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UTERINE FIBROIDS (LEIOMYOMATAS). What are they?. Smooth Muscle Tumor of the Uterus The most common uterine tumor Occurring in about 30% of women above the age of 30 years. Occurs up to 75% of hysterectomy specimens Symptomatic in 1/3 of cases. Patient Characteristics. Age: 30-40 years.

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what are they
What are they?
  • Smooth Muscle Tumor of the Uterus
  • The most common uterine tumor
    • Occurring in about 30% of women above the age of 30 years.
  • Occurs up to 75% of hysterectomy specimens
  • Symptomatic in 1/3 of cases
patient characteristics
Patient Characteristics
  • Age:
    • 30-40 years.
    • Rare before 30 or after 40 years
  • Parity:
    • Common in nulliparas, patients with low parity.
    • It is rare in multiparas.
  • Race:
    • 3-9 times more common in negroids.
  • Family history:
    • Usually positive.
  • Hyper-estrenemia:
    • Estrogen receptors (ER) more than the surrounding myometrium but less than those in the endometrium
      • Common in low parity.
      • Atrophies and shrinks after menopause.
      • Common association with other hyper-estrenic conditions as endometriosis, endometrial hyperplasia and endometrial carcinoma.
slide5

[60%]

[20%]

[15%]

characteristics
Characteristics
  • Size
    • from microscopic to very huge size filling the whole abdominal cavity (up to 40 kg was recorded).
  • Shape
    • Spherical, flattened, or pointed according to the type.
  • Cut section:
    • On cut section,, whorly in appearance, and more pale than the surrounding uterine muscle.
  • Consistency:
    • firmer than the surrounding myometrium.
    • Soft fibroid occurs in pregnancy, cystic changes, vascular, inflammatory, and malignant changes.
    • Hard fibroid occurs in calcification.
  • Capsule:
    • Is a pseudo-capsule formed by compressed normal surrounding muscle fibres.
    • the blood supply comes through it,
    • it is the plain of cleavage during myomectomy
    • its presence differentiate the myoma from adenomyosis.
  • Blood supply:
    • Nourishes the myoma from the periphery,
    • The tumor itself is relatively avascular.
presentations
Presentations
  • Asymptomatic:
    • Accidentally discovered during examination.
    • It is the commonest presentation, especially in subserous and interstitial fibroids.
  • Vaginal bleeding: It is the commonest symptom,
    • Menorrhagia or polymenorrhea: (commonest): This occurs due to:
      • Associated hormonal imbalance and endometrial hyperplasia.
      • Surface ulceration of submucous fibroid.
      • Interstitial fibroid acts as F.B. preventing full contraction of myometrium to decrease blood loss.
      • Pelvic congestion.
      • Increased uterine size, vascularity, and endometrial surface area.
    • Metrorrhagia: due to:
      • In submucous fibroid due to ulceration of the surface, necrosis of the tip, or secondary infection.
      • Associated endometrial polyp.
      • Associated malignancy (cancer body or sarcomatous change).
    • Contact bleeding: (rare)
      • ulcerated or infected tip of submucous fibroid polyp.
    • Post-menopausal bleeding:
      • Either due to sarcomatous change or associated endometrial carcinoma.
  • Picture of iron deficiency anemia.
presentations1
Presentations
  • Discharge:
    • Leucorrhea and mucoid discharge due to pelvic congestion.
    • Muco-sanguinous discharge with ulcerated fibroid polyp.
    • Muco-purulent discharge due to secondary infection.
  • Swelling:
    • Either abdominal swelling due to large fibroid or vaginal swelling due to a polyp.
  • Infertility [in 5-10% of cases]:
    • Most important is the underlying predisposing factor as anovulation and hormonal disturbance.
    • Broad ligamentary fibroid may stretch or distort the tubes.
    • Corneal fibroids may obstruct the uterine end of the tube.
    • S.M.F. acts as F.B. interfering with implantation.
    • Cervical fibroid may obstruct the cervical canal.
    • Associated endometriosis or endometrial hyperplasia.
  • Pain: uncommon
    • Intermittent colicky pain in submucous fibroid (acts as F.B. in the uterine cavity).
    • Dull-aching pain and congestive dysmenorrhea due to pelvic congestion.
    • Acute abdomen in red degeneration, torsion, ruptured vessel, and inflammation.
presentations2
Presentations
  • Pressure symptoms
    • Cervical fibroid:
      • Anteriorly on the urethra causing acute retention of urine, or the bladder causing frequency of micturition.
      • Laterally on the ureters causing colic and back pressure on the kidneys.
      • Posteriorly on the rectum causing dyskasia, constipation, and sense of incomplete defecation.
    • Huge fibroid:
      • On the pelvic veins causing edema, pain, and varicose veins in the lower limbs.
      • On the GIT causing distension and dyspepsia.
      • On the diaphragm causing dyspnea.
  • Spontaneous abortion:
    • Before myomectomy [ 40%]
    • 20% after myomectomy.
signs of fibroid
Signs of fibroid
  • General examination:
    • signs of chronic anemia.
  • Abdominal examination:
    • large pelvi-abdominal swelling in huge fibroids.
  • Pelvic examination:
    • symmetrically or asymmetrically enlarged uterus.
  • Speculum examination
    • fibroid polyp.
differential diagnosis
Differential Diagnosis
  • Causes of symmetrically enlarged uterus:
    • Pregnancy
    • Subinvolution of the uterus.
    • Submucous or interstitial fibroid.
    • Metropathia hemorrhagica.
    • Adenomyosis uteri.
    • Carcinoma or sarcoma of the uterus.
    • Pyo, hemato, or physometra.
  • Causes of asymmetrically enlarged uterus:
    • Subserous fibroid.
    • Localized adenomyosis.
    • Ovarian, tubal, or broad ligamentary swelling.
    • Pregnancy in a rudimentary horn.
management
Management
  • Conservative Management
    • small asymptomatic fibroid,
    • fibroid in pregnancy or puerperium.
  • Just keep observation every 6 months.
  • Beware of underlying and/or associated pathology
medical treatment
Medical Treatment:
  • Pre-operative till the time of surgery.
  • Patient near the menopause, or newly married with minimal symptoms.
  • Red degeneration with pregnancy.
  • Lines of treatment:
    • Symptomatic:
      • Correction of anemia,
      • haemostatics,
      • analgesics, and anti-spasmodics (anti-PG).
    • Anti-estrogens:
      • large dose of progesterone,
      • Tamoxifen, Danazol,
      • LH-RH analogues
        • useful in decreasing the size and vascularity of the tumor by 50% which is beneficial before myomectomy
surgical management
Surgical Management

