Uterine Fibroid Presentation for ONGpptx

Uterine Fibroid Presentation for ONGpptx

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  Uterine Fibroids Dr ChiemekaOzoemena HO Urogynecology 5/10/2023
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  Fibroids • Synonyms :Myoma, Leiomyoma, Fibromyoma • Most common benign neoplasm in uterus and female pelvis • Incidence : 20 to 40% of reproductive age women
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  Epidemiological risk factors Increasedrisk • Increased risk • Age 35 to 45 years • nulliparous or low parity • Black women • strong family history • Obesity • early Menarche • Diabetes • hypertension Decreased risk • ↑↑ parity • Exercise • ↑↑intake of green vegetables • Progesterone only contraceptives • Cigarette smoking
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  Etiology It arises fromsmooth muscle cells of myometrium • Exact etiology not known • Monoclonal origin ( arising from single cell) confirmed by G6PD studies • Genetic basis definite • Various growth factors like TGFβ , EGF, IGF-1, IGF-2, BFGF are recently implicated in the development of fibroids
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  Fibroid - Etiology Geneticbasis: Responsible for 40 % cases of fibroids • Translocation between Chromosome 12 & 14 • Trisomy 12 • Rearrangement of short arm of Chromo 6 • Rearrangement of long arm of Ch. 10 • Deletion of Ch.3 or Ch.7q
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  Fibroid - Etiology Estrogenalthough not proven to fcause fibroids, is definitely implicated in its growth since: • Its Uncommon before puberty & regress after menopause • Higher incidence in nulliparous women • Common in obese women • May increase during pregnancy • Studies show high concentrations of estrogen receptors in leiomyoma than myometrium • Common in fifth decade due to anovulatory cycles with high or unopposed estrogen
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  Types of Fibroids •More common in uterine corpus, less common in cervix • All fibroids are interstitial to begin with and then enlarge • May remain intramural, become subserosal or submucosal • Subserosal may become pedunculated & occassionally parasitic receiving blood from other organs usually omentum • Submucous fibroid may become pedunculated and present in the vagina through the cervix • Large submucous fibroid may pull down the cervix resulting in chronic inversion
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  Classification of Fibroids
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  Fibroid Pathology • Grossappearance- Multiple, discrete, spherical, pinkish white, firm capsulated masses protruding from surrounding myometrium. Pseudo capsule is made up of compressed myometrium giving it a distinct outline • Microscopy- nonstriated muscle fibres are arranged in interlacing bundles of varying size & running in different directions (whorled appearance). Varying amount of connective tissue is intermixed with smooth muscle fibres
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  Fibroid Pathological variants •Microscopic variants  Cellular myoma, mitotically active myoma, bizarre myoma, lipoleiomyoma, • Intravenous leiomyomatosis • LPD – leiomyomatosis peritonealis dissemination • Secondary changes- Hyaline, calcific, necrosis, red degeneration during pregnancy, fatty degeneration • Leiomyosarcoma- 0.49-0.79%, more common in the 5th decade, diagnosed with presence of mitotic figures
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  Clinical presentation - Asymptomatic-most common - Abnormal uterine bleeding – 30-50% of patients . It is due to ↑↑ surface area, ↑↑vascularity, thinning and ulceration of overlying myometrium, endometrial hyperplasia, venous obstruction, interference with contractions. More common with submucosal but may occur with all types - Anemia due to excessive blood loss - Pelvic pain in 1/3rd patients, backache. Acute pain due to torsion, infection, expulsion, red degeneration, vascular complication Dysmenorrhoea – Spasmodic as well as congestive
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  Clinical presentation - Pressuresymptoms Lump in abdomen Urinary symptoms- urgency, frequency, incontinence, rarely urethral obstruction Bowel symptoms- constipation, intermittent intestinal obstruction - Abdominal distention- with large fibroids - Rapid growth- with pregnancy and malignancy - Infertility – 2 to 10 % cases- Anovulatory, irregular cavity interfering with sperm transport, endometrial changes * Rare symptoms : Ascites, polycythemia
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  Effects of fibroidon pregnancy : • Pregnancy : Abortion Pressure symptoms Malpresentation Retrodisplacement of uterus • Labour : Preterm labour Malpresentation Uterine inertia PPH Dystocia MRP • Puerperium : Subinvolution Sec. PPH Puerperal sepsis Inversion
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  Effects of pregnancyon fibroid : • Increase in size & softening occurs . Increase occurs mainly in the 1st trimester & in 22 to 32 % cases. • Red degeneration in 2nd trimester – due to rapid growth there is congestion with interstitial hemorrhage & venous thrombosis • Impaction in pelvis • Torsion • Infection • Expulsion • Injury- Pressure necrosis during delivery • Rupture of subserous vein  Internal hemorrhage
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  Fibroid - Signs Generalexamination– Anemia due to prolonged heavy bleeding . P/A – If > 12 weeks size , firm, nodular, arising from pelvis, lower limit can’t be reached, relatively well defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen P/S – Cervix pulled higher up P/V – Uterus enlarged, nodular. D/D from ovarian tumour  Uterus not separately felt , transmitted movement present, notch not felt. P/R – May help in difficult cases .
