BY

DR JAMES P SEWE
• Fibroid (Syn: myoma, leiomyoma, fibromyoma, myomata,
fibromyomata) is not only the commonest benign tumour
of the uterus but is also the commonest benign solid
tumour in the female.
• Histologically its composed of smooth muscle
(Myometrium) and fibrous connective tissue
• Myomas are frequently multiple and as many as 200 may
be found in one uterus; more often, the number is between
5 and 30.
• Incidence: Estimate: 20% of women at age 30 have got
fibroids in the uterus. Most are asymptomatic. Incidence of
symptomatic fibroids among outpatient population is about
3%. The incidence is higher in black women
• Predisposing factors: 1. Nulliparity/ relative infertility 2.
Race: Higher among the Negroids 3. Genetics: Familial 4.
Mechanical stresses; controversial 5. Ovarian function:
Predominantly oestrogen dependent. Evidence: a. Growth
potentiality limited to child bearing years b. Increased
growth during pregnancy c. Non occurrence before
menarche d. Cessation of growth after menopause e.
Fibroids tend to have more oestrogen receptors than the
adjacent tissues f. Association with anovulation 6. Obesity
• Associated factors: 1. Ovarian follicular cysts 2.
Endometrial hyperplasia 3. Endometrial carcinoma 4.
Endometriosis
• Prevalence: Highest between ages 35 and 45
• Histogenesis: Aetiology remains unclear
• Hypothesis: It arises from the neoplastic single smooth
muscle cell of the myometrium, the stimulus of which is
obscure. The following are implicated.
• 1. Chromosomal abnormality: In about 40%, there is
either a re-arrangement or deletion in chromosome 6 or 7.
Abnormal proliferation may be due to this genetic potential
• 2. Polypeptide growth factors: Epidermal growth factor
(EGF), Insulin-like growth factor-1,transforming growth
factor (TGF), stimulate the growth of leiomyoma either
directly or via oestrogen
• SITES: Fibroids could either be within the body or cervix
of the uterus
• Fibroids are described as being subserous, interstitial or
submucous according to their relationship to the peritoneal
coat and to the endometrium
• The site is determined by the position of their origin and by
the direction in which they grow; an interstitial fibroid can
become submucous or sub-peritoneal. Subserous and
submucous fibroids often become pendunculated
• Most fibroids are situated in the body of the uterus but in 1-
2% of the cases, they are confined to the cervix and usually
in the supravaginal portion
 Classification by anatomic location:
 Body (corporeal): 1. Interstitial(Intramural) – 75%. May

be pushed outwards or inwards. In 70% of the cases, they

remain in the same position. 2. Subserous (Subperitoneal) –
15%. . In this condition, intramural Fibroids is pushed
outwards towards the peritoneal cavity and could be either
partially or completely covered by peritoneum. When
completely covered by peritoneum, it attains a pedicle and
hence pendunculated subserous fibroids. These could be
Subserous, Broad ligament (Pseudo) – when its pushed
out in between the layers of the broad ligament, Parasitic
(Wandering) – when the pedicle is torn and the fibroids
gets its nutrition from the omental and mesenteric adhesions
 3. Submucous – 5% - when intramural fibroids is pushed
towards the uterine cavity and is lying underneath the
endometrium. It could be sessile or pendunculated (Polyp).
It could make uterine cavity irregular. Pendunculated
submucous fibroid may come out through the cervix. It may
be infected or ulcerated to cause metrorrhagia. Its Rare but
causes maximum symptoms
 Cervical: Commonly single and is either interstitial or
subserous. Rarely; does it become submucous or polypoidal.
The subserous tumour usually grows out into or other broad
ligament. Cervical fibroid, being extraperitoneal, remains
fixed displaces the bladder and the ureters. Its removal
becomes hazardous
 A myoma developing from a subtotal hysterectomy stump is
rare but can create surgical challenges
 Cervical Fibroids could be located anteriorly, posteriorly,
centrally or laterally
 Pseudocervical fibroids: This is a fibroid polyp arising from the
uterine body which occupies and distends the cervical canal
 PATHOLOGY: Naked eye appearance:
 Uterus: Enlarged, shape is distorted by nodular growth of
varying sizes. Occasionally uterus is uniformly enlarged by a
single fibroid. Its firm.
 Cut surface: Smooth and whitish. Cut section shows whorled
appearance and trabeculation. These are due to intermingling
of fibrous tissues with muscle bundles.
 The false capsule formed by compressed adjacent myometrium.
The periphery of the tumour is more vascular with more growth
potential. The centre of the tumour is least vascular and likely
to degenerate.
 Microscopic appearance: Tumour consists of smooth
muscles and fibrous connective tissues of varying
proportions
 Originally, it only consists of only muscle element but later

