Fibroid Uterus

Fibroids are benign neoplasms of uterus arising from smooth muscle rests of vessel walls or uterine musculature

Contain smooth muscle cells and varying amounts of connective tissue.

Incidence - 5-20% Age -reprodutive age

more in forties

Etiology

Myomas are oestrogen dependent

-Rarely found before puberty

-Increase in size during pregnancy

-And during OC pill usage

-Regress after menopause Monoclonal in origin Chromosomal abnormalities 1,6,7,12,14,

del q 21-22 Seen more in black women

Classification

Based on uterine layer

interstitial 75%

(intramural)

submucous 15%

subserous 10% Various other cassifications based on

hysteroscopy and location of submucous fibroid

Classification

Based on location

- corporeal

- cervical

- isthmic Based on origin

-uterine

-Extrauterine –Ex: broad ligament

fibroid

Types of Fibroids

Anatomy and histology

Well circumscribed Pseudoencapsulated Firm in consistency C/S - pinkish white,whorled in appearance Microscopically –bundles of plain muscle

cells,separated by varying amonts of fibrous strands

Cut section of fibroid

Secondary changes

Atrophic degeneration - seen after menopause Hyaline degeneration Cystic degeneration Calcareous degeneration Red degeneration - aseptic degeneration

seen in second trimester of

pregnancy Sarcomatous degeneration

Clinical features

Depend on size,site,reproductive status Asymptomatic 50% Menstrual symptoms 30-50% Pelvic pain 30% Subfertility Pressure symptoms Abdominal lump Pregnancy related complications

Menstrual symptoms Most common-menorrhagia Inter menstrual bleeding in submucous

myoma

Pelvic pain Dysmenorrhoea Dyspareunia Pelvic pressure Torsion of subserous pedunculated fibroid Red degeneration

Pressure symptoms

Urinary symptoms acute retention of urine Frequency urgency dysuriaRectal symptoms- constipation rectal pain difficult defaecationHydro ureteronephrosis due to pressure on ureter

Causes of menstrual symptoms

Increase in total surface area Mechanical distortion of uterine cavity Interference with contractility Dilatation and congestion of endometrial

venous plexuses Endometrial hyperplaia due to high estrogen Pelvic congestion Ulceration of endometrium over submucous

fibroids leading to intermenstrual bleeding

Causes of subfertility

Distortion and elongation of endometral cavity leading to difficult sperm ascent

Impaired contractility of uterus Congestion of endometrial venous plexuses Defective implantation Cornual blockdue to fibroid Elongation and streching of tube over a large

fibroid Associated anovulation

Pregnancy related symptoms

Effects on pregnancy Recurrent abortions Preterm labour Fetal malpresentations Obstructed labour Post partum haemorrhage Subinvolution Puerperal sepsisEffects on fibroid Increase in size Red degeneration

Physical signs

Woman may be anaemic

P/A -Suprapubic mass with well defined

margins

P/S –fibroid polyp may be seen

P/V –enlarged uterus-regular or irregular

cervical movements transmitted to the

mass

Associated conditions

Follicular cysts Theca lutein cysts Endometriotic cysts Pevic inflammatory disease Ovarian tumours Endometrial hyperplasia Endometrial carcinoma

Complications

Secondary changes Sarcomatous change <0.5% Torsion of pedunculated fibroid Inversion due to submucous fibroid Capsular haemorrhage Infection of myomatous polyp

Differential diagnosis

Full bladder Pregnancy Adenomyosis Bicornuate uterus Endometriosis-chocolate cyst Chronic PID Ovarian tumour Endometrial cancer Chronic inversion Pelvic kidney

Investigations

Hb% Blood grouping and typing Ultrasound abdomen to know site,size and

number Hysteroscopy HSG and sonosalpingogram for submucous

myoma MRI in case of sarcoma IVP in broad ligament fibroid

Ultasound picture

Management

Management

Asymptomatic Fibroids <12 weeksneed not be treated

surgical

Myomectomy Hysterectomy

medical

Indications for Medical management

To control menorrhagia To improve hemoglobin before surgery For preoperative shrinkage of large fibroid To reduce vascularity To postpone surgery if woman is not fit for surgery In elderly women until menopause is reached To convert abdominal hysterectomy to a vaginal

one by decreasing the size of uterus Iron therapy for anaemia

Medical management

Combined OC pills Progestogens like MPA, Norethisterone LNG – IUCD (MIRENA) NSAIDS Antifibrinolytics Mifepristone 10-25 mg daily for 3 months Danazol 400-800 daily for 3 to 6 months GnRH analogues for 3 months Gestrinone

Myomectomy

Indications Women with infertility where all other causes have been ruled out Women desirous of child bearing Women who wish to retain their menstrual functionRoutesAbdominal myomectomyVaginal - in submucous fibroid polypHysteroscopic –in submucous fibroid polypLaparoscopic myomectomy

Principals of myomectomy Preoperative Hb% restoration and to keep adequate

blood ready All other factors for infertility like azoospermia are

ruled out Consent for hysterectomy is taken Preoperative D&C and papsmear are taken Should be done in preovulatory phase of

menstruation to reduce blood loss Haemorrhage is controlled with myomectomy (Bonney’s) clamp,20 units of vasopressin in 60 ml

saline

Technique of myomectomy

Keep incision as anterior as possible A single incision is given As many fibroids as possible are removed

through multiple tunnelling incision Myoma cavity thoroughly obliterated with

several catgut sutures

Results Pregnancy rate of 40-50%

Laproscopic myomectomy

Complications of myomectomy

Primary ,reactionary and secondary haemorrhage

Trauma to the bladder,ureter and bowel during surgery

Adhesions and intestinal obstruction Recurrence of fibroids and persistence of

menorrhagia

Hysterectomy

Indications Woman over 40 yrs of age Multiparous women Associated pathology such as endometriosis,

PID, adenomyosis,endometrial hyperplasia Suspested malignancy

Hysterectomy

Routes Abdominal Vaginal Laparoscopic Laparoscopic assisted vaginal hysterectomy

Hysterectomy

Indications for vaginal hysterectomy When uterus is mobile Size<14 weeks No previous surgery No pelvic pathology

Other wise an abdominal hysterectomy is done

Multiple fibroids

Laparoscopic hysterectomy Avoids scar Minimizes pain Shortens hospital stay Early recovery

Contraindications to LAVH Uterus >14-16 weeks Broad ligament, cervical fibroid Extensive pelvic adhesions

Complications of hysterectomy

Anaesthetic complications Primary ,reactionary and secondary

haemorrhage Trauma to the bladder,ureter and bowel

during surgery Adhesions and intestinal obstruction Sepsis Burst abdomen Incisional hernia

Uterine artery embolization

Improves symptoms in 70-80% of women Preoperative shrinkage Reduces vascularityTechnique Performed through percutaneous femoral

catheterization using polyvinyl alcohol,gel foam or metal coils

Contraindicated in subserous pedunculated fibroid and in women desirous of pregnancy

Uterine artery embolization

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