FIBROIDS;

ENDOMETRIAL
POLYPS;
ADENOMYOSIS
Mian Muhammad Saad
Irfan
Saif Ali Qureshi
 ANATOMY
• The uterus is shaped like an inverted pear
tapering inferiorly to the cervix and in its
non-pregnant state is situated entirely
within the pelvis.
• It is hollow and has thick, muscular walls.
• Its maximum external dimensions are
approximately 7.5 cm long, 5 cm wide and
3 cm thick.
• An adult uterus weighs approximately 70
g.
• In the upper part, the uterus is termed the
body or ‘corpus’.
• The area of insertion of each Fallopian tube
is termed the ‘cornu’ and that part of the
body above the cornu is called the
‘fundus’.
• The uterus tapers to a small constricted
area, the isthmus, and below this is the
 HISTOLOGY
• The uterus consists of three layers: the
outer serous layer (peritoneum), the
middle muscular layer (myometrium)
and the inner mucous layer
(endometrium).
• The peritoneum covers the body of the
uterus and posteriorly it covers the
supravaginal part of the cervix. The
peritoneum is intimately attached to a
subserous fibrous layer.
• The muscular myometrium forms the
main bulk of the uterus and is made up
of interlacing smooth muscle fibres
intermingling with areolar tissue, blood
vessels, nerves and lymphatics.
• The inner endometrial layer has tubular
glands that dip into the myometrium.
 BLOOD SUPPLY
• The internal iliac (hypogastic) artery:
• This vessel is about 4 cm in length and begins at the
bifurcation of the common iliac artery in front of the
sacroiliac joint.
• It soon divides into anterior and posterior branches;
the branches that supply the pelvic organs are all from
the anterior division.
• The uterine artery provides the main blood supply to
the uterus.
• The artery first runs downwards on the lateral wall of
the pelvis, in the same direction as the ureter. It then
turns inward and forwards lying in the base of the
broad ligament.
• On reaching the wall of the uterus, the artery turns
upwards to run tortuously to the upper part of the
uterus, where it anastamoses with the ovarian artery.
In this part of its course, it sends many branches into
the substance of the uterus.
 FIBROIDS
• A fibroid is a benign tumour of uterine
smooth muscle termed a ‘leiomyoma’.
• The gross appearance is of a well-
demarcated, firm, whorled tumour.
• They are highly prevalent, being found in
approximately 40% of women overall, and
are more common in nulliparous and obese
women and in those with a family history or
of African descent.
• They are usually multiple and can
substantially increase the size of the uterus.
• Fibroids are classified according to their
location in relation to the uterine wall.
 NATURAL HISTORY
• Fibroids are benign, oestrogen-dependent tumours
that can enlarge during pregnancy in response to
the hyperoestrogenic state, become common with
advancing reproductive age and shrink after the
menopause when ovarian oestrogen production
ceases.
• They can undergo degenerative change usually in
response to outgrowing their blood supply.
• Three forms of degeneration are recognized:
• Red – haemorrhage and necrosis occurs within the
fibroid typically presenting in the mid-second
trimester pregnancy with acute pain.
• Hyaline – asymptomatic softening and liquefaction
of the fibroid.
• Cystic – asymptomatic central necrosis leaving
cystic spaces at the centre. Degenerative changes
can initiate calcium deposition leading to
calcification.
 CLINICAL
• Most fibroids are small and asymptomatic, but
they can beFEATURES
associated with the following
conditions:
• AUB (usually HMB and IMB).
• Reproductive failure.
• Subfertility.
• Recurrent pregnancy loss.
• Bulk effects on adjacent structures in the
pelvis.
• Pressure and pain.
• Bladder and bowel dysfunction.
• Abdominal distension.
• EXAMINATION FINDINGS SUGGESTIVE OF
FIBROIDS:
• General: signs of anaemia.
• Abdominal examination: visible and/or
palpable abdominal mass arising from the
pelvis.
 DIAGNOSIS
• Often the clinical features obtained from the history and
examination alone will be sufficient to establish the diagnosis.