on, fibrous tissues intermingle with the muscle bundles

hence fibroids is an innappropriate and it should be called
‘myomata’ or ‘fibromyomata’
 FIBROID DEGENERATIVE CHANGES:
 These include: 1. Hyaline degeneration 2. Cystic

degeneration 3. Fatty degeneration 4. Calcific degeneration

(10%) 5. Red degeneration 6. Atrophy 7. Necrosis 8.
Infection 9 Vascular changes (Telangiectasia)
Hyaline degeneration: The most common (65%). Common
especially in tumours having more connective tissues
The least vascular central part is the common site. The feel

is soft elastic as opposed to the normal firm

Macroscopy: Irregular homogenous areas with loss of

whorl-like appearance
Microscopy: Hyaline changes of both the muscles and

fibrous tissues
Cystic degeneration: Usually occurs following menopause
and is common in interstitial fibroids. Its formed by the
liquefaction of the areas with hyaline changes. Cystic spaces
lined by irregular rugged walls.
Differentials of a big fibroid include ovarian cyst or

pregnancy
Fatty degeneration: Usually occurs at or after menopause.
Fat globules are deposited mainly in the muscle cells
Calcific degeneration (10%) : Usually involves subserous
fibroids with small pedicles or myomas of postmenopausal
women.
Usually preceeded by fatty degeneration. There is

precipitation of calcium carbonate or phosphate

‘Womb stone’ Is when the whole tumour is a calcified mass

Red degeneration ( Carneous, necrobiosis): Occurs in a

large fibroid mainly during second half of pregnancy or in the
puerperium. Its said to occur because the enlarging uterus puts
tension on the capsule of the tumour, thus reducing its blood
supply. Infection does not play a part.
Red degeneration cont’d:
Macroscopy: Dark areas with cut section revealing raw-beef

appearance often containing cystic spaces. Odour is fishy due

to fatty acids. Colour is due to the presence of haemolysed
red cells and haemoglobin
Microscopy: Evidences of necrosis is present. Vessels are

thrombosed but extravasation of blood is unlikely.

Atrophy: Occur following menopause due to loss of
oestrogen support. Similar reduction also occurs following
pregnancy enlargement
Necrosis: Circulatory inadequacy may lead to central
necrosis of the tumour. Tends to occur in mucous or
pendunculated subserous fibroid
Infection: Gains access to the tumour core through the
thinned and sloughed surface epithelium of submucous
fibroids. Usually happens following delivery or abortion.
Intramural fibroid may also be infected following delivery.
Vascular changes: Dilatation of the vessels (Telangiectasis)
and dilatation of the lymphatics (Lymphangiectasis) inside the
myoma may occur. Aetiology remains obscure
Sarcomatous changes: Sarcomatous change may occur in <

0.1% of the cases (0.1-2.0%). The usual tumour is

leiomyosarcoma.
Danger signs for sarcoma include: Recurrence of fibroid

polyp, sudden enlargement of fibroid and fibroid along with

postmenopausal bleeding.
 Uterus: Shape is distorted; usually asymmetrical,
occasionally uniform. Myohyperplasia is almost a constant
finding may be due to hyperoestrinism but also work
hypertrophy in an attempt to expel the fibroid.
 Endometrium: May be normal. In others, there are features

of anovulation with evidence of hyperplasia. There is

dilatation and congestion of the myometrial and endometrial
venous plexuses. As a result it becomes thick, congested and
oedematous. The endometrium overlying submucous
fibroid may be thin and necrotic with evidence of infection
 Uterine cavity may be elongated and distorted in

intramural and submucous varieties

 Uterine tubes: Associated tubal infection (15%)
seems coincidental
 Ovaries: May be enlarged, congested and studded

with multiple cysts. The cause may be due to

hyperoestrinism.
 Ureter: Broad ligament fibroid may result into

displacement and compression of the ureters

resulting in hydroureter and hydronephrosis
 Endometriosis: Increased incidence of

endometriosis and adenomyosis (30%)

 Endometrial carcinoma: The incidence remains

unaffected
 Degenerations
 Necrosis
 Infections
 Sarcomatous change
 Torsion subserous pendunculated fibroids
 Haemorrhage

- Intracapsular
- Rupture surface vein of subserous fibroids
 Intrapefunctionritoneal
 Polycythaemia due to:

- Erythropoietic function by the tumour

- Altered erythropoietic function of the kidney through
ureteric pressure
 Patient profile: Nulliparous or long period of secondary
infertility
 Incidence: Peaks between 35 – 45 years. Tendency

towards delayed menopause

 Symptoms: Majority of the small and some large ones are

symptomless (75%). Most are frequently incidental

findings during physical, laparoscopic examinations or
during laparotomy
 Symptoms are related to anatomic sites and size of the

tumour. The nearer the fibroid is to the endometrial cavity,

the more its likely to cause symptoms especially menstrual
ones.
 A small submucous fibroid may produce more symptoms

than a big subserous fibroid

 Fibroid does not cause pain unless complicated by: 1.
Extrusion from the uterus as a polyp 2. Torsion of its pedicle
or of the uterus 3. Degeneration 4. Adhesion to other organs
5. Sarcomatous change
 Pain is often caused by an associated lesion, especially

endometriosis
 General effects: Anaemia resulting from menorrhagia

manifest as: palpitations, lassitude and even weight loss

 Polycythaemia is a rare finding. Postulates for the

phenomenon include: The tumour itself being

erythropoietic, large tumour embarasses respiration leading
to compensatory production of RBCs, tumour presses on the
ureter and affects erythropoietic function of the kidney.
 Polycythaemia increases the risk of thromboembolism
 Hypoglycaemia: Rare and occurs when the myomas show
unusual cellular activity and is more likely when they are
retroperitoneal
Menstrual abnormalities:
 Menorrhagia (30%) is the classic symptom of

symptomatic fibroid. The menstrual loss increases with

successive cycles and is heaviest on day 2 and 3 when it can
be described as ‘flooding’. Its conspicuous in sub-mucous
or interstitial fibroids
 Causes of menorrhagia include: 1. Increased surface area

2. Interference with normal uterine contractility due to

interposition of fibroid 3. Congestion and dilatation of the
subjacent endometrial venous plexuses caused by the
obstruction of the tumour
 4. Endometrial hyperplasia due to hyperoestrinism
(Anovulation) 5. Pelvic congestion 6. Role of prostanoids –
imbalance of thromboxane (TXA2) and prostacycline
(PGI2) with relative deficiency of the former
 Metrorrhagia: or irregular bleeding may be due to: 1.

Ulceration of submucous fibroid or fibroid polyp 2. Torn

vessels from sloughing base of a polyp 3. Associated
endometrial carcinoma
 Dysmenorrhoea: The congestive type 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,
Subserous broad ligament or cervical fibroids are usually
ass. With menstrual abnormalities.
 Asymptomatic – majority (75%)
 Menstrual abnormalities: Menorrhagia,

metrorrhagia
 Dysmenorrhoea
 Dyspareunia
 Infertility
 Pressure symptoms
 Recurrent pregnancy losses (Abortion, preterm

labour)
 Lower abdominal or pelvic pain
 Abdominal enlargement
INFERTILITY: Infertility (30%) may be a major complaint.
Probable attributing factors include:
 Uterine: 1. Distortion and/elongation of the uterine cavity

leading to difficult sperm ascent 2. Preventing rythmic uterine

contraction due to fibroids during intercourse leading to
impaired sperm transport 3. Congestion and dilatation of the
endometrial venous plexuses leading to defective nidation 4.
Atrophy and ulceration of the endometrium over the
submucous fibroids; this leads to defective nidation 5.
Menorrhagia and dyspareunia
Tubal: 1. Cornual block due to position of the fibroid 2.

Marked elongation of the tube over a big fibroid 3. Associated

salpingitis with tubal block
 Ovarian: Anovulation
 Peritoneal: Endometriosis
 Unknown: Majority
 Pregnancy related problems: eg abortion, preterm labour

and IUGR are high. Reasons include: defective

implantation of the placenta, poorly developed
endometrium, reduced space for growing foetus and
placenta. Red degeneration and torsion of subserous
pendunculated fibroid is common in pregnancy. PPH is
also rare.
 Lower abdominal pain: Fibroids are usually painless.

Pain may be due to: Tumour: Degeneration, torsion of

subserous pendunculated fibroid, extrusion of polyp
 Associated Pathology: Endometriosis, PID
 Abdominal swelling/s (Lump): Sense of heaviness and a

lump in the abdomen

 Pressure symptoms: These are rare. Posterior fibroid may be

impacted in the pelvis producing constipation, dysuria or

urinary retention.
 Broad ligament fibroid may produce ureteric compression >

hydroureter> hydronephros>infection>pyelitis
SIGNS:
 Varying degrees of pallor depending on severity of bleeding
 Abdomen: Tumour may be pelvic and hence not palpable

per abdomen. If >= 14 weeks: Firm nodular masses.

