UTERINE FIBROIDSUTERINE FIBROIDS

Dr. SALWA NEYAZIDr. SALWA NEYAZI

CONSULTANT OBSTETRICIAN GYNECOLOGISTCONSULTANT OBSTETRICIAN GYNECOLOGIST

PEDIATRIC & ADOLESCENT GYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGIST

LEIOMYOMALEIOMYOMA

What is a leiomyoma?What is a leiomyoma?It is a benign neoplasm of the muscular wall of the uterus It is a benign neoplasm of the muscular wall of the uterus

composed primarily of smooth muscle composed primarily of smooth muscle

What is the incidence of leiomyomas?What is the incidence of leiomyomas?They are the most common pelvic tumorsThey are the most common pelvic tumors

It is found in 25% of white women & 50% of black womenIt is found in 25% of white women & 50% of black women

ETIOLOGYETIOLOGY

UnknownUnknown

Each individual myoma is unicellular in originEach individual myoma is unicellular in origin

EstogensEstogens no evidence that it is a causative factor , it no evidence that it is a causative factor , it has been implicated in growth of myomashas been implicated in growth of myomas

Myomas contain estrogen receptors in higher Myomas contain estrogen receptors in higher concentration than surrounding myometriumconcentration than surrounding myometrium

Myomas may increase in size with estrogen therapy & in Myomas may increase in size with estrogen therapy & in pregnancy & decrease after menopausepregnancy & decrease after menopause

They are not detectable before pubertyThey are not detectable before puberty

Progestrone increase mitotic activity & reduce apoptosis Progestrone increase mitotic activity & reduce apoptosis in size in size

There may be genetic predisposition There may be genetic predisposition

PATHOLOGYPATHOLOGY

Frequently multipleFrequently multiple

May reach 15 cm in size or largerMay reach 15 cm in size or larger

Firm Firm

Spherical or irregularly lobulatedSpherical or irregularly lobulated

Have a false capsuleHave a false capsule

Can be easily enucleated from surrounding myometriumCan be easily enucleated from surrounding myometrium

CLASSIFICATIONCLASSIFICATION

Submucous leiomyomaSubmucous leiomyoma

Pedunculated submucousPedunculated submucous

Intramural or interstitialIntramural or interstitial

Subserous or Subserous or subperitonealsubperitoneal

Pedunculated abdominalPedunculated abdominal

ParasiticParasitic

IntraligmentaryIntraligmentary

Cervical Cervical

MICROSCOPIC STRUCTUREMICROSCOPIC STRUCTURE

Whorled appearance Whorled appearance nonstriated muscle fibers nonstriated muscle fibers arranged in bundles running in different directionsarranged in bundles running in different directions

Individual cells are spindle shaped uniformIndividual cells are spindle shaped uniform

Varying amount of connective tissue are interlaced Varying amount of connective tissue are interlaced between muscle fibersbetween muscle fibers

Pseudocapsule of areolar tissue & compressed Pseudocapsule of areolar tissue & compressed myometriummyometrium

Arteries are less dense than myometrium & do not have Arteries are less dense than myometrium & do not have a regular pattern of distributiona regular pattern of distribution

1-2 major vesseles are found at the base or pedicle1-2 major vesseles are found at the base or pedicle

SECONDARY CHANGESSECONDARY CHANGES

11--BENIGN DEGENERATIONBENIGN DEGENERATION

AtrophicAtrophic

Hyaline Hyaline yellow, soft gelatinous areas yellow, soft gelatinous areas

Cystic Cystic liquefaction follows extreme hyalinizationliquefaction follows extreme hyalinization

Calcific Calcific circulatory deprivation circulatory deprivation precipitation of ca precipitation of ca carbonate & phosphatecarbonate & phosphate

Septic Septic circulatory deprivation circulatory deprivation necrosis necrosis infection infection

Myxomatous (fatty) Myxomatous (fatty) uncommon, follows hyaline or uncommon, follows hyaline or cystic degenrationcystic degenration

11--BENIGN DEGENRATION (cont’d)BENIGN DEGENRATION (cont’d)