Myomectomy vs. Hysterectomy

??!!

  • Indications:
    • Symptomatic cases or uterus larger than 12 weeks size.
    • Suspected malignancy (rapidly enlarging or post-menopausal growth).
    • Multiple huge fibroids liable to complications.
    • Infertility.
myomectomy
Myomectomy
  • Abdominal Myomectomy
  • Vaginal Myomectomy
  • Endoscopic Myomectomy
    • Hysteroscopic
    • Laparoscopic
  • Embolization techniques ( Interventional Radiology)
principle
Principle
  • Myomectomy aims at
    • removal of all the myomas,
    • with conservation of a functioning uterus to preserve the reproductive function.
  • Generally the morbidity is higher than those with hysterectomy.
    • It is associated with much blood loss
    • Liability of recurrence of fibroid.
  • Myomectomy is better reserved only for those keen to preserve the reproductive function.
principle1
Principle
  • The patient must be prepared for the possible need for an emergency hysterectomy.
  • Precautions to minimize blood loss during myomectomy:
    • The timing of operation is post-menstrual (minimal pelvic congestion).
    • Pre-operative LH-RH analogues: may be given for 3 months before surgery to reduce the size and vascularity of the myomas.
    • Intraoperative hemostasis
      • Vertical midline incision is the least vascular
      • application of Bonney’s myomectomy clamp or a rubber tourniquet
      • Use ring forceps to occlude the ovarian vessels
      • Careful dissection to enucleate all the masses is needed to avoid recurrence.
      • Avoid anesthetic agents that induce uterine relaxation (e.g. halothane).
      • Vasopressin (pitressin) 20 IU in 20 ml in normal saline are injected in the uterine wall at the site of incision.
      • Obliteration of the tumour cavities.
      • Buried sutures to the tumor bed after shelling out of the masses.
      • Use absorbable sutures.
  • Blood needs to be prepared for possible transfusion
slide25
Technique of abdominal myomectomy:
      • Preliminary diagnostic curettage to exclude endometrial carcinoma.
      • The uterine incision:
    • Avoid incisions on the posterior uterine wall, for the risk of adhesions to the bowel.
    • The smallest incision is designed to enable removal of as many lesions as possible.
    • Tunneling in the uterine wall is utilized to minimize many incisions and peritoneal trauma.
    • Try to avoid opening the endometrial cavity.
  • To keep the uterus anteverted
    • ventrosuspension or plication of the round ligaments and uterosacral ligaments.
  • Dextran solution, Ringer lactate solution or dexamethazone could be instilled in the peritoneal cavity to minimize postoperative adhesions.
vaginal procedures
Vaginal Procedures
  • Vaginal myomectomy:
    • Indicated when a fibroid polyp is not larger than 8 weeks pregnancy size.
    • The polyp is grasped and twisted until the pedicle tears.
    • If the pedicle is too thick it is cut with scissors.
    • A large polyp could be cut as piece-meal fashion (morcellation).
hysterectomy
Hysterectomy
  • Patient around 40 years, and completed her family.
  • The number or site contraindicate myomectomy
  • Severe bleeding during myomectomy.
  • Major damage of the uterus by myomectomy which affects its function for pregnancy.
  • Recurrent fibroids.
  • Suspicious of malignancy
secondary changes in fibroids
Secondary Changes in Fibroids
  • Degenerative
  • Vascular
  • Inflammatory
  • Malignant Changes
degenerative changes
Degenerative Changes
  • Hyaline degeneration:
    • Commonest secondary change.
    • Usually starts around the menopause, and in the center of the fibroid.
    • Macroscopically, fibroid looks homogenous, waxy, soft, with loss of whorly appearance.
  • Fatty changes:
    • Likely to start around the age of menopause.