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  Fibroid - Diagnosis Investigations •USG : Well defined hypoechoic lesions. Peripheral calcification with distal shadowing in old fibroids Adenomyosis is differentiated by diffuse lesion, less echodense , disordered echogenicity & more prominent at or just after menstruation • Hysteroscopy : Submucous fibroids • Saline infusion sonography- help differentiate submucous from intramural fibroids
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  Fibroid USG
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  Fibroid Diagnosis MRI :Most accurate imaging modality for diagnosis of fibroid. It does precise fibroid mapping & characterization  Detects all fibroids accurately  D/D from adenomyosis  D/D from adnexal pathology  Ovaries are easily seen  Detects small myomas(0.5 cm) H S G : Not done for diagnosis. Done for infertility evaluation filling defects may be seen.
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  Fibroid MRI
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  Fibroid D/D • Pregnancy •Adenomyosis • Ovarian tumour • Ectopic pregnancy • Endometriosis • T O mass
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  Fibroid- Management Expectant :asymptomatic incidental fibroids Size < 12 weeks, nearing menopause • Regular follow up every 6 months • Routine pelvic examination • Baseline imaging to compare regression
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  Medical Management • Nota definitive treatment • For symptomatic relief from pain- NSAIDs • Also decrease menstrual blood loss • Preoperatively to decrease the size • Drugs used: Progestogens, antiprogestogens(Mifepristone), androgens ( Danazol, Gestrinone) & GnRH analogues are used
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  GnRH analogues GnRH Agonistsare commonly used drugs :- • Triptorelin (Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline (Zoladex) 3.6 mg SC for 3 months • Advantages : Decrease in size of myoma by 20 to 50 % Decrease in bleeding increases Hb level Decreases blood loss during surgery Converts hysterectomy into myomectomy Converts Abd. hyst into vag. hysterectomy Makes hysterectomic resection possible
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  GnRH analogues • Disadvantages: High cost Hypoestrogenic side effects- medical menopause Effect is reversible Rarely ↑↑ bleeding due to degeneration Occasionally difficulty in enucleation.
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  Medical - NewerTherapy SERM – Raloxifen • 60 mg /day is tried for 6 to 12 mths. • Higher doses ( 180 mg) are required for effective decrease in size. • Better if combined with GnRH analogs
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  Medical - NewerTherapy SPRM – Asoprisnil (Selective Progesterone Receptor Modulator) • 5 to 25 mg/day is used • Mechanism of inhibitory action is not known • Possible risk of endometrial hyperplasia is not studied
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  Medical - NewerTherapy Mifepristone • 5 – 10 mg is tried • No loss of bone density • Promising results • Decrease in myoma volume by 26-74 %. • No effect on bone density • Endometrial hyperplasia may limit its longterm use.
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  Medical - NewerTherapy Aromatase inhibitors • Directly inhibit estrogen synthesis & rapidly produce hypoestrogenic state Fadrozole/ Letrozole is tried in couple of studies • 71 % reduction occurred in 8 weeks • Appears to be promising therapy
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  Medical - NewerTherapy • Progesterone releasing IUD- LNG-IUD • Fibroids with uterus <12 weeks size with menorrhagia • However, expulsion rates higher in presence of fibroidsThird generation IUCD • Contains Progesteron LNG 60 mg releasing 20 ug /day • Fibroids decreases in size 6 – 12 mths of use. • May have variable effects on uterine myomas depending upon balance of growth factors • Couple of studies have shown beneficial results • Suitable for those who also desire contraception
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  Surgical Management * Hysterectomy Abdominal  Vaginal  LAVH, TLH * Myomectomy  Abdominal  Vaginal  Hysteroscopic  Laproscopic Laparoscopically Assisted Vaginal Hysterectomy (LAVH) is a surgical procedure using a laparoscope to guide the removal of the uterus and/or Fallopian tubes and ovaries through the vagina (birth canal). Total laparoscopic hysterectomy (TLH) is the complete hysterectomy including transection of the uterine vessels and opening/closure of the vaginal vault performed laparoscopically.
