UTERINE FIBROIDS

BY: DR DOLAPO ADU

 OUTLINE
1. INTRODUCTION
2. INCIDENCE OF UTERINE FIBROIDS
3. RISK FACTORS
4. ETIOPATHOGENESIS
5. DIAGNOSIS
6. MANAGEMENT AND COMPLICATIONS
7. REFERENCES
INTRODUCTION
A fibroid is a benign tumour of uterine smooth muscle termed a
‘leiomyoma’. It is the commonest benign tumor of the uterus and also
the commonest 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]
The gross appearance is of a well-demarcated, firm, whorled tumour.
They are usually multiple and can substantially increase the size of the
uterus.[1] They contain large aggregation of extracellular matrix
consisting of collagen, elastin, fibronectin and proteoglycan.
 INCIDENCE
• Uterine fibroids are highly prevalent, being found in approximately 40% of
women overall, and are more common in nulliparous and obese women
and in those with a family history or of African descent. [1]
• The incidence of uterine fibroid depends on age and race.[3] It is quite high
in Nigerian women with over 80% of those above 25 years of age having
fibroids if only of the size of a seedling.[4] The vast majority of these
fibroids are not symptomatic. Fibroids are more common among blacks, 3–
9 times more than in Caucasians. They occur after menarche and the
majority would undergo atrophy at menopause.
• They are more common in nulliparous or in those having one child
infertility. The prevalence is highest between 35–45 years.[2]
PATHOGENESIS
PATHOGENESIS
It is predominantly an estrogen-dependent tumor. Estrogen and progesterone is
incriminated as the cause. Estrogen dependency is evidenced by:
1. Growth potentiality is limited during childbearing period.
2. Increased growth during pregnancy.
3. They do not occur before menarche.
4. Following menopause ,there is cessation of growth and there is no new
growth at all.
5. It seems to contain more estrogen receptors than the adjacent myometrium.
6. Frequent association of anovulation.

The growth potentiality is not squarely distributed amongst the fibroids which
are usually multiple, some grow faster than the other
TYPES OF FIBROIDS
1. Interstitial or intramural (75%)- Initially, the fibroids are intramural in position
but subsequently, some are pushed outward or inward. Eventually, in about 70
percent, they persist in that position.
2. Subperitoneal or subserous (15%)- In this condition, the intramural fibroid 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 fibroid.
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, the intramural fibroid may be
pushed out in between the layers of broad ligament and is called broad
ligament fibroid (false or pseudo).
3. 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.
4. 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, specially the ureter.In the vaginal cervix, the fibroid is usually
pedunculated and rarely sessile.

5. Pseudocervical fibroid: A fibroid polyp arising from the uterine body

when occupies and distends the cervical canal, it is called pseudocervical
fibroid.
 DIAGNOSIS
1. HISTORY-
Presenting Symptoms:
Most fibroids are small and asymptomatic, but they can be associated with the following conditions:
A. Menstrual Abnormalities:
(a) Menorrhagia(30%) is the classic symptom of symptomatic fibroid. The menstrual loss is progressively
increased with successive cycles. It is conspicuous in submucous or interstitial fibroids. The causes are:
• Increased surface area of the endometrium (Normal is about 15 sq cm).
• Interference with normal uterine contractility due to interposition of fibroid.
• Congestion and dilatation of the subjacent endometrial venous plexuses caused by the obstruction of the
tumor.
• Endometrial hyperplasia due to hyperestrinism (anovulation).
• Pelvic congestion.™ Role of prostanoids—imbalance of throm-boxane (TXA2) and prostacyclin (PGI2)
with relative deficiency of TXA2.
B.) Metrorrhagia or irregular bleeding may be due to:
• Ulceration of submucous fibroid or fibroid polyp.
• Torn vessels from the sloughing base of a polyp.
• Associated endometrial carcinoma.