Red (carneous) degenerationRed (carneous) degeneration

Commonly occurs during pregnancy Commonly occurs during pregnancy

Edema & hypertrophy Edema & hypertrophy impede blood supply impede blood supply aseptic aseptic degenration & infarction with venous thrombosis & degenration & infarction with venous thrombosis & hemorrhagehemorrhage

Painful but self-limitingPainful but self-limiting

May result in preterm labor & rarely DICMay result in preterm labor & rarely DIC

2-MALIGNANT TRANSFORMATION2-MALIGNANT TRANSFORMATIONTransformation to leiomyosarcomas occurs in 0.1-0.5%Transformation to leiomyosarcomas occurs in 0.1-0.5%

CLINICAL FINDINGSCLINICAL FINDINGS

11--SYMPTOMSSYMPTOMS

Symptomatic in only 35-50% of PtSymptomatic in only 35-50% of Pt

Symptoms depend on location, size, changes & Symptoms depend on location, size, changes & pregnancy statuspregnancy status

1-Abnormal uterine bleeding1-Abnormal uterine bleeding

The most common 30%The most common 30%

Heavy / prolonged bleeding (menorrhagia) Heavy / prolonged bleeding (menorrhagia) iron iron deficiency anemiadeficiency anemia

11--Abnormal uterine bleeding (cont’d)Abnormal uterine bleeding (cont’d)

Submucous myoma produce the most pronounced Submucous myoma produce the most pronounced symptoms of menorrhagia, pre & post-menstrual spottingsymptoms of menorrhagia, pre & post-menstrual spotting

Bleeding is due to interruption of blood supply to the Bleeding is due to interruption of blood supply to the endometrium, distortion & congestion of surrounding endometrium, distortion & congestion of surrounding vessels or ulceration of the overlying endometriumvessels or ulceration of the overlying endometrium

Pedunculated submucous Pedunculated submucous areas of venouse areas of venouse thrombosis & necrosis on the surface thrombosis & necrosis on the surface intermenstrtual intermenstrtual bleedingbleeding

22--PAINPAIN

Vascular occlusion Vascular occlusion necrosis, infection necrosis, infection

Torsion of a pedunculated fibroid Torsion of a pedunculated fibroid acute painacute pain

Myometrial contractions to expel the myomaMyometrial contractions to expel the myoma

Red degenration Red degenration acute painacute pain

Heaviness fullness in the pelvic area Heaviness fullness in the pelvic area

Feeling a massFeeling a mass

If the tumor gets impacted in the pelvis If the tumor gets impacted in the pelvis pressure on pressure on nerves nerves back pain radiating to the lower extremitiesback pain radiating to the lower extremities

Dysparunea if it is protruding to vaginaDysparunea if it is protruding to vagina

33--PRESSURE EFFECTSPRESSURE EFFECTS

If large may distort or obstruct other organs like ureters, If large may distort or obstruct other organs like ureters, bladder or rectum bladder or rectum urinary symptoms, hydroureter, urinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edemaconstipation, pelvic venous congestion & LL edema

Rarely a posterior fundal tumor Rarely a posterior fundal tumor extreme retroflexion of extreme retroflexion of the uterus distorting the bladder base the uterus distorting the bladder base urinary retentionurinary retention

Parasitic tumor may cause bowel obstructionParasitic tumor may cause bowel obstruction

Cervical tumors Cervical tumors serosanguineous vaginal discharge, serosanguineous vaginal discharge, bleeding, dyspareunia or infertilitybleeding, dyspareunia or infertility

44--INFERTILITYINFERTILITY

The relationship is uncertainThe relationship is uncertain

27-40% of women with multiple fibroids are infertile 27-40% of women with multiple fibroids are infertile but other causes of infertility are presentbut other causes of infertility are present

Endocavitary tumors affect fertility moreEndocavitary tumors affect fertility more

5- SPONTANEOUS ABORTIONS5- SPONTANEOUS ABORTIONS~2X N ~2X N incidence before myomectomy 40% incidence before myomectomy 40%

after myomectomy 20%after myomectomy 20%

More with intracavitary tumorsMore with intracavitary tumors

EXAMINTIONEXAMINTION

Most myoma are discovered on routine bimanual pelvic Most myoma are discovered on routine bimanual pelvic exam or abdominal examinationexam or abdominal examination