• A full blood count should be taken in women with HMB; severe
anaemia associated with HMB invariably indicates the presence
of significant fibroids.
• Transvaginal ultrasound scan (TVUSS): good for detecting and
locating submucous fibroids and small intramural fibroids.
• Transabdominal ultrasound scan (TAUSS): good for detecting
larger intramural and subserosal fibroids and excluding
hydronephrosis secondary to pressure from fibroids obstructing
the ureters.
• Saline infusion sonohysterography (SIS): good for detecting and
locating submucosal fibroids and endometrial polyps.
• Hysteroscopy: good for detecting submucosal fibroids and
endometrial polyps; good for planning subsequent
hysteroscopic surgical treatment; surgical hysteroscopy can
remove polyps, adhesions and submucosal fibroids.
• Magnetic resonance imaging (MRI): good for describing the
morphology and location of fibroids; indicated prior to uterine
 TREATMENT
Medical
• Tranexamic acid /non-steroidal anti-inflammatory
drugs [NSAIDs]/COCP/LNG-IUS (Mirena®): all are
simple and fertility sparing (although COCP/LNG-
IUS are contraceptive) and avoid more invasive
interventions, but they are generally less
effective in the presence of submucosal fibroids
or a uterus >12 weeks size where an enlarged
uterine cavity can be expected.
• COCP: contains oestrogen, which may increase
the growth of oestrogen-dependent fibroids.
• LNG-IUS: increased likelihood of expulsion if
cavity is enlarged or distorted by submucosal
fibroids.
• GnRH-agonists: reduce fibroid volume prior to
surgery but induce a temporary oestrogen
deficient ‘menopausal’ state precluding long-
term use.
• Ulipristal acetate (SPRM): oral medication and, as
with GnRH-agonists, it reduces fibroid volume
Surgical
• Hysteroscopic myomectomy: minimally invasive, day-case
procedure for submucous fibroids that avoids surgical incisions
and is effective in resolving HMB and improving fertility. Will not
treat other types of fibroid.
• Myomectomy: fertility sparing and will treat HMB and bulk
symptoms. Usually requires a laparotomy, but a less invasive
laparoscopic approach is possible with smaller and fewer fibroids.
Associated with intraoperative bleeding from vascular fibroids, a
1% risk of unplanned hysterectomy and postoperative intra-
abdominal adhesions.
• Hysterectomy: indicated for women with no future fertility desires.
May be achieved vaginally, laparoscopically or via open surgery
depending on the size of the uterus. Definitive, guaranteeing
amenorrhoea but as invasive as myomectomy.

Radiological
• Uterine artery embolization: minimally invasive, avoids general
anaesthesia and surgery. Although fertility sparing there are
concerns over effect on subsequent reproductive function.
Equivalent patient satisfaction compared with myomectomy but
the need for further treatments much higher.
• Novel radiological treatments are currently being explored to
 ADENOMYOSIS
• The endometrium is usually well demarcated
from the underlying myometrium.
• Adenomyosis is a disorder in which endometrial
glands and stroma are found deep within the
myometrium.
• Adenomyosis can only be definitively diagnosed
following histopathological examination of a
hysterectomy specimen.
• Histologically, adenomyosis is characterised by
the presence of endometrial glands and stroma
in the uterine myometrium, with surrounding
myometrial hypertrophy and hyperplasia, the
latter often resulting in significant uterine
enlargement.
• The lesions are seen haphazardly and at varied
depths within the myometrium.
• Women with adenomyosis are usually
 CAUSE
• The adenomyotic tissue is presumed to be derived
from the endometrium by abnormal ingrowth and
invagination of its basal layer triggered by a
weakness at the endometrial– myometrial junction.
• Disruption of this interface was previously presumed
to be caused by pregnancy-related factors such as
increased intrauterine pressure or surgical trauma
such as curettage or CS.
• However recent epidemiological data have thrown
some doubt on this hypothesis.
