Dr Henan Dh Skheel 2016 5th year

directed lecture
Liomyoma (fibroid)
A benign(non-caseous) tumor arising from the smooth
muscles layer and accompanying connective tissue of the
uterus”
• fibroid is chiefly composed of smooth muscle fibres & a
small amount of connective tissue.
• The name fibroid is a misnomer, more appropriate term
for this tumor of smooth muscle is Myoma or
Leiomyoma.
Pathology
• GROSS:
• nodular structures
• Oval or rounded shaped ,firm in consistency, whorled
appearance on cut section
• single but mostly multiple (up to 125)
• Size typically size of grape fruit but varies Tiny seedling to
a huge abdominal mass
• Microscopy:
• Smooth muscle cell bundles arranged in whorled pattern
with variable amount of connective tissue
• Predominance of fibrous tissues rarely seen
•
Epidemiology.
• most common tumor of the female body
• Present in 20-30 % of women of reproductive age,only a
fraction of these will require treatment.
• Age : never occurs before menarche , regresses after
th th
menopause ,peak incidence 4 & 5 decades
• Parity : higher in Infertile & women of low parity.
• Race : twice common in black women, African American
women are three times more likely to get fibroids than
Caucasian women.
 • Hereditary factor : women with family history , twice
more likely to develop fibroids.
Etiology
Exact aetiology is unknown, current working hypothesis is
that genetic predispositions, prenatal hormone exposure and
the effects of hormones ,growth factors and xenoestrogens
cause fibroid growth.
• 50% cases shows karyotypically detectable chromosomal
abnormalities .
• 70% cases with fibroids have specific mutations MED12
protein.
• Risk factors: African-American descent, nulliparity ,
obesity (fat aromatase), polycystic ovary syndrome
,diabetes and hypertension.
• While pregnancy & smoking decreases risk of fibroids

Classification

• Intramural fibroids
Within Body of • Subserosal fibroids
uterus • Submucous fibroids

Cervical

Intraligamentary

• Intramural fibroid :
Within uterine wall ,surrounded by myometrium ,
non capsulated but pseudocapsule form with growth ,
blood supply is through nutrient arteries entering through the
pseudocapsule.
•
• Subserosal fibroid
Originates from outer myometrium & projects outwards from
uterus covered with peritoneum, attain large size to lack of
surrounding myometrium.
• Submucous fibroids :
Arises from inner myometrium, covered with endometrium .
Projects inwards from uterine wall into uterine cavity ,may get
pedunculated.
• Cervical fibroid :
Less common(1-2%), arises from cervix , usually single,
Confined to the supravaginal portion of cervix,
Either intramural or intraluminal.
• Intraligamentary fibroids :
Arises from smooth muscles fibres with in the broad ligament
e.g round ligament & ovarian ligament
Symptoms
 Fibroids are mostly asymptomatic , particularly when
small in size.
• Menorrhagia is common intramural & sub mucous
fibroids, with increased blood loss but regular cycle.
• Due to :
Increased endometrial surface area.
ulcerated and damaged endometrium over the fibroid.
mechanical compression of venous drainage by fibroid .
• Intermenstrual bleeding in case of submucous fibroid
• Postcoital bleeding caused by pedunculated submucous
fibroid
 • Subfertility :
30% of patients with fibroid have problems
related to fertility. However Its unclear whether fibroid is a
cause or effect of infertility , possible explanations are
a) delay in child bearing predispose to development of
fibroid
b) fibroid causes interference in implantation
• Pain : pain usually start when complications occurs e.g
torsion
red degeneration
sarcomatous degeneration
• Urinary symptoms :
cervical fibroid – irritation of bladder – increased frequency
large cervical fibroid – impaction of pelvis – urinary
retention
• Pressure symptoms :
Large fibroids causes interference with venous and
lymphatic drainage of the lower limb causing edema and
varicosities.
Pressure on pelvic vein may cause hemorrhoids.
• Abdominopelvic mass :
A large fibroid may fill the abdominal cavity causing
dyspepsia due to stomach irritation & dyspnea due to
pressure on lungs.
Examination

General physical examination

• No specific findings
• Excessive 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 after 12weeks size of pregnancy
• Single fibroid -- central uterus with smooth surface
• Multiple fibroids – irregular mass maybe shifted to a side
• Fibroids – firm ,non tender unless undergone degeneration.
Pevic examination :
• Protuding fibroids easily seen
• Speculum examination – patients with mennorrhagia
,intermestrual and postcoital bleeding.
• Bimanual examination –
• Single fibroid -- central uterus with smooth surface
• Multiple fibroids – irregular mass maybe shifted to a side
• Fibroids – firm ,non tender unless undergone degeneration
Complications
1. Related to site of fibroid
• Subserous fibroid : if pedunculated ,can undergo torsion or
twist in the pedicle occludes blood supply leading to
ischemic necrosis presenting with acute pain.
Sessile subserous fibroid may get adherent with the bowel or
omentum ,if develop its own blood supply and get separated
from the uterus forming Parasitic fibroid.
Submucous fibroid : if pedunculated may prolapse through
cervix causing Intermenstrual and postcoital bleeding . Get
infected and ulcerated and may cause uterine inversion
• Cervical fibroid : may get impacted in pelvis causing
ureteric obstruction and urinary retention.
2-degeneration
Blood supply to fibroid is from periphery and the central area
is relatively deprived of circulation so a rapidly growing
fibroid easily undergo degeneration ,these include
• Hyaline degeneration
Soft , on cut section whorled pattern lost & become cystic.
 • Fatty degeneration :
Fatt

