Fibroid Uterus

FIBROID UTERUS

S KAIBAH KONYAK2011

FIBROIDS

THE COMMONEST

-BENIGN TUMOUR OF THE UTERUS

-BENIGN SOLID TUMOUR IN FEMALE

HISTOLOGICALLY

-LEIOMYOMA/MYOMA/FIBROMYOMA

FIBROIDS

Arising from the myometrium or muscles of its vessel walls

Composed of smooth muscles interspersed with varying amounts of fibrous tissue

INCIDENCE

20% OF WOMEN AT AGE OF 303% SYMPTOMATIC CASES IN O.PBLACK WOMEN HAS THE

HIGHEST MORE COMMON IN

NULLIPAROUSMOST COMMON AGE-35 TO 45

YEARS

HISTOGENESIS

ORIGIN

- AETIOLOGY IS UNKNOWN

- IT IS PRESUMED THAT IT ARISES FROM THE SINGLE SMOOTH MUSCLE OF THE MYOMETRIUM

GROWTH

PREDOMINANTLY AN ESTROGEN DEPENDENT TUMOUR

EVIDENCES:

INCREASED GROWTH DURING PREGNANCY

RARE BEFORE MENARCHE

CEASE TO GROW FOLLOWING MENOPAUSE

MORE ESTROGEN RECEPTORS THAN ADJACENT MYOMETRIUM

ASSOCIATION OF ANOVULATION

CYTOGENIC

Cytogenitic abnormalities-50%-

Translocation of chro. 7;12 & 14, Structural abnormalities-chr.6 Progesterone &GnRH-inhibits growth of myomas

Less common in smokers

Bcl-2 an inhibitor of apoptosis significantly increased in leiomyoma.

RISK FACTORS FOR FIBROID

NULLIPARITY

OBESITY

EARLY MENARCHE

HYPERESTROGENISM

ETHNICITY – AFROCARRIBEAN

FAMILY HISTORY

CLASSIFICATION OF UTERINE FIBROIDS

BODY(CORPOREAL) CERVICAL

INTERSTITIAL(75%) SUBSEROUS (15%) SUBMUCOUS(10%)

SESSILE PEDUNCULATED

ANTERIOR POSTERIOR CENTRAL LATERAL

INTRAMURAL

MOST COMMON(75 %)

WITHIN THE MYOMETRIAL WALL

PSEUDOCAPSULE

BLOOD SUPPLY – THROUGH THE PSEUDOCAPSULE

SUBSEROUS(15 %)-TUMOR GROWS OUTWARDS TO THE PERITONIAL

SURFACE

- (further extrusion outwards with development of a pedicle)

PEDUNCULATED SUBSEROUS FIBROID

-(gets attached to vascular organ & cut off from uterine origin)

WANDERING PARASITIC FIBROID

SUBMUCOUS(10 %)

Grows inwards into the cavity

Make the uterine cavity irregular & distorted

Pedunculated fibroid can come out through cervix

SUBMUCOUS It may become infected

Ulcerated menorrhagia,

metorrhagia

Infertility, recurrent miscarriage

SUBMUCUS MYOMATOUS POLYP

(Submucus myoma force itself towards vagina by a pedicle)

CERVICAL FIBROID

Intramural,subserous or submucous

Anterior/posterior/central/lateral

Impacted in the pelvis bladder

compression & urinary symptoms

PSEUDOCERVICAL FIBROID A FIBROID POLYP ARISING FROM THE

UTERINE BODY WHEN IT OCCUPIES AND DISTENDS THE CERVICAL CANAL

BROAD LIGAMENT FIBROID

TRUE

NO ATTACHMENT TO THE UTERUS

URETER MEDIAL TO THE FIBROID

FALSE

COMMON

ARISES FROM THE LATERAL UTERINE WALL

GROWS BETWEEN LAYERS OF BROAD LIGAMENT

URETER LATERAL TO THE FIBROID

MORPHOLOGYBODY/CORPOREAL FIBROIDS

GROSS APPEARANCECIRCUMSCRIBED

DISCRETE

ROUND

FIRM,GRAY WHITE TUMORS

MORPHOLOGY

SIZE VISIBLE NODULES TO MASSIVE TUMOR

CUT SECTION

SMOOTH AND WHITISH

WHORLED APPEARANCE

MICROSCOPY

Consists of whorled pattern of

smooth muscles and fibrous

connective tissue

Subserous and cervical myomas :