C.) Dysmenorrhea: The congestive variety may be due to associated pelvic

congestion or endometriosis. Spasmodic type is associated with extrusion
of polyp and its expulsion from the uterine cavity. Subserous, broad
ligament or cervical fibroids are usually unassociated with menstrual
abnormalities
B.) Infertility: Infertility (30%) may be a major complaint. The probable known
attributing factors are:
1. Uterine:
• Distortion and or elongation of the uterine cavity → difficult sperm ascent.
• Preventing rhythmic uterine contraction due to fibroids during intercourse
→ impaired sperm transport.
• Congestion and dilatation of the endometrial venous plexuses → defective
nidation.
• Atrophy and ulceration of the endometrium over the submucous fibroids →
defective nidation.
• Menorrhagia and dyspareunia.
2. Tubal- Cornual block due to position of the fibroid.
• Marked elongation of the tube over a big fibroid.
• Associated salpingitis with tubal block.
3. Ovarian:
• Anovulation
4. Peritoneal:
• Endometriosis
5. Unknown—(majority)

Pregnancy-related problems : like abortion, preterm labor and intrauterine growth

restriction are high. The reasons are defective implantation of the placenta, poorly
developed endometrium, reduced space for the growing fetus and placenta. Red
degeneration and torsion of subserous pedunculated fibroid is common in
pregnancy. Labor dystocia, postpartum hemorrhage are also more.
• Pain lower abdomen- Fibroids are usually painless. Pain may be due to
some complications of the tumor or due to associated pelvic pathology.
Due to tumor: -Degeneration. - Torsion subserous pedunculated fibroid -
Extrusion of polyp.
Associated pathology: - Endometriosis. -PID
• Abdominal swellings (lump)- The patient may have a sense of heaviness
in lower abdomen. She may feel a lump in the lower abdomen even
without any other symptom.
• Pressure symptomsPressure symptoms are rare in body fibroids. The
fibroids in the posterior wall may be impacted in the pelvis producing
constipation, dysuria or even retention of urine. A broad ligament
fibroid may produce ureteric compression → hydroureteric and
hydronephrotic changes → infection → pyelitis.
• On Examination:
General examination reveals varying degrees of pallor depending upon the
magnitude and duration of menstrual loss.

Abdominal examination:
The tumor may not be sufficiently enlarged to be felt per abdomen. But if
enlarged to 14 weeks or more, the following features are noted.
Palpation- Feel is firm, more toward hard; may be cystic in cystic
degeneration.
Margins are well-defined except the lower pole which cannot be reached
suggestive of pelvic in origin.
Surface is nodular; may be uniformly enlarged in a single fibroid. Mobility is
restricted from above downwards but can be moved from side to side.
Pelvic examination
Bimanual examination reveals the uterus irregularly enlarged by the
swelling felt per abdomen. That the swelling is uterine is evidenced by:
• Uterus is not felt separated from the swelling and as such a groove is
not felt between the uterus and the mass.
• The cervix moves with the movement of the tumor felt per abdomen.
The only exception of these two findings is a subserous pedunculated
fibroid.
INVESTIGATIONS
The investigations aim at:
• To confirm the diagnosis
• Preoperative assessment

To confirm diagnosis:
1. Ultrasound and Color Doppler (TVS) findings are:
(i) Uterine contour is enlarged and distorted.
(ii) Depending on the amount of connective tissue or smooth muscle
proliferation, fibroids are of different echogenecity-hypoechoic or
hyperechoic.
• SIS: good for detecting and locating submucosal fibroids and
endometrial polyps.
• Hysteroscopy: good for detecting submucosal fibroids and
endometrial polyps; also good for planning subsequent
hysteroscopic surgical treatment. Surgical hysteroscopy can
remove polyps, adhesions and submucosal fibroids.
• Magnetic resonance imaging (MRI): good for describing the
morphology and location of fibroids. It is also indicated prior
to uterine artery embolization and to monitor treatment
response.

Preoperative assessment: Apart from routine preoperative

investigations, intravenous pyelography to note the anatomic
changes of the ureter may be helpful.
Differential diagnosis: The fibroid of varying sizes may be
confused with: (1) Pregnancy (2) Full bladder (3) Adenomyosis
(4) Myohyperplasia (5) Ovarian tumor (6) TO mass
Fibroid VS Adenomyosis

• Fibroid- nulliparous
• Adenomyosis- multiparous
• On scan- Irregular Junctional zone, hypoechoic , fan shaped
shadowing, asymmetrical thickening
MANAGEMENT
• CONSERVATIVE
• MEDICAL
• SURGICAL
Conservative management is appropriate where asymptomatic fibroids are detected
incidentally.