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  Surgical Management Vaginal hysterectomyis favoured if  • Uterus < 16 wks, preferably < 14 wks • No associated pathology like endometriosis , PID, adhesions • Uterus mobile & adequate lateral space in pelvis • Experienced vaginal surgeon
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  Surgical Management Myomectomy isdone in following :- • Infertility • Recurrent pregnancy loss & no other cause found for it • Young patients • Patients who wish to preserve their uterus
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  Hysteroscopic myomectomy • Forsubmucous myoma causing infertility, RPL, AUB or pain • Criteria :- < 5 cm in size < 50 % intramural component < 12 cm uterine size • Gn RH analogue may be given preoperatively • Suspicion of malignancy, infection & excessive mural component contraindicates surgery • Advantages are short procedure, rapid recovery & all disadvantages of laprotomy avoided • Large fibroids can be morcellated prior to removal
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  Laproscopic myomectomy In 3phases  excision of myoma, repair of myometrium & extraction • Suitable for subserous & intramural fibroids upto 10 cm size • Complications are those of operative laproscopy + myomectomy • Fibroid excised are remoyed by electronic morcellators or through posterior colpotomy incision vaginally.
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  Abdominal myomectomy - Otherfactors for infertility should be ruled out - Consent for hysterectomy - Blood matched & handy - Pap’s smear & endometrial sampling to rule out malignancy - Medical or mechanical means to control blood loss  Bonney’s Myomectomy clamp, rubber tourniquet, manual ( finger compression) pressure at isthmic region or use of vasopressin 10 – 20 units diluted in 100ml saline infiltrated before putting the incision .
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  Abdominal myomectomy • Minimumincisions are kept – preferably single midline vertical, lower, anterior wall • Removal of as many fibroids as possible through one incision & secondary tunnelling incisions • Meticulous closure of all dead space • Proper haemostasis • Multiple small fibroids can be removed enbloc by wedge resection • Measures for adhesion prevention should be taken
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  Abdominal myomectomy • Morcellation– Deeply embedded tumours are best removed by cutting them into bits. • Bonney’s hood – for posterior fundal large fibroid transverse fundal incision posterior to tubal insertion is made & uterine wall after enucleation is sutured anteriorly covering the fundus as a hood.
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  Vaginal myomectomy • Submucouspedunculated or small sessile cervical fibroids are removed vaginally. • Ligation of pedicle if accessible • Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids • To gain access to pedicle of higher & big fibroid incision on the cervix can be made.
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  Laproscopic myolysis • ByND-YAG laser or long bipolar needle electrode thro. Laproscope blood supply of myoma is coagulated. • Without blood supply myoma atrophies. • Applicable to 3 -10 cm size & myomas < 4 in number * Cryomyolysis is under investigation
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  Uterine artery embolization •By interventional radiologist • Catheter is passed retrograde through Right femoral artery to bifurcation of aorta & then negotiated down to opposite uterine artery first. • Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or gelfoam are used for embolization. • 60 – 65 % reduction in size of fibroid • 80 – 90 % have improvements in menorrhagia & pressure symptoms
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  Uterine artery embolization
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  Uterine artery embolization •High vascularity & solitary fibroid are associated with greater chance of longterm success. • Pregnancy, active infection & suspicion of malignancy are absolute contraindications • Desire for fertility is also a contraindication to UAI • The risk of ovarian failure must be counselled • Post embolization syndrome ( fever ,vomiting, pain) can occur
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  Uterine artery embolization
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  MAGNETIC RESONANCE-GUIDED FOCUSEDULTRASOUND - MRgFUS • A non-invasive, non-surgical procedure that involves radiofrequency — focused beams of acoustic energy — to heat and destroy a small, targeted area of tissue in the uterus without harming adjacent tissues.
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  MRgFUS • Side effects: –Skin burn – Pain – Nerve damage (rare) • Advantages 1. Noninvasive technique 2. Local anaesthesia—takes 1 to 2hr to do 3. No hospitalization 4. No scar 5. Quick recovery 6. Fertility preservation technique • Contraindications 1. Calcified fibroid. 2. Degenerated fibroid. 3. Interstitial laser ablation is done laparoscopically by inserting laser fibres into the myoma.
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  CONCLUSION Benign gynecological diseaseis common and may cause women many problems, some of which can have a significant impact on quality of life. New modalities are being sought for uterine fibroids. This, together with work studying the etiology and pathogenesis of these benign tumors, should lead to progress and the development of new treatment options in the future
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  REFERENCES • Shaw’s Textbookof Gynecology Chapter 29 Benign Disease of the Uterus • Barjon K, Mikhail LN. Uterine Leiomyomata. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls • Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. • Dewhurst's Textbook of Obstetrics & Gynaecology, Chapter 59 Benign Disease of the Uterus
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  Thank You