Retroflexed retroverted uterus Retroflexed retroverted uterus obscure the palpation obscure the palpation of myomas of myomas

LABORATORY FINDINGSLABORATORY FINDINGSAnemiaAnemia

Depletion of iron reserveDepletion of iron reserve

Rarely erythrocytosis Rarely erythrocytosis pressure on the ureters pressure on the ureters back back pressure on the kidneys pressure on the kidneys erythropoietin erythropoietin

Acute degeneration & infection Acute degeneration & infection ESR, leucocytosis, ESR, leucocytosis, & fever& fever

IMAGINGIMAGING

Pelvic U/S is very helpful in confirming the Dx & Pelvic U/S is very helpful in confirming the Dx & excluding pregnancy / excluding pregnancy / Particularly in obese PtParticularly in obese Pt

Saline hysterosonography Saline hysterosonography can identify submucous can identify submucous myoma that may be missed on U/Smyoma that may be missed on U/S

HSG HSG will show intrauterine leiomyoma will show intrauterine leiomyoma

MRI MRI highly accurate in delineating the size, location & highly accurate in delineating the size, location & no. of myomas , but not always necessaryno. of myomas , but not always necessary

IVP IVP will show ureteral dilatation or deviation & urinary will show ureteral dilatation or deviation & urinary anomaliesanomalies

HYSTROSCOPY HYSTROSCOPY for identification & removal of for identification & removal of submucous myomassubmucous myomas

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Usually easily diagnosedUsually easily diagnosed

Exclude pregnancyExclude pregnancy

Exclude other pelvic massesExclude other pelvic masses

-Ovarian Ca-Ovarian Ca

-Tubo-ovarian abscess -Tubo-ovarian abscess

-Endometriosis-Endometriosis

-Adenexa, omentum or bowel adherent to the uterus -Adenexa, omentum or bowel adherent to the uterus

Exclude other causes of uterine enlargement:Exclude other causes of uterine enlargement:

-Adenomyosis-Adenomyosis

-Myometrial hypertrophy-Myometrial hypertrophy

-Congenital anomalies-Congenital anomalies

-Endometrial Ca-Endometrial Ca

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Exclude other causes of abnormal bleeding Exclude other causes of abnormal bleeding

Endometrial hyperplasia Endometrial hyperplasia

Endometrial or tubal CaEndometrial or tubal Ca

Uterine sarcoma Uterine sarcoma

Ovarian CaOvarian Ca

PolypsPolyps

AdenomyosisAdenomyosis

DUBDUB

EndometriosisEndometriosis

Exogenouse estrogensExogenouse estrogens

Endometrial biopsy or D&C is essential in the evaluation of Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Caabnormal bleeding to exclude endometrial Ca

COMPLICATIONSCOMPLICATIONS

11--COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY

≥≥ 2/3 of women with fibroids & unexplained 2/3 of women with fibroids & unexplained infertility conceive after myomectomyinfertility conceive after myomectomy

Red degenerationRed degeneration

In the 2In the 2ndnd or 3 or 3rdrd trimester of pregnancy trimester of pregnancy rapid rapid in size in size vascular deprivation vascular deprivation degeneration degeneration

Causes pain & tendernessCauses pain & tenderness

May initiate preterm laborMay initiate preterm labor

Managed conservatively with bedrest & narcotics Managed conservatively with bedrest & narcotics + tocolytics if indicated+ tocolytics if indicated

After the acute phase pregnancy will continue to After the acute phase pregnancy will continue to termterm

COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY

DURING LABORDURING LABOR

Uterine inertiaUterine inertia

MalpresentationMalpresentation

Obstruction of the birth canalObstruction of the birth canal

Cervical or isthmeic myoma Cervical or isthmeic myoma necessitate CS necessitate CS

PPHPPH

COMPLICATIONS IN NONPREGNANT WOMENCOMPLICATIONS IN NONPREGNANT WOMEN

Heavy bleeding with anemia is the most commonHeavy bleeding with anemia is the most common

Urinary or bowel obstruction from large parasitic myoma Urinary or bowel obstruction from large parasitic myoma is much less commonis much less common

Malignant transformation is rareMalignant transformation is rare

Ureteral injury or ligation is a recognized complication of Ureteral injury or ligation is a recognized complication of surgery for Cx myomasurgery for Cx myoma

