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A brief description of uterine fibroids, classifications, degenerative changes, pathophysiology, risk factors clinical presentations and management
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Myometrium: Uterine Fibroids
• PathologyA fibroid is a benign tumour of uterine smooth muscle, a
leiomyoma.
• Gross appearance:
Firm, whorled tumour located adjacent to & bulging into
the endometrial cavity (submucous fibroid)
Centrally within the myometrium ( Intramural fibroids)
Attached to uterus by narrow pedicle (Pedunculated
fibroid)
Pathology
• Fibroids can arise separately from the uterus esp.
from broad lig presumably embryonal remnants
• Appearance may be altered and 3 form are;
1. Red
2. Hyaline
3. Cystic
Pathology
1. Red degeneration is due to acute disruption of
blood supply.
May present with acute onset of pain and tenderness
over the uterus,
assoc with mild pyrexia & leukocytosis.
2. Hyaline degeneration;
When fibroids outgrow its blood supply
Pathophysiology
•Aetiology
• Key feature is occurrence in reproductive yrs.
• Racial or familial predisposition.
• Possibility of abnormal ER has been explored
• Both main Progesterone Receptor subtypes are expressed
in myoma & normal myometrium
Pathophysiology
• Exp’t Progesterone has been shown to stimulate production of apoptosis-inhibiting protein and EGF.• Oestradiol has the effect of stimulating expression
of EGF• Reduced expression of Inhibitory factors eg MCP-1
may contribute to loss of inhibitory required for fibroid growth• Tx by Ovarian suppression is assoc with increase in
MMP and decease in TIMP activity
Pathophysiology
• Cytogenic studies: Indiv Myoma are monoclonal in origin but ell from diff myomas within the uterus are independent in origin• Clonal expansion of tumour cell precede dev’t of
cytogenic aberration• Common cytogenic aberations are detected in
chromosomes 12, 6, 7 , aring chrom 1 & translocation involving 12 & 14.• Relevant areas on chrom 12, 6 & 7 contain putative
GR & TSG.
Pathophysiology
• Risk of malignant transformation 0.5%
• In leimyosarcoma, tissue are of more extensive
genetic Instability
• With frequent deletions especially involving
chromosomes 1 & 10
Clinical Features
• Common & detectable in 20% of women over 30yrs
• Autopsy shows prevalence of up to 50%.
• Risk factorsNulliparityObesityA family history African racial origin
• Majority don’t cause symptoms & identified coincidentally
Clinical Features
Common PC
Menstrual disturbances
Pressure symptoms esp. urinary frequency.
Pain is unusual except in acute degeneration
Menorrhagia may occur coincidentally
Clinical Features
• Subfertility may result from mechanical distortion or
occlusion of Fallopian tube
• Prevention of implantation esp by submucous
fibroids
• Risk of miscarriage is not increased once pregnancy
is established
• In late pregnancy may be the cause of abnormal lie.
Clinical Features
• Postpartum hemorrhage may occur due to
inefficient uterine contraction.
• Abdominal examination may indicate presence of a
firm mass arising from pelvis
• Bimanual exams; the mass is felt to be part of the
uterus usually with some mobility
Differential diagnosis
• Other causes of abdominopelvic mass should be evaluated.
• Uterus with fibroids is firm in contrast to that enlarged with pregnancy.
• An ovarian tumour
• Leimyosarcoma typically resent with rapidly enlarging abdominopelvic mass.
Less mobility of uterus than expetedin fibroid and general signs of cachexia
Investigations
1. Clinical features alone is usually sufficient
2. Hb conc to help indicate anaemia if there is clinically significant menorrhagia.
3. Ultrasonography is is useful in distinguishing a uterine from an ovarian mass.
4. Imaging of Urinary tract to exclude hydronephrosis
5. Clinical suspicion of sarcoma: do needle biopsy or urgent laparotomy
Tx
Conservative management is appropriate
Ovarian suppression using GnRH agonist
Mifepristone has been shown to be effective in shrinking
fibroids.
Choice of tx is by patients PC and aspiration for normal
menstruation and fertility.
Hysteroscopic resection
Myomectomy
Pretreatment with GnRH for 2 months facilitates the process.
Management
a) Pelvic examination often reveals an enlarged &
tender uterus.
b) If the woman has no symptoms and the uterus is
not enlarged, no tx is indicated.
c) If the woman is symptomatic, hysterectomy is the
preferred tx, since adenomyosis does not respond
well to hormonal treatment.
Recommended