Fibroids by mavish

Prepared by:

Mahwish GulRoll # 08-089

Final yr MBBS

FIBROIDS

What is fibroid?Its epidemiology?its gross & microscopic features? Its types?What causes fibroid?What are its signs and symptoms?Its treatment options?Its complications?Its differential diagnosis?Effect of fibroids on pregnancy & pregnancy on

fibroids?

Basic considerations during the presentation:

• Actually fibroid is a misnomer because there is very little connective tissue in it.

• Its other name is LEIOMYOMA or MYOMA. • It is chiefly composed of the smooth muscle fibers

& contains fibrous tissue in small amount.• Tumor arises from the muscle tissue and NOT

from the fibrous tissue of the uterus.• It is a BENIGN in nature.• Predominantly occurs in the body of the uterus

and less commonly in the cervix.

What is fibroid?

Most common tumor not only of the uterus but of the whole female body!

Present in 20-30% of the women of reproductive age.

Disease of the reproductive age, never occurs before menarche & regresses after menopause.

Commonly occurs in infertile & women with low parity.

Incidence is more common in black women where it presents at a younger age as well.

Family history +

epidemiology

Nodular outgrowth which causes enlargement of the uterus and distortion of its normal structure.

Could be single but are usually multiple.Size varies from a few millimeters to the size

of the football.Oval or rounded in shape.Firm in consistency.Characteristic whorled appearance on cut

surface which becomes convex.Its colour is generally lighter than surrounding

myometrium.Could be surrounded by the pseudo-capsule.

GROSSLY we see:

Multiple leiomyomas in the same uterus

Whorled appearance on cut surface

Colour lighter than the surrounding myometrium

Bundles on muscle cells seen running in all directions.

Nuclei of these cells are rod shaped and uniform in shape and size.

Variable amount of connective tissue present in between.

Microscopically:

Female hormonesMechanical stressRacial factorsGenetic factorsParity

Aetiology

Receptors Does not occur before menarche & regresses

after menopause In size when treated with GnRH

analogues In size in response to oral contraceptives Incidence in obese women Incidence in smokers

What is the role of estrogens & progesterone?

•subserous

•Intramural

•submucous

body

cervical

intraligamentary

CLASSIFICATION

Originates from the outer

myometrium & projects

outwards from the

uterine surface covered

with the peritoneum.

May attain a large size

because of unrestricted

growth.

May become

pedunculated.

Subserous type

Lies within the uterine

wall & is surrounded by

the normal myometrium

on all sides.

May be surrounded by

pseudo-capsule.

Large intramural fibroid

may distort the uterine

cavity & increase its

surface area.

Intramural type

Arises from the inner

myometrium & is

covered by the

endometrium.

Projects inwards into

the uterine cavity &

may become

pedunculated.

Submucous type

Less common.

1-2% of the cases.

Often single.

Usually confined to

supravaginal portion of

cervix.

Either intramural or

subserous.

Cervical type

Rare

Arises from smooth muscle

fibres within the broad

ligament.

Should be differentiated

from the subserous fibroid.

Intraligamentary type

Usually silent (in more than 50% of the cases)Menstrual problems e.g I. Menorrhagia > surface area >

endometrium becomes ulcerated covering the submucous type > vasularity

II. Intermenstrual bleedingIII. Postcoital bleedingIV. Irregular bleeding

SYMPTOMS

Abdominopelvic mass (in the absence of pregnancy)Subfertility

occurs in 30% of the patients with fibroid (unclear whether fibroid is a cause of subfertility or an effect) possible explanations: > delay in child bearing & interfere with implantation of the fertilized ovum.