No evidence that COCP No evidence that COCP the size of myomas the size of myomas

Postmenopausal women on HRT must be followed up Postmenopausal women on HRT must be followed up with pelvic exam or U/S every 6 M with pelvic exam or U/S every 6 M

TREATMENTTREATMENT

TREATMENTTREATMENT

DEPENDS ON:DEPENDS ON:

AgeAge

ParityParity

Pregnancy statusPregnancy status

Desire for future pregnancyDesire for future pregnancy

General healthGeneral health

SymptomsSymptoms

Size Size

LocationLocation

A-EMERGENCY MEASURESA-EMERGENCY MEASURES

Blood transfusion/ PRBC to correct anemiaBlood transfusion/ PRBC to correct anemia

Emergrncy surgery indicatd for:Emergrncy surgery indicatd for:

- infected myoma- infected myoma

-acute torsion-acute torsion

-intestinal obstruction-intestinal obstruction

Myomectomy is contraindicated during pregnancy Myomectomy is contraindicated during pregnancy

B-SPECIFIC MEASURESB-SPECIFIC MEASURES

Most cases asymptomatic Most cases asymptomatic no treatment no treatment

Postmenopausal Postmenopausal no treatment no treatment

Other causes of pelvic mass must be excludedOther causes of pelvic mass must be excluded

The Dx must be certainThe Dx must be certain

Initial follow up every 6 M Initial follow up every 6 M to determine the rate of to determine the rate of growth of the myomagrowth of the myoma

Surgery is contraindicated in pregnancySurgery is contraindicated in pregnancy

The only indication for myomectomy in pregnancy is The only indication for myomectomy in pregnancy is torsion of a pedunculated fibroidtorsion of a pedunculated fibroid

Myomectomy is not recommended during CSMyomectomy is not recommended during CS

Pregnant women with previous multiple myomectomy / Pregnant women with previous multiple myomectomy / especially if the cavity was entered especially if the cavity was entered should be should be delivered by CS to delivered by CS to risk of scar rupture in labor risk of scar rupture in labor

GNRH AGONISTSGNRH AGONISTS

RX results in:RX results in:

1-1- size of the myomas 50% maximum size of the myomas 50% maximum

2- This shrinkage is achieved in 3M of RX2- This shrinkage is achieved in 3M of RX

3-Amenorrhea & hypoestrogenic side-effects occur3-Amenorrhea & hypoestrogenic side-effects occur

4-Osteopososis may occur if Rx last > 6M4-Osteopososis may occur if Rx last > 6M

It is indicated forIt is indicated for

1-1- bleeding from myoma except for the polypoid bleeding from myoma except for the polypoid submucous typesubmucous type

2-Preoperative to 2-Preoperative to size size allow for vaginal hysterectomy allow for vaginal hysterectomy

myomectomymyomectomy

laparoscopic myomectomy laparoscopic myomectomy

C-SUPPORTIVE MEASURESC-SUPPORTIVE MEASURES

PAP smear & endometrial sampling for all Pt with PAP smear & endometrial sampling for all Pt with irregular bleedingirregular bleeding

Before surgeryBefore surgery

-Correct Hb-Correct Hb

-Prophylactic antibiotics-Prophylactic antibiotics

-Mechanical & antibiotic bowel preparation -Mechanical & antibiotic bowel preparation if difficult if difficult surgery is anticipatedsurgery is anticipated

Prophylactic heparin postoperativeProphylactic heparin postoperative

D-SURGICAL MEASURESD-SURGICAL MEASURES

1-Evaluation for other neoplasia1-Evaluation for other neoplasia

2-Myomectomy2-Myomectomy

For symptomatic Pt who wish to preserve fertility For symptomatic Pt who wish to preserve fertility

Open myomectomyOpen myomectomy

Laparoscopic myomectomyLaparoscopic myomectomy

Hysteroscopic myomectomyHysteroscopic myomectomy

3-Hysterectomy3-Hysterectomy

Vaginal hysterectomyVaginal hysterectomy

Abdominal hysterectomyAbdominal hysterectomy

4-Uterine artery embolisation4-Uterine artery embolisation