FIBROID UTERUS S KAIBAH KONYAK 2011
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