Heaviness in the lower abdomenPainUrinary retentionUrinary frequencyDyspepsiaDyspneaIntestinal obstructionConstipationHaemorrhoidsEdema of the legsVaricosities of the legs

General physical examinationNo specific findingsExcessive loss of blood may cause anemia ,presenting

with pallor and in extreme cases with breathlessness Edema and varicosities of limbs are rare findings with

large fibroids .Abdominal examination :Uterus palpable abdominally

Single fibroid -- uterus with smooth surfaceMultiple fibroids – irregular mass maybe shifted to a sideFibroids – firm ,non tender unless undergone

degeneration.Pelvic examination :

Protruding fibroids easily seen

Signs

• ultrasound

investigations

Hysteroscopy & curettage

• laproscopy

hysterosalpingogram

Hysterosalpingogram showing two submucous leiomyoma

CT scan

MRIComplete blood picture >Hb >associated polycythemia

conservative treatment

Medical treatment

Surgical treatment

depends on symptoms, size & site of tumor, age of patient & her reproductive status + patients choice

Treatment

kept under observation, repeated follow ups done

>approaching menopause + no

symptoms + small tumor + no complications

(should be examined every 4-6 months interval till menopause)

1. Expectant treatment

Correct anemiaGnRH analogues (prescribed for 3-6months duration)

*IM injection> monthly *SC injection> 12 hourly *nasal spray> 6hourly

-- reduce size & vasularity > by causing pseudo-monopause > by supression of ovaries

(menorrhagia is improved upto 80% & size reduced by 50%)

-- temporary treatment -- only used now a days to prepare the patient for surgery >

causes less bleeding DISADVANTAGES:1. Expensive2. Effects last for the duration of treatment3. Causes postmenopausal symptoms (hot flushes, night sweats,

psychological disturbances) 4. If used for >6months– osteoporosisOther drugs:Danazol, antiprogestogens

2. Medical treatment

Occlude uterine artery by

particulate emboli (polyvinyl

alcohol)

Approached by trans femoral route

Causes ischemic necrosis of

fibroids & reduce their size

COMPLICATIONS:

>failure to canalize

>hematoma formation

>infection

>pain

3.Surgical treatment >uterine artery embolism (UAE)

(removal of the myomas & conservation of the uterus)

Preferred treatment for the following circumstances:

*age <40*symptomatic fibroid*patient wishing to have more children*patient with recurrent abortions*Infertile patients*patient wishing to conserve her uterus

> myomectomy

Contraindications:>associated carcinoma *treatment should be directed against

malignancy>Suspicion of sarcomatous change>pregnancy * myomectomy should be postponed till

3months after delivery > cuz of increased congestion of uterus

* pedunculated subserous must be removed however to prevent torsion in puerperium

Cont…..

Preparation: >Hb corrected >rule out endometrial carcinoma or any other

abnormality by D & C before myomectomy >X-ray abdomen >IVU

Routes:>abdominal>vaginal>endoscopic

Cont…

COMPLICATIONS:>sepsis>recurrence (5-10%)>persistant symptoms>oozing from uterine wound>intra peritoneal adhesions>haemorrhage *heavy intraoperative bleeding (atleast 2units blood

should be available prehand)Minimized by applying bonney’s myomectomy clamp or

simple rubber tourniquet

Bonney’s myomectomy clamp

Cont…

(removal of the uterus)Treatment of choice under following conditions:*age>40*multiple fibroids*completed her family*severe symptoms

Carried out by:>abdominal route >vaginal route

>hysterectomy

complications

degeneration

torsion

Sarcomatouschange

infection

(cuz of reduced blood supply to the tumor) types:>atrophic>hyaline>cystic>calcific>septic>red>myxomatous(fatty)

DEGENERATION

ATROPHIC: >size of tumor decreases after menopause or after

pregnancy>due to withdrawl of estrogens>size decreases but the myoma does not disappear

HYALINE:>commonest of all(except for tiniest tumors)>homogenous & glassy areas on microscopy>fibrous tissue gets involved first &then the Ms fibres