 Investigations aim at: 1.Confirmation
1. of diagnosis 2.
Preoperative assessment
 Most are diagnosed from history and physical examination
 1. Pelvic scan and colour doppler
 2. Magnetic Resonance Imaging (MRI): More accurate.

Helps to differentiate adenomyosis and fibroids. Expensive,

not routinely used
 3. Laparoscopy: Done when uterine size < 12/52 and

associated with pain and infertility

 4. Hysteroscopy: Helps to diagnose submucous fibroids
 5. Uterine curretage: Useful in irregular bleeding to detect

any co-existing pathology and to study endometrial pattern

 Pre-op assessment: Hb, LFTs, U/E/Cs, Grouping and X-
matching.
 IVP: To note the anatomic changes of ureters

DIFFERENTIAL DIAGNOSIS:
 1. Pregnancy 2. Full bladder 3. Adenomyosis 4.

Myohyperplasia 5. Ovarian tumour

MANAGEMENT:
 Divided into: 1. Symptomatic 2. Asymptomatic

SYMPTOMATIC:
 Medical: Drugs used either as palliation or rarely as

alternative to surgery
 One must ascertain the diagnosis before medical treatment
 Medical Management of Fibroids Cont’d:
Objectives:
To improve menorrhagia and to correct anaemia
To minimise the size and vascularity of the tumour

in order to facilitate surgery

To facilitate hysteroscopic or laparoscopic surgery

in selected cases of infertility

As alternative to surgery in perimenopausal

women or surgically at risk women

When postponement of surgery is planned

temporarily
Drugs to Minimise blood loss:
Various drugs are used to minimise blood loss and to correct

anaemia when a definite surgery cannot be performed for

sometime
Drugs include: 1. Antifibrinolytics 2. Antiprogesterones 3.

Danazol 4. GnRH analogues: a. Agonists b. Antagonists 5.

Prostaglandin synthetase inhibitors
Antiprogesterones:
1. Mifepristone (RU 486): Effective in menorrhagia. Reduces

the size of the Fibroids significantly. Treatment lasts 3

months. Longer treatment causes endometrial hyperplasia
 Danazol: Can reduce the volume of fibroid slightly. Use: 3-
6/12. Reason: Androgenic side effects. May produce
amenorrhoea due to its antigonadotrophin and androgen
agonist activities
 GnRH agonists: include: goserelin, luporelin, buserelin and

nafarelin. Mxn. Of action: sustained pituitary down

regulation and suppression of ovarian function. Initial
transient pituitary stimulation is observed
 GnRH antagonists: Cetrorelix or ganirelix causes immediate

suppression of the pituitary and the ovaries. Onset of

amenorrhoea is rapid
 Antifibrinolytics: Reduces amount of blood loss

significantly. Tranexaminic acid 2-4 gms daily is used for

menorrhagia
Prostaglandin synthetase inhibitors:
 Used to relieve pain due to associated endometriosis or

degeneration of fibroids. Does NOT improve menorrhagia

Levonorgestrel-releasing Intrauterine system(LNG-IUS):
Reduces blood loss and uterine size.
Not recommended with uterine size > 12/52 or with

distorted uterus
Pre-op therapy: Used to reduce uterine size and vascularity
prior to either myomectomy or hysterectomy
Operation will be technically easier in broad ligament or

cervical fibroids
Therapy is given for 3/12; however, with stoppage of

therapy, the tumour returns to its original size

 Benefits of GnRH analogue therapy:
Improvement of menorrhagia and may produce
amenorrhoea
Improvement of anaemia
Relief of pressure symptoms
Reduction in the size of the fibroid (50%) when

used for a period of 6 months

Reduction in the vascularity of the tumour
Reduction in blood loss during myomectomy
May facilitate laparoscopic or hysteroscopic

surgery
Surgical procedures include:
Myomectomy: Methods include: 1. Laparotomy 2.

