Introduction

 M.C. tumor of uterus and female pelvis

 M.C. indication for hysterectomy
 Benign tumor composed mainly of smooth
muscle cells and varying amount of fibrous
connective tissue
 Origin from smooth muscle cells
 Unicellular origin
Risk factors
 Race: africans
 Age
 Obesity
 Oral contraceptive pills/HRT
 Nulliparity
 Family history of leiomyoma of uterus
 Early age of menarche & late menopause
 Estrogen producing tumours of ovary
 Hypertension
 H/O PID
 Genetic predisposition - hereditary
leiomyomatosis and renal cell carcinoma,
Reed’s syndrome, cowden syndrome
Types
1. Body
 Interstitial- intra mural 70%
 Subserous
-pedunculated
-wandering fibroid
 Submucous -5%
-polypoid change
-surface necrosis
-infection
-degeneration(sarcomatous)
2.Cervical -1-2%
.supravaginal - interstitial or
subserous and rarely polypoidal
-disturb pelvic anatomy, specially ureter
.vaginal –sessile /pedunculated
.pseudocervical fibroid
3.Ligamentry
.broad ligament- true/pseudo
.round ligament
4.Ovarian -rare
Pathology
 Appearnace
-uterus enlarged
-shape distorted,occ.uniform enlargement
-clear distinction between myometrium
and myoma
-c/s glistening pinkish white& gray
-firm & whorl like arrangement of muscle
& fibrous tissue
Clinical features
 Asymptomatic
 Abnormal uterine bleeding

menorrhagia
metrorrhagia
anemia
 Pelvic mass
 Pressure symptoms:
-urinary frequency
-urinary incontinence
-hydronephrosis
-constipation
-tenesmus
 pelvic pain
 Reproductive dysfunction- infertility

-alteration of endometrial contour

-alteration of uterine and subendometrial
blood flow
-alteration of overlying endometrium
-alteration of biochemical environment
-enlargement and deformity of uterine cavity
-cervical displacement
-generation of dysfunctional &altered uterine
contractility
-tubal ostia may be obstructed
 Pregnancy related
-myoma growth
-red degeneration
-spontaneous miscarriage
-obstetric complications

 malignancy
Rare associations
 Ascites
 Polycythemia
 Familial syndrome with renal cell
carcinoma
 Benign metastasizing uterine myoma
 Intravenous leiomyomatosis
 complications
 Torsion
 Haemorrhage
 Infection
 Sarcomatous change
 Degeneration
 Ascites- pseudo meigs syndrome
Differential diagnosis
 Endometrial polyp
 Endometrial hyperplasia
 Adenomyosis
 DUB
 Endometriosis
 Ovarian tumors
 PID
 Degeneration
 Hyaline - m.c.
central part of fibroid
smooth, irregular homogenous areas with
loss of whorl like appearance
 Cystic - formed by liquefaction of areas of
hyaline degeneration- filled with clear or
gelatinous material
 Fatty degeneration
 Calcareous
calcified cyst-at periphery
honeycomb/ mulberry appearance
wombstone
 Red degeneration - m.c. in pregnancy
raw beef appearance, fishy odour
 Atrophy
 Necrosis – dark & haemorrhagic
 Infection –m.c. in submucous fibroid,
mainly streptococcal
Management of leiomyoma
1. Expectant
2. Medical
3. Surgical
Depends on:
 Symptoms, age of patient
 Size and site of fibroid
 Reproductive status
 Growth rate
 Associated pathology
 Desire of the patient
Expectant management

Indications :
 Asymptomatic fibroid

 Near to menopause

 When sure that mass is benign

 F/U is possible ( interval of 6 month)

Indication of surgery in asymptomatic

 Possible malignancy of mass

 More risk of complications as mass
enlarges in size
 Improve fertility if myomectomy done
 Possible to grow if HRT given after
menopause
 Potential compromise of adjacent ovarian
function
Medical management
Aim :
1. Relief of symptoms
2. Reduction in size of fibroid
 Low dose OCP’s & progestins
-decrease the flow
-no significant reduction in uterine size
 GnRH agonist
-binds to GnRH receptors; result in
hypogonadotropic hypogonadal state i.e.
pseudomenopause
 Reduces vascularity
 Reduces individual cell size
 Action seen between 1-3 weeks
 Effect last as long as t/t is continued
 Indications :
1. Premenopausal age group.
2. Awaiting for surgery
3. Relieves symptoms & improvement of
anemia
4. To plan route of surgery after reduction in
size
 Results:
reduction in myoma volume to abt 40-50% by
3-6 mths; max at 12 wks
 Advantages :
1. Reduces myoma size
2. Reduces blood loss
3. Improves anemia
 Disadvantages :
1. Regrowth of small myoma after surgery
2. Difficult dissection
3. Osteoporosis,hot flushes

