least vascular and likely to degenerate.
 Pathology

Gross Appearance：

Transverse section :
 light gray
 a whorl-like arrangement or an intermingling
(intertwining) pattern
 Absence of Degenerative changes shows Wh
orled Appearance & Trabeculation due to Inte
rmingling of Fibrous Tissue.
 Pathology

Microscopic examination：
 composed of smooth muscle cells and varying amou
nts of fibrous connectives tissue

 Individual cells are quite uniform in size, spindle sha

ped, have elongated nuclei.

 Non-striated muscle fibers are arranged in interlacin

g bundles of varying size running in different directio
ns.
 Secondary Changes in Fibroids

• Degeneration
• Atrophy
• Necrosis
• Infection
• Vascular Changes
• Sarcomatous Changes
 Degeneration

 Hyaline degeneration (65%)

 Cystic degeneration
 Fatty Degeneration
 Calcific Degeneration (10%)
 Red degeneration
 Sarcomatous change
 Degeneration

Red degeneration

 most common during second half of pregnan

cy and puerperium
 Due to venous thrombosis and congestion wi
th interstitial hemorrhage
 Cut section is Raw Beef appearance, Fishy O
dour due to fatty acids
 Degeneration

← Red degeneration

← Hyaline degeneration
 Degeneration

Sarcomatous change

 malignant
 rare, less than 0.1%
 old women
 enlarge rapidly with irregular vaginal blee
ding
 Degeneration

Sarcomatous change
 Associated Changes in Pelvic Org
ans

Uterous: Myohyperpla Ovary: Enlarged, Cong

sia due to hyperstrenis ested & Studded with
m or work hypertrophy multiple Cysts
Uterine Tubes: Tubal In Ureter: Displacement,
fection Hydroureter, Hydronep
Endometrosis (30%): I hrosis
ncreased Association
 Symptoms of Fibroid

 Asymptomatic (75%)  Subfertility

 Menstrual Abnormality  Recurrent Pregnancy Lo
ss
: Menorrhagia, Metrorr
 Lower Abdomical or Pel
hagia vic Pain
 Dysmenorrhea  Abdominal Enlargemen
 Dyspareunia t
 Symptoms

1. menorrhagia (30%) and prolonged menses

 large intramural myoma
 submucous myoma
2. abdominal enlargement
 Symptoms

4. pressure effects
 pressure bladder or rectum → urinary frequency, con
stipation
 intraligamentous myoma and large cervical myoma →
obstruct ureter
5.others
 infertility
 spontaneous abortion
 abdominal pain
 Signs

• O/E: Pallor
• Per Abdomen: (felt only after 14 weeks or more)
• Palpation: Firm, Hard, Cystic in Cystic Degeneration
• Margin Well Defined
• Surface Nodular
• Restricted Mobility Above Downwards

• Percussion: Dull
 Sign

associated with：
 size
 location
 number
 degeneration

large myoma→ palpable abdominal mass

Pelvic examination：
uterus: enlarged，irregular and hard
 Complications

1. Degeneration
2. Necrosis
3. Infection
4. Sarcomatous Changes
5. Torsion of Subserous Pendunculated Fibroid
6. Haemorrhage (Intracapsular, Intraperitoneal)
7. Polycythemia
 Life Threatening Complications

• Persistent Menorrhagia, Metrorrhagia or V

aginal Bleeding leads to Severe Anaemia
• Rupture Veins  Severe Intraperitoneal H
aemorrhage
• Severe Infection  Septisemia
• Sarcoma
 Investigations

• Ultrasound & Colour Doppler (TVS)

• Saline Infusion Snography
• MRI
• Laparoscopy
• Histeroscopy
• HSG
• Uterine Curattage
Ultrasound
Ultrasound
 Diagnosis

Hysteroscopy
 Diagnosis

Laparoscopy
 Differential diagnosis

 Pregnancy
 Full Bladder
 Adenomyosis
 Myohyperplasis
 Ovarian Tumour
 TO Mass
 Treatment

According to :

 age
 desire for childbearing
 symptoms
 location , size and amount of myoma
 Treatment

Observation and Follow Up

 Small，asymptomatic，especially near meno

pause
 Interval：3～6 months
 Medical management

Indications：

 smaller than 2 months in size

 slight symptoms
 near menopause
 Confirmed diagnosis
 Medical Management

• Antiprogesterone (Mifepristone)
• Antigonadotropins (Danazol)
• GnRH Analogue
• LNG-IUS
• COCs
• Prostaglandin Synthetase Inhibitors
• Selective Progesterone Receptor Modulat
ors (SPRMs)
 Surgical measures

Indications：
 greater than 10 weeks in size
 menorrhagia→ anemia
 pressure effects
 grows rapidly
 failure in medical treatment
 infertility or recurrent abortion
 Surgical measures

Approaches：

laparotomy
hystereoscopy
laparoscopy
 Surgical measures

1. Myomectomy
Laparotomy / Laparoscopy / Hysteroscopy
 preserve fertility, <35 years old
 Indications:
a. Persistent Uterine Bleeding
b. Excessive Pain or Pressure
c. Size > 12 weeks
d. Distortion of Uterine Cavity
e. Recurrent Pregnancy Loss
f. Rapid Growing Myomas
g. Subserous Peducnculated Fibroid
2. Embelotherapy
3. Laparoscopic Uterine Artery Ligation
4. Myolysis
5. Endometrial Ablation
6. Hysterectomy
•Large myoma
•Numerous tumors
•Obviously symptomatic patient
•No wish of preserving fertility
•Suspected to malignant transformation
 Myomas during pregnancy

Impact on pregnancy and delivery ：

 abortion
 preterm labor
 fetal malpresentation
 placenta previa
 birth canal obstruction
 postpartum hemorrhage
 Myomas during pregnancy

Red degeneration

Clinical finding:
 rapid growth of myoma
 pain, fever, WBC↑

Conservative treatment