CYSTIC:>hyaline degeneration(if extensive) may progress into cystic

degeneration>liquifaction of hyalinized areascystic cavities>walls of cavity irregular>cavity filled withgelatinous material>whole tumorone large cystic cavitysimulate pregnancy or

ovarian cyst

CALCIFIC:>carbonate &phosphate salts deposited in the

tumor>seen as radioopaque shadows>more commonly in subserous myomas

SEPTIC:>necrosis in the center of large myoma

MYXOMATOUS:>rare>Fatty change occurs in the fibroid >Require differentiation from uterine lipoma

RED:>most commonly seen durong pregnancy & puerperium but may occur

without pregnancy as well>due to thrombosis of the veins ischemia & necrosis>soft, on section looks red or pink with areas of necrosis in the center

>microscopically structureless>onset of symptoms sudden*pain *increased size(mistaken for torsion of myoma or ovarian cyst,concealed accidental

haemorrhage etc)>TREATMENT: analgesics, bed rest & observation(usually settle down within a week or so)

>very rare (0.2% of cases)>usually starts in the center of the tumor

*if myoma enlarges rapidly or becomes painful &tender malignant change should be suspected

INFECTION>more common during puerperium &after abortion>more common in myomas that have undergone necrosis

TORSION>pedunculated subserous>more commonly seen during pregnancy &puerperium>sudden pain, enlarges in size & becomes tender

*difficult to differentiate from red degeneration & torsion of ovarian cyst

SARCOMATOUS CHANGE

Usually easily diagnosedExclude pregnancyExclude other pelvic masses -Ovarian Ca -Tubo-ovarian abscess -Endometriosis -Adenexa, omentum or bowel adherent to the uterus Exclude other causes of uterine enlargement: -Adenomyosis -Myometrial hypertrophy -Congenital anomalies -Endometrial Ca

DIFFERENTIAL DIAGNOSIS

Exclude other causes of abnormal bleeding Endometrial hyperplasia Endometrial or tubal Ca Uterine sarcoma Ovarian CaPolypsAdenomyosisEndometriosisExogenous estrogens*Endometrial biopsy or D&C is essential in the

evaluation of abnormal bleeding

1. adenomyosis

• Disease of multiparous women

• Menorrhagia is associated with severe dysmenorrhea

• Uterus : uniformly enlarged ,tender

• Ultrasound : thickened myometrium with swiss cheese appearance

• Cut surface : lacks whorled appearance and capsule.

2.Ovarian tumor

• Confused with pedunculaed sub serous tumor

• Menorrhagia often absent

• Mass feels separate from the uterus while fibroids has limited mobilty

• Ultrasound may be helpful but diagnosis is not confirmed until laproscopy or laprotomy is performed

3. Pregnancy with or without myomas >amenorrhea +>uterus soft nd cystic>clinical signs of pregnancy>pregnancy test +>U/S

4. PID & endometriosis>tenderness on bimanual examination>adhesions on pelvic examination

5. Myohyperplasia>in response to excessive or prolonged unopposed

estrogen influence e.g metropathia haemorrhagica

EFFECTS OF MYOMAS>On pregnancy 1.abortion*distortion of uterine cavity*interference in accommodation & increase in

size*defective placentation*impacted myomas in pelvis

2.premature onset of labour

3.malpresentations*interfere with descent of the presenting part

During labour 1. Abnormal uterine contractions

prolonged labour 2. Cervical dystocia*interfere with dilatation of the cervix 3. Obstructed labour*usually with cervical & broad ligament

myomas 4. Retained placenta*interfere with its separation 5. PPH*cuz of retained placenta & abnormal uterine

contractions

During puerperium 1. Sepsis*submucous myomas may get infected 2. Delayed involution of uterus

Effects of pregnancy on myomas

1. increase in size• Due to congestion & odema of tumor• After pregnancy return to their original size2. Change in consistency• Become soft• Due to congestion & odema of tumor3. Red degeneration• More common during pregnancy & puerperium• Due to increased tendency for thrombosis4. Torsion & infection• These complications are more common during

pregnancy & puerperium