Laparoscopy 3. Hysteroscopy
Embolotherapy
Myolysis
Hysterectomy

MYOMECTOMY:
Definition: Is the enucleation of myomata from

the uterus leaving potentially functioning organ

capable of future reproduction
 CONSIDERATIONS PRIOR TO SURGERY:
Done mainly to preserve reproductive function of the

uterus
Wish for menstrual function in parous women should be

judiciously complied with

Myomectomy is riskier in big and multiple fibroids
Recurrence and persistence rate in fibroids is 30-50%
Risk of persistent menorrhagia is about 1-5%
Pregnancy rate post myomectomy is 40-60%
Pregnancy following myomectomy should be a mandatory

C/S although scar rupture is rare

 Persistentuterine bleeding
 Excessive pain or pressure symptoms
 Size > 12/52. Patient desirous of pregnancy
 Unexplained infertility with distortion of the

uterine cavity
 Recurrent pregnancy wastage due to fibroids
 Rapidly growing myomata during follow up
 Subserous pendunculated fibroids
 Hysteroscopy or hysterosalpingography

done to exclude any submucous fibroid,

polyp or tubal block
 Diagnostic D & C: Done in cases of

irregular cycles; to remove a polyp and

also to exclude endometrial carcinoma
 Seminalysis
 Infected Fibroid
 Myoma after menopause
 Suspected malignant change
 Parous women where hysterectomy is safer and

also is a definitive therapy

 Functionless fallopian tubes ( Bilateral

hydrosalpinx, tubo-ovarian mass. Decision should

be judicious given newer microsurgical techniques
and Assisted Reproductive Techniques (ART)
 Pelvic or endometrial TB
 During pregnancy or * during caesarean section
 Some indications are relative. Restoration of anatomy and
function of the uterus, tubes and ovaries not only improves
fertility but also avoids future hazards
 Final decision as to myomectomy or hysterectomy is made

intra-op. and hence informed consent should read

‘Myomectomy/Hysterectomy’
Myomectomy/Hysterectomy
 Vaginal Myomectomy:
 Submucous pendunculated fibroid May be removed

vaginally
 Morcellation (Removal
( piecemeal) is applied in large
tumours
 A moderately sized fibroid can be removed by twisting

using ring (Sponge) forceps

 ENDOSCOPIC SURGERY:
Hysteroscopy: Done when fibroid is 3-4cm in diameter.

Pedicle or the base of is coagulated using electrocautery.

Nd:YAG laser can also be used.
Complications of hysteroscopic surgery include: uterine

perforation, fluid overload, haemorrhage etc.

Laparocopy: Subserous and intramural fibroids can be

removed laparoscopically.
Electrocautery, LASER and extracorporeal sutures are used

for haemostasis.
Not suitable in large, deep intramural, multiple or

technically innacessible fibroids.

Myolysis: This is dessication of fibroids using Laser or
bipolar diathermy.
diathermy
Embolotherapy: Embolisation of uterine arteries causes
avascular necrosis followed by shrinkage of the fibroids
Occlusion of the uterine arteries is achieved by injecting

polyvinyl alcohol particles through percutaneous femoral

catherisation.
Option where surgery is not preferred
Result: menorrhagia improves by 80-90%, size reduces by

60%
Contraindications: Active pelvic infection, desire for future

pregnancy, drug allergy

 Hysterectomy is the operation of choice in symptomatic
fibroids.
 Indications: 1.
1 Women over 40 years 2. Completed family
size
 Total hysterectomy is performed; however sub total

hysterectomy may be done in conditions such as:

 Sudden deterioration of the general condition of the patient

intra-op.
 Associated endometriosis especially involving the

rectovaginal septum
 Oophorectomy is performed in postmenopausal women but

should as much as possible be preserved in earlier age when

healthy
Advantages of hysterectomy:
1. No chance of recurrence 2. Adnexal pathology

and unhealthy cervix if any are also removed

Vaginal hysterectomy: Performed for fibroids of

10-12 weeks of pregnancy associated with uterine

prolapse
Vaginal hysterectomy with repair of pelvic floor is

the operation of choice

Pre-treatment with GnRH analogue may facilitate

vaginal hysterectomy
 Torsion of subserous pendunculated
fibroid
 Massive intraperitoneal haemorrhage

following rupture of veins over

subserous fibroid
 Uncontrolled infected fibroid
 Uncontrolled bleeding fibroid
 Fibroids detected accidentally on routine examination for
complaints other than fibroids
 Management can be: 1. Observation 2. Surgery

Observation: One must be certain of the diagnosis.

Sarcomatous change is so rare as NOT to justify removal of
the fibroid
Judicious observation may be instituted in cases:
 Size < 12/52
 Diagnosis certain
 Follow up possible
 6/12 examinations at intervals of 6/12. Appearance of

symptoms or increase in size, surgery is indicated

THANKS FOR THE AUDIENCE
AJUOGA SEWE