MEDICAL TREATMENT:
The main types of medical treatment for Heavy menstrual bleeding ; namely the
• Levonorgestrel intrauterine system (LNG-IUS), tranexamic acid, mefenamic acid and the
combined oral contraceptive pill (COCP) tend to be ineffective in the presence of a submucous
fibroid or an enlarged uterus that is palpable abdominally (>12 weeks size).
• The only effective medical treatment is to use injectable gonadotrophin-releasing hormone
(GnRH) agonists, which induce a menopausal state by shutting down ovarian oestradiol
production. However, GnRH treatment is not tolerated by all women because of severe
menopausal symptoms. More recently, the selective progesterone receptor modulator
(SPRM) ulipristal acetate has been shown to be as effective as GnRH agonists in reducing
fibroid volume and alleviating HMB symptoms, although it is not yet widely accepted into
clinical practice. In addition to being an oral tablet, this SPRM does not induce a menopausal
state and associated symptoms. However, neither GnRH nor SPRM represent a viable long-
term treatment option. Moreover, when ovarian function returns, the fibroids regrow to their
previous dimensions.
• Hysteroscopic myomectomy: minimally invasive, day-case procedure for submucous fibroids that avoids
surgical incisions and is effective in resolving HMB and improving fertility. Will not treat other types of
fibroid.
• Myomectomy: fertility sparing and will treat HMB and bulk symptoms. Usually requires a laparotomy,
but a less invasive laparoscopic approach is possible with smaller and fewer fibroids. Associated with
intraoperative bleeding from vascular fibroids, a 1% risk of unplanned hysterectomy and postoperative
intra-abdominal adhesions.
• Hysterectomy: indicated for women with no future fertility desires. May be achieved vaginally,
laparoscopically or via open surgery depending on the size of the uterus. Definitive, guaranteeing
amenorrhoea but as invasive as myomectomy.
• Radiological
• • Uterine artery embolization: minimally invasive, avoids general anaesthesia and surgery. Although
fertility sparing there are concerns over effect on subsequent reproductive function. Equivalent patient
satisfaction compared with myomectomy but the need for further treatments much higher.• Novel
radiological treatments are currently being explored to destroy fibroids through thermal ablation. These
include MRI-guided transcutaneous focussed ultrasound and transcervical intrauterine ultrasound-
guided radiofrequency ablation. However, the effectiveness and safety of these interventions need
further study before they can be considered for use in routine clinical practice.
INDICATIONS OF MYOMECTOMY
• Persistent uterine bleeding despite medical therapy.
• Excessive pain or pressure symptoms.
• Size >2 weeks, woman desirous to have a baby.
• Unexplained infertility with distortion of the uterine cavity.
• Recurrent pregnancy loss due to fibroid.
• Rapidly growing myoma during follow-up.
• Subserous pedunculated fibroid
PRE-REQUISITES TO MYOMECTOMY
• Hysteroscopy or hysterosalpingography—to exclude any submucous fibroid or a polyp or any tubal
block.
• Hysteroscopy/endometrial biopsy—in cases of irregular cycles, not only to remove a polyp but also to
exclude endometrial carcinoma.
• Examination of the husband from fertility point of view (semen analysis).

CONTRAINDICATIONS TO MYOMECTOMY
• Infected fibroid.
• Growth of myoma after menopause.
• Suspected malignant change (sarcoma).
• Parous women where hysterectomy is safer and is a definitive treatment.
• Function less fallopian tubes (bilateral hydrosalpinx, tubo-ovarian mass) – decision must be judicious
with the advent of microsurgery and Art.
• Pelvic or endometrial tuberculosis.
• During pregnancy or during cesarean section.
COMPLICATIONS OF UTERINE
FIBROIDS
• Degenerations
• Necrosis
• Infection
• Sarcomatous change (rare)
• Torsion of subserous pedunculated fibroid
• Hemorrhage– intracapsular– ruptured surface vein of subserous
fibroid →intraperitoneal
• Polycythemia due to– erythropoietic function by the tumor– Altered
erythropoietic function of the kidney through ureteric pressure
COMPLICATIONS OF UTERINE
FIBROIDS
1. Degeneration:
REFERENCES
1. Ten teachers
2. DC DUTTA
3. N. Bhatla, “Tumour of the corpus uteri,” in Jeffcoate Principles of
Gynaecology Revised, pp. 467–477, Butterworth, London, UK, 5th
edition, 2001.
4. A. Agboola, “Tumours of the corpus uteri,” in Textbook of Obstetrics
and Gynaecology for Medical Students, A. Agboola, Ed., vol. 1, pp. 235–
247, University Services Educational Publishers, Ibadan, Nigeria, 1988.