 Add back therapy: low dose OCP’s +

calcium
 Dose :
1. Leuprolide acetate -3.75 mg IM/mth
2. Gorselene 3.6 mg IM/mth
 GnRH antagonist:
 block pituitary GnRH rec & cause immediate

decline in FSH & LH

 Shorter duration of t/t & s/e

 Pituitary function normalises upon cessation

of t/t
 Ganirelix/cetrorelix

 Decrease in myoma vol. by 25-40% within 3

wks
 S/E-hot flushes,headache
 Aromatase inhibitors: fadrazole
 Directly inhibit ovarian estrogen synthesis &

rapidly produce hypoestrogenic state

 S.estrogen decrease after day1 of t/t

 Target local source of estrogen

 Myoma vol. decrease by 60% at 4 wk & 70%

by 8 wk
 Can be initiated at any time in menstrual

cycle
Danazol :
 Synthetic derivative of 17 alpha ethinyl
testosterone
 MOA:
1. Decrease frequency of GnRH pulse----
suppresssion of FSH &LH
2. Inhibit enzymes of steroidogenesis
3. Suppress endometrial growth
Net result- pseudomenopause
 Dose :200-400mg/d
 Should be commenced in early follicular
phase
Gestrinone:
 Derivative of ethinyl nortestosterone with

antiestrogenic & antiprogestogenic properties

 Induces amenorrhoea & decrease myoma

vol. by 40% at 6 mth & persist for atleast 18

mths after discontinuation
 Dose-2.5 mg twice weekly
Mifepristone :
 Decrease the no. of progesterone rec. in

myoma,inhibit ovarian cyclicity,reduces

uterine artery blood flow
 Dose -25mg/d

 After 3 mths-decrease in myoma volume by

50%
 S/E- vasomotor symp/endometrial

hyperplasia
Steroid receptor modulators
 Tamoxifen : act as antagonist in breast
tissue & agonist effect on bone,CVS &
endometrium
-don’t affect uterine size
-blood loss & intensity of pelvic pain improves
S/E- ovarian cyst/ hot flushes /dizziness/
endometrial thickening
Raloxifen :
 No agonist activity on endometrium & subtle

antiestrogenic effects
 Decrease uterine & myoma size

 Target myoma with less effect on normal

endometrium
 s/e-hot flushes
Investigations
 Routine blood investigations
 Ultrasonography
 Saline contrast sonography
 Hysteroscopy
 Endometrial biopsy
 MRI
 IVP
 Pap smear
Hysterectomy

Indications :
 Symptomatic fibroid not responding to

medical t/t
 Women over 40 yrs/ completed family

 Associated with malignancy

 Associated pelvic pathology

 Myomectomy
 Indications :
1. Infertile patients
2. Wants further child bearing
3. Wants to retain uterus
 Routes :
1. Abdominal
2. Vaginal
3. laproscopic
 Pre-op prep:
1. Hb restored
2. X-match and arrange blood
3. Consent for hysterectomy
4. If infertile- r/o other causes of infertility
5. R/O adnexal pathology
6. Endometrial biopsy
7. HS
8. Done in preovulatory period
Laproscopic myomectomy
 Indications same but less suitable for
cervical ,broad ligament and multiple
fibroids
 Atraumatic enucleation done
Complications
1.Intra-op:
 Conversion to laparotomy
 Bowel or bladder injury
2.Post op:
 Fever
 Phlebitis
3.Long term:
 Adhesions
 Uterine fistula
Hysteroscopic resection
 For submucous myoma of gr 1 & 2
 Pre-op inves: USG , HSG, saline contrast
 Size of hysteroscope: 5 mm in infertile pt. & 8 mm
in other cases
 Liquid distension media:
glycine/ mannitol/ sorbitol
 F/U : after 8 wk of surgery
1. If myoma completely removed
2. Adhesions
 Results : 90% improvement in menorrhagia
pregnancy rate-47% to 67%
Complications:
 Haemorrhage

 Intravasation of distension media

 Uterine perforation

 Bowel or bladder injury d/t use of electic

current
Myolysis
 Coagulation destroy the stroma ,
denature protein, destroy vascularity
reluting in shrinkage of myoma
 Methods:
1. ND:YAG
2. Monopolar/bipolar
3. Diathermy
4. Cryoprobe(at -180 degree C)
Uterine artery embolisation
 1st advocated in 1995 for leiomyoma
 Indication : pt with symptomatic fibroid & those
who refuses for surgical methods because of
fear of severe bleeding
 C/I:
1. Pregnancy
2. Acute pelvic infection
3. Severe contrast medium allergy
4. Arteriovenous malformation
5. Desire for future preg.
6. Undiagnosed pelvic mass
Technique:
 Written consent
 Done as day care procedure,but may hv to admit
overnight for post embolisation syndrome
 Goal is to deliver particulate material(PVA particles
or microspheres/gelatin coated tris-acryl polymer)
into both uterine arteries to produce ischemic
chages to myoma
 Intravenous analgesia or epidural
 Single femoral artery catheterised and pelvic
arteriography performed
 For uterine cramping-NSAIDS
 No work for 2 wks & analgesia for 2 wks along
with prophylactic antibiotics