    • Lipids reach the fibroid through the blood, so fatty change starts at the periphery of the fibroid, resulting in a yellow soft fibroid.
slide35
Calcification:
    • Step following fatty change when fatty acids undergo saponification with Ca salts giving Ca stearate and palmitate, forming layers of calcifications.
    • Clinically, the fibroid become hard like bone (Womb stone).
    • Radiologically, show a radio-opaque shadow with typical onion skin appearance.
  • Red degeneration (Necrobiosis):
    • Usually occurs in the middle trimester of pregnancy, due to increased vascularity and venous stasis, the tumor enlarges with hemorrhage inside the tumor.
    • It is called necrobiosis because it shows dead parts (central) and living parts (peripheral).
slide37
Atrophic changes:
    • Atrophy occurs due to estrogen withdrawal as after menopause, puerperium, or anti-estrogen use.
    • All myomas decrease in size after the menopause except in calcification it remains stationary, or with malignant change or HRT it increases in size.
  • Myxomatous change:
    • Occurs near the menopause, in the center of the myoma, forming a gelatinous mucoid material which may undergo pseudo-cystic changes.
  • Pseudo-cystic changes:
    • A step following hyaline or myxomatous changes, when it liquefies & becomes soft in consistency.
vascular changes
Vascular Changes
  • Torsion (Axial rotation):
    • Occurs in moderate-sized, pedunculated, subserous fibroid with no adhesions.
    • The precipitating factor is sudden twisting movement as trauma, intestinal movement, or fetal kick, leading to axial rotation which is prevented from re-twisting by the lashing effect of the pulsating pedicle.
    • The clinical effects depend on the onset of torsion:
      • Sudden torsion leads to acute abdomen and necrosis of the tumor.
      • Gradual torsion leads to gradual decrease of the blood supply from the pedicle which ends in the development of parasitic tumor.
  • Telangeactasis:
    • Likely to occur with pregnancy, malignant change, and cervical fibroid due to increased vascularity.
    • There are numerous dilated blood vessels on the surface of the fibroid which may rupture leading to acute abdomen and internal hemorrhage.
  • Lymphangeactasis:
    • Likely to occur around the age of menopause as the fibroid is full of lymphatics.
    • Dilated lymphatic vessels on the surface may rupture leading to lymphatic exudates and strong adhesions.
  • Congestion and edema: A result of impaction, incarceration, torsion, infection, or pregnancy
inflammatory changes
Inflammatory changes
  • Ways of infection:
    • Trauma of submucous fibroid e.g. D & C or labor.
    • Near by inflammation e.g. appendicitis.
    • Blood-borne (very rare).
  • Result of infection:
    • The fibroid becomes congested, tender, and even abscess formation; it becomes soft and heals by adhesions to the surrounding
malignant changes
Malignant changes
  • Rare (0.5%) into leiomyosarcoma (round, spindle, mixed or giant cell histopathology types).
  • Symptoms suggestive:
    • The fibroid becomes more painful.
    • Post-menopausal bleeding or growth of the tumor.
  • Signs suggestive:
    • The fibroid become softer, tender, or fixed.
    • Rapid growth of the tumor.
complications of fibroid
Complications of fibroid
  • Degenerative changes.
  • Vascular changes.
  • Inflammatory changes.
  • Malignant changes.
  • Pregnancy complications e.g. abortion, and preterm labor.
  • Pressure complications on the urethra, bladder, ureters, rectum, and pelvic veins.
  • Rarely, chronic inversion of the uterus.
  • Polycythemia and hypertension due to the release of erythropoietic agent.
  • Infertility.
  • Secondary parasitic attachment of fibromyomas to other abdominal structures gaining another blood supply.