more fibrous tissue and less of muscle

SECONDARY CHANGES IN FIBROID

DEGENERATIONS

ATROPHY

NECROSIS

INFECTION

VASCULAR CHANGES

SACROMATOUS CHANGES

DEGENERATION

HYALINE DEGENERATION-65%

CYSTIC DEGENERATION

FATTY DEGENERATION

CALCIFIC DEGENERATION-10%

RED DEGENERATION

HYALINE DEGENERATION

Commonest degeneration affecting all fibroids

CENTRAL PORTION

Least vascularMost prone to degeneration

Becomes soft & elastic

HYALINE DEGENERATION

CUT SURFACE

Loss of characteristic whorled appearance

MICROSCOPYHyaline changes of muscles and

fibrous tissue

CACIFIC DEGENERATION

Due to circulatory impairment

Common after menopause

Occur in sub-serous fibroid with narrow pedicle

Calcium carbonate or phosphate is deposited in

the centre of the tumor which is least vascular

WOMB STONE (CALCIFIED FIBROID)

RED DEGENERATION

Occurs in large fibroid

During

PregnancyPuerperium

Cause

Vascular Thrombosis of blood vessels →

coagulative necrosis

RED DEGENERATION

TUMOR APPEARS DARK

CUT SURFACE SHOWS

-HEMORRHAGICC MEATY

APPEARANCE

MICROSCOPY

-EVIDENCE OF THROMBOSIS

NECROSIS OF VESSELS

COMPLICATIONS OF FIBROID

DEGENERATION

TORSION OF SUBSEROUS PEDUNCULATED

FIBROIDS

INFECTION

HAEMORRHAGE

COMPLICATIONS OF FIBROID

SACROMATOUS CHANGE

LEOMYOMATOSIS

PSEUDO MEIGS SYNDROME

POLCYTHEMIA – increased erythropoietin production by fibroid

TORSION - Sub-serous pedunculated fibroid

may undergo rotation at its site of attachment to the uterus

-Veins occluded & tumor engorged with blood

-Very severe a/c abdominal pain

INFECTION

Common in SUBMUCOUS fibroids & especially MYOMATOUS POLYPI projecting into vagina

Covered by only a layer of endometrium that becomes thinned out and sloughs

Blood stained purulent discharge

Often following delivery or abortion

puerperal sepsis

SACROMATOUS CHANGES

Not>0.5% cases

More in intramural & submucous

Rare<40yrs

Most common - leiomyosarcoma

Fibroids complicating pregnancy

Pregnancy causes increase in size of fibroids.

High tendency to undergo degenerative changes.

Severe pain abdomen.

Respiratory embarrassment ,urinary retention, obstructed labour.

Increased risk of miscarriage, preterm labour , abnormal presentations,accidental hemorrhage,dystocia,PPH,peurperal sepsis,uterine inversion.

SYMPTOMS

Many are asymptomatic and discovered only on routine gynecological examinations

Peak incidence between age of 35 and 45

Nulliparity and infertility are usual associations.

CLINICAL FEATURES

Usual type of bleeding associated with fibroid is

menorrhagia

o This is more with sub-mucous fibroids, also seen with intramural fibroids.

Another less common pattern is metrorrhagia

Some women have menometrorrhagia

ABNORMAL UTERINE BLEEDING

Increase in endometrial surface area

Increased vascularity

Interference with normal uterine contractions

Ulceration and haemorrhage over fibroid

Compression of venous plexus

Associated endometrial hyperplasia and anovulation

Mechanism of menorrhagia

Pelvic discomfort or pressure occur with large fibroids,

broad ligament fibroids compress sciatic nerve

-posterior fibroids cause low back ache

pressure symptoms

Fibroid arising from cervix produce bladder discomfort and compression

Initially increased urinary frequency then voiding difficulties

Sometimes acute retention can occur due to fibroid impacted in pouch of Douglas

Large fibroids and broad ligament fibroids cause ureteric compression and hydronephrosis

Urinary symptoms

CAUSES:

Red degeneration

Expulsion of sub mucous fibroid

Hemorrhage into the fibroidTorsion of fibroidAcute retention of urine

PELVIC PAIN

OTHER SYMPTOMS ARE:

Edema of lower limbs

Large fibroids cause venous stasis, difficulty in defecation even

dyspareunia

Infertility a)cornual myomas cause tubal occlusion

b)impaired gamete and embryo transport

c)altered relation between semen and

vaginal pool of secretion

d)distortion of cavity

Recurrent miscarriage

early miscarriage due to defective implantation

second trimester miscarriage due to distortion of cavity

A/E reveal a pelvic mass with smooth or irregular surface and firm consistency

Except in case of pedunculated fibroids lower border may not be palpable

Signs

Bimanual palpation is done to differentiate between an ovarian tumour and fibroid

In case of fibroid uterus is not felt separated also there will be transmitted mobility