y change occurs in the fibroid

Require differentiation from uterine lipoma
• Red degeneration :
Thrombosis of peripheral blood vessels , while other become
distended and engorged with red blood cells.
Cut section: appear reddish due to presence of thrombotic and
hemolytic changes.
• Calcification due to poor blood supply.
3. Rarely sarcomatous degeneration also occurs
(0.1%)Infections :
Subserous fibroid can acquire infection from
Appendicitis
Diverticullitis
Pyosalpinges
Submural fibroids – after abortion and during perpurium
Submucosal fibroids –after ulceration
4. Hematological complications :
menorrhagia-exessive bleeding -anemia
fibroids--increased erythropoietin production-
polycythemia
Investigations
 • Ultrasonography
Investigation
of choice

• Hysteroscopy and curettage

Under special • Laparoscopy
circumstances

• Hysterosalpingogram
• Modern imaging techniques
Other
investigation • Complete blood picture

Ultrasonography
• Investigation of choice
• Typical fibroid appearance :: mild to moderate
echogenic mass in the uterine wall that causes nodular
distortion of uterine outline.
• Small intramural or Submucous fibroid :: recognized
by distortion of the normally linear central
endometrial echoes.
• Fibroids with hyaline degeneration :: anechoic area
within fibroid
• Fibroids with cystic degeneration:: will give Snow
storm appearance.
Hysteroscopy
• provides a direct veiw of uterine cavity, & is indicated
during
Abnormal uterine bleeding
Small submucous fibroids missed during ultrasound
Curettage may help to diagnose a co existing endometrial
pathology ,which may be the actual cause of menorrhagia.
 Laproscopy
Indication
When the mass cannot be differentiated on the ultrasound
and fibroid associated with infertility or pelvic pain
Other investigations
Hysterosalpingogram : carried out as a part of infertility
investigation and can pick small submucous fibroids
1. Modern Imaging Technique : CT scan and MRI are
more accurate in describing pelvic mass but too
expensive for routine examination.
Complete Blood Picture : In severe menorrhagia hemoglobin
will be low and polycythemia can also be diagnosed

Treatment
Conservative medical and surgical
conservative

• Asymptomatic fibroid of size less than 12 weeks

pregnancy in a patient of 42 years of age is left alone
in a hope that I would regress after menopause.
• Even an asymptomatic fibroid of size more that 12
weeks of pregnancy does not justify prophylactic
removal as risk of sarcomatous change is less than
0.1%.
• Only mangment required is a regular follow up till
menopause.
• These days, Removal only indicated in case of a very
large fibroid or a rapidly increasing in size due to
concern about the nature of the mass .
• Medical treatment
• Ideal drug – complete regression of fibroids
 • GnRH analogues is the only drugs which has shown
promising results .
• GnRH analogues :
Monthly IM depot injection
Daily Nasal spray
prescribed for 3 months
improved 80% cases of menorrhegia,
50% of the fibroid size is reduced
Disadvantages: expensive , effects only last during therapy ,
cause post menopausal symptoms (hot flushes , night sweats ,
psychological disturbance)

• Therefore only given when reduction in size and

vascularity is required prior to myomectomy &
hysterectomy.
• Long term use (6months or more) only allowed when
patient is unfit for surgery ( obses ,extensive
adhesions) or approaching her menopause.
• Other drugs : these shows reduction in size of
fibroids up to some extent
• Danazol
• Gestrinone
Surgical treatment
• Surgical treatment is present in the form of
a) Myomectomy
b) Hysterectomy
Myomectomy
The term myomectomy is used for an operation
where the uterus is conserved and fibroid is removed.
Preferred treatment in following conditions,
1. Symptomatic fibroids in young patient,
2. Infertile patients when fibroids are only pathology,
3. Patients wishing to have more childrens,
 4. Patients with recurrent abortion ,fibroids likely to
be the underlying cause,
5. Patients wishing to conserve her uterus

Routes of myomectomy
• Abdominal myomectomy
Most common method, perform through abdomen.
• Vaginal myomectomy
For pedunculated submucosal fibroids protruding through
cervix removed vaginally by ligating its pedicle with cautery.
• Endoscopic myomectomy
Disadvantages of Myomectomy
• Hemorrhages
Patient hemoglobin less than 11 gm/dl , two pints of cross
matched blood should be kept for transfusion
Uncontrolled hemorrhages may lead to hysterectomy.
• Early post operative complications
Post operative oozing from the uterine wound causes pyrexia
and paralytic ileus thus prolonging post operative recovery
• Delayed complications
Intraperitoneal adhesions causing infertility and intestinal
obstruction.
• Recurrence
15% risk
Hysterectomy
• Removal of uterus
• Mostly through abdomen although small fibroids can
be removed through vaginal hysterectomy
• Advantages :
a) Low post operative morbidity
• No risk of recurrenc
• Its preferred over myomectomy under theses
circumstance
1. Patients above 40 years of age
 2. Presence of multiple fibroids
3. Patients with complete family
4. Patients experiencing severe symptoms
Differential diagnosis
• Adenomyosis :
Also called adenomyoma
Disease of multiparous women
Menorrhagia is associated with severe dysmenorrhea
Uterus : uniformly enlarged ,tender
Ultrasound findings : thickened myometrium with swiss chees
appearance
Cut surface : lacks whorled appearance and capsule.
• Ovarian tumors :
Confused with pedunculaed sub serous fluid
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..
•