Fibroids

The Uterus
Layers of the Uterus
The uterus has three main layers, starting from inside to
outside:
Endometrium
Myometrium
Perimetrium
Fibroids
Leiomyoma, Fibromyoma, Myoma
Most common benign uterine tumor.
Leading cause of hysterectomy in the US.
Estimated 50% or greater of all women eventually develop
fibroid. A minority, 20 to 30% of these women are
symptomatic
Most frequently symptomatic ages 30s & 40s.
More common in AA than White females.
It is an estrogen sensitive tumor: may enlarge during
pregnancy.
Not a precursor for Leiomyosarcoma (the malignant tumor of
the uterus)


Tumor characteristics
Undergoes:
Degeneration
Dystrophic calcification
Hyalinization: the reason for the term fibroids
Small: symptomatic if located within the uterine cavity
Large: Usually go unnoticed and located outside of the uterus

Risk Factors
African American
2-3 times greater risk than white women.
Obesity
21 % Increased risk for each 10 kg increase in weight.
Increased conversion of androgen to estrone in obese women.
Family history
1
st
degree relative, 3-5 times more risk of developing fibroids.
Diet
Meat, ham and beef increase risk.
Hypertension
Every 10 mmHg in diastolic pressure there was an 8% increase in
diagnosis of unterine fibroid.
Symptoms
Symptoms depend on size and location
Menorrhagia: when located in the submucosa, is the most common
symptom. This may also lead to Iron deficieny anemia.
Painful menstruation
Painful sexual intercourse
Pressure on bladder leading to: Frequency, urgency, incontinence
Abnormal gynecologic hemorrhage
Abdominal discomfort or bloating
Pressure on colon: constipation, painful defecation
Backache
Some cases infertility but only accounts for 3% of cases; in such cases
a fibroid is located in submucosal position and it is thought that this
location may interfere with functioning of lining and ability of the embryo
to implant.
Classification
Submucosal Fibroids
Intramural Fibroids (most common)
Subserosal Fibroids
Pedunculated Fibroids
Extrauterine Fibroids

Submucosal Fibroids
Leiomyomata that are primarily on the endometrial side of the
uterus and protrude into the uterine cavity
In muscle beneath the endometrium of the uterus
Distorts uterine cavity
Small lesion which may lead to bleeding and infertility
Can prolapse through cervix, leading to labor-like uterine
contractions
Intramural Fibroids
Leiomyomata that are primarily located in the uterine muscle
It is the most common type
They begin as small nodules in the muscular wall of the
uterus
They may expand inwards and cause distortions and
elongation of the uterine cavity
Subserosal Fibroids
Leiomyomata that are primarily on the outside of the uterus,
on the serosal surface.
They are located underneath the mucosal surface of the
uterus
They can become very large
They can grow out into a papillary manner to become
pedunculated growths
They can detach from the uterus and become parasitic
leiomyomata
Pedunculated Fibroids
They are intra-cavitary fibroids located on the stalk
They can be passed through the cervix

Extrauterine Fibroids
Parasitic myomas
They are located in other parts of the body
Related or identical to metastasizing leiomyoma

Carneous Degeneration
These are changes of the leiomyomata due to rapid growth
The center of the fibroid becomes red, causing pain
It is synonymous with red degeneration
Etiology


Exact mechanism is unknown
Evidence suggest that uterine fibroid grows from a single mutated uterine
smooth muscle cell, and are thereby monoclonal tumors.

GENETIC

Chromosomal rearrangement.
translocations between chromosomes 12 and14.
Deletions of chromosome 7
Trisomy of chromosome 12 in large tumors.
60% may have yet undetected mutations
More than 100 genes are up and down regulation in fibroid cells

internatinal Journal of Cancer
International Journal of Cancer

Diagnosis
Pelvic examination: irregular pelvic mass that is mobile,
midline and moves contiguously with the cervix
Transabdominal Ultrasound
Transvaginal Ultrasound
MRI
Sonohysterography (Gynecologic ultrasonography)
Sonography is the most readily available and least costly to
differentiate fibroids from other pelvic pathology . It is
reasonably reliable for evaluation of uterus with< 375 cc
volume and 3-4 or fewer fibroids.
Differential Diagnosis
Adenomyosis
Endometrial polyp
Pregnancy
Endometrial carcinoma
Treatment
Many uterine fibroids are asymptomatic and only need to be monitored.
Very rarely uterine leiomyomata degenerate into leiomyosarcoma
Medication to control symptoms (like pain) such as NSAIDs
Medications to shrink tumors: GnRH agonists such as Danazol but
often once you stop the treatment the tumors regrow to pretreatment
size
Thus GnRH agonist therapy is reserved for tumor shrinkage or
correction of anemia prior to operative treatment.
Hysterectomy: for symptomatic fibroids when future pregnancy is
undesired.
Ultrasound fibroid destruction
Myomectomy for women who still desire children
Uterine artery embolization
Uterine Artery Embolization
Technique performed under anesthesia by cannulizing the
femoral artery and catheterizing both uterine arteries directly
Infusing embolization particles that preferentially float to the
fibroid vessels
This causes fibroid infarction and subsequent hyalinization
and fibrosis
Initial studies with follow-up over 5 years shows symptom
relief for approx. 75% of women
However this intervention should not be used in women who
want to get pregnant in the future because there is an
increased risk of placentation abnormalities.





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you? Fine. Thats fine. You know what?
Thats just GREAT. These perfectly
good eggs. That I spent all month
slaving over. Its fine. Ill just throw
them away. Whatever. No big deal.