• There is some evidence that endometrial cells in
adenomyosis develop greater invasive potential and
that this, together with altered myometrial
contractility, results in disruption of the endometrial–
myometrial junction.
• Angiogenic growth factors, genetic factors and
hormonal influences are also likely to be involved.
 CLINICAL
• The ectopic endometrium is responsive to
FEATURES
cyclical hormonal changes that result in
bleeding within the myometrium, leading to
increasingly severe secondary
dysmenorrhoea (pain throughout menses),
uterine enlargement and HMB.
• Examination may reveal a bulky and
sometimes tender ‘boggy’ uterus,
particularly if examined perimenstrually.
• However, both the history and the clinical
findings are non-specific. Further
investigation is helpful in distinguishing
between adenomyosis and uterine fibroids.
 DIAGNOSIS
• Transvaginal ultrasound scanning (TVS) should be
used as a primary screening modality for the
diagnosis of adenomyosis.
• Ultrasound examination of the uterus may be helpful
for diagnosis when adenomyosis is particularly
localized, showing haemorrhage-filled, distended
endometrial glands.
• Sometimes this may give an irregular nodular
development within the uterus, very similar to that of
uterine fibroids.
• MRI is the investigation of choice although expensive,
as it provides excellent images of the myometrium,
endometrium and areas of adenomyosis
 TREATMENT
• Given the practical difficulty in making the
diagnosis of adenomyosis preoperatively,
conservative surgery and medical treatments
are so far poorly developed.
• In general, any treatment that induces
amenorrhoea will be helpful as it will render the
ectopic endometrium quiescent, relieving pain
and excessive bleeding.
• Thus, the use of the progestin-containing long-
acting reversible contraceptives such as the
LNG-IUS and depot Provera and short-term
GnRH agonists should be considered.
• On ceasing treatment, however, the symptoms
rapidly return in majority of the patients, and
hysterectomy remains the only definitive
treatment.
 ENDOMETRIAL POLYPS
• Endometrial polyps are focal endometrial outgrowths
containing a variable amount of glands, stroma and
blood vessels, which influence their macroscopic
appearance.
• They are common and estimated to be present in
around 10–20% of women with AUB and 10% of women
with subfertility.
• Risk factors for endometrial polyp development include
obesity, late menopause, the use of the partial
oestrogen agonist tamoxifen and possibly the use of
hormone replacement therapy (HRT).
• Endometrial polyps contain hyperplastic foci in 10–25%
of symptomatic cases and 1% is frankly malignant.
• The risk of polyps harbouring serious endometrial
disease is increased after the menopause and with the
use of tamoxifen.
• Endometrial polyps may be pedunculated or sessile,
 CLINICAL
FEATURES
• Endometrial polyps may be
asymptomatic but can cause
abnormal uterine bleeding (AUB)
(heavy menstrual bleeding [HMB], IMB
and postmenopausal bleeding [PMB])
and adversely impact on fertility.
• Most polyps do not appear to be
subject to the normal cellular
mechanisms that regulate the
endometrium.
• Consequently, they are relatively
insensitive to cyclical hormonal
changes, leading them to persist and
 DIAGNOSIS
• Endometrial polyps can be diagnosed by
transvaginal ultrasound scan (TVUSS).
• But because they are focal, intracavity
pathologies the most accurate tests are:
• Outpatient hysteroscopy (OPH);
• Saline infusion sonography (SIS);
• This investigation involves distending the
uterine cavity with fluid, thereby aiding
detection
 TREATMENT
• Smaller endometrial polyps can
spontaneously resolve but most persist
such that once diagnosed, removal is
indicated (polypectomy) in order to
alleviate AUB symptoms, optimize fertility
and exclude hyperplasia or cancer.
• Polypectomy is a simple procedure that
can be performed as a day-case under
general anaesthesia, but is now
increasingly performed as an outpatient
with or without local anaesthesia.
• A hysteroscope is used to visualize the
polyp(s) and to allow miniature instruments
to be passed down its operating channel in
order to remove the polyp with scissors,
THANK YOU