Title: uterine fibroids
1Uterine Fibroids
2Uterine fibroids
3Uterine Fibroid
- The commonest benign tumour of the uterus
- The commonest benign solid tumour in female
- Histologically composed of smooth muscle and
fibrous connective tissue,hence called,uterine
leiomyoma,myoma,or fibromyoma.
4Uterine Fibroids
- Usually multiple
- Various sizes
- Genetic predisposition
- more common in black races
- More common in the obese
- Less common in smokers
- Accounts for 30 of hysterectomies
5Incidence
- At least 20-25 of women at their 30 have fibroid
which remain asymptomatic - Symptomatic fibroid at OPD is 3
- Common in nulliparous or one child infertility
- Highest prevalence between the age of 35-45
6ORIGIN
- AETIOLOGY still unknown
- Hypothesis is that it arises from the neoplastic
single smooth muscle cell of the myometrium
7Theories
- 1.Chromosomal abnormality-in about 40 there is a
chromosomal abnormality esp.chromosome six or
seven(rearrangement,deletions) - This leads to abnormal cellular proliferattion
8ORIGIN ct.
- 2.Role of polypeptide growth factors
- Epidermal growth factors (EGF)
- Insulin-like growth factor-1(ILGF-1)
- Transforming growth factor(TGF)
- These growth factors stimulate fibroid either
directly or through oestrogen - A positive family history is often present
9Growth
- Oestrogen dependent tumour as evidenced by
- Growth potentiality limited during child bearing
period - Increased growth during pregnancy
- Do not occur premanarche
- Cessation of growth post menopause and no new
tumours at all - Seem to have more oestrogen receptors as compared
to the adjacent myometrium - Frequent association of anovulation
10Growth ct
- Usually the fibroids are multiple and of
different sizes - They grow at different paces i.e some grow faster
more than others and they grow to abdomen
detectable size for about 3-5 years - They grow rapidly during pregnancy or amongst
pill users(high dose pills) - Rapid growth also due to degeneration or
malignant change.
11RISK FACTORS
- High risk
- Nulliparity
- Obesity
- Hyperoestrogenic state
- Black women
- Less risk
- Multiparity
- Smoking
12Fibroid Locations(Types)
- 1.Subserous or subperitoneal (15)
- Project from the uterus into the peritoneal
cavity - Sometimes pedunculated
- Least likely to cause symptoms
- Either partially or completely covered by the
peritoneum - Penduculated fibroids whose pedicle become
torn,wandering or parasitic fibroid,gets
nourishment from the mesentery or omental
adhesions
13Fibroid Locations(Types)..
- 2.Submucous (5 of all fibroids)
- Project into the uterine cavity
- Sometimes pedunculated
- Most likely to cause symptoms
- Can distort the uterine cavity
- They may be penduculated come out of the through
the cervix
14Fibroids locations ct
- May become infected or ulcerated to cause
menorrhagea - They are most symptomatic fibrois
- Fate of submucous fibrois
- Surface necrosis
- Polypoid change-following pedicle formation
- Infection
- Degenerations including sarcomatous change
15Fibroid Locations(Types)..
- 3.Intramural or interstitial (75)
- Most common
- Usually multiple
- 4.Cervical (1-2)
- May be interstitial or subperitoneal,rarely
polypoidal - Interstitial fibroid may displace or expand the
cervix - They all disturb the pelvic anatomy esp. the
ureters
16Fibroid locations ct.
- 5.Pseudocervical fibroid
- This is a fibroid polyp arising from the uterine
body which occupies the and extends the cervical
canal
17PATHOLOGY
- NAKED EYE APPEARANCE
- The uterus is distorted by multiple nodules of
various sizes - A single fibroid can cause a uniform enlargement
- They feel firm in consistency
- Cut surface of the tumour is smooth and whitish
18PATHOLOGY
- Naked eye appearance ..
- False capsule is formed compressed adjacent
myometrium - The capsule is separated from the growth by a
thin areolar tissue - The blood vessels run through this plane to
supply the tumour
19PATHOLOGY.
- NAKED EYE APPEARANCE ct
- More vascular in the periphery with the growth
potentiality - Less vascular in the centre with high
potentiality of degenertation
20PATHOLOGY..
- Microscopic appearance
- Consists of smooth muscles and fibrous connective
tissue in different proportions - Originally muscle elements,later on fibrous
tissues mixed with muscle bundles - Hence the name myomata,or fibromyomata
21SECONDARY CHANGES IN FIBROIDS
- Includes
- Hyaline Degenerations
- Cystic degeneration
- Atrophy
- Necrosis
- Infection
- Vascular changes
- Sarcomatous changes
22DEGENERATIONS
- 1.Hyaline degenaration
- The most common,accounts for 65
- Affects all sizes of fibroids except the smallest
ones - Affects the central part of the fibroid ,the
least vascular - The changes feels soft elastic
- Microscopically affects both the muscles and
firous tissues
23DEGENERATIONS ct..
- 2.Cystic degeneration
- Occurs following menopause
- Common in interstitial fibroids
- Cystic changes are lined by ragged walls
- Cystic changes of an isolated fibroid can be
confused with an ovarian cyst or pregnancy
24DEGENERATIONS ct..
- 3.Fatty degenaration
- Usually seen at or after menopause
- Fat globules are deposited mainly in the muscles
cells
25DEGENERATIONS ct..
- 4.Calcific degeneration
- Involves subserous fibroids with small pedicle,
or postmenopausal women - Usually proceeded by fatty degenaration
- There is precipitation of calcium carbonate or
phosphate within the fibroid - The completely calcified fibroid is called a
womb stone
26DEGENERATIONS ct..
- 5.Red degeration(carneous degeneration)
- Cause is unknown,probably vascular and not
infection - Occurs in a large fibroid mainly in second half
of pregnancy and puerperium - Partial recovery, and therefore called
necrobiosis - Microscopically-evidence of necrosis,thrombosed
vessels but no extravassation of blood
27DEGENERATIONS ct..
- 6.Atrophy
- Occur following menopause due to loss of
oestrogen support - Tumour regresses in size
- The reduction also occurs following pregnancy
enlargement
28DEGENERATIONS ..
- 7.Necrosis
- Central necrosis due to inadequate circulation
- Common in the submucous polyps or penduculated
subserous fibroids
29DEGENERATIONS ct..
- 8.Infection
- Follows delivery or abortion
- Infection gets access through the thinned and
sloughed surface epithelium of the submucous
fibroid - Can also occur in intramural fibroid after
delivery - Vascular changes
- Dilatation of vessels(telengictasis),or
dilatation of lymphatics (lympangiectasis) in the
myoma may occur. - Cause-unknown
30DEGENERATIONS ct..
- 9.Sarcomatous changes (0.1)
- Usual type is leiomyosarcoma
- Suspision raised by
- Reccurence of fibroid polyp
- Sudden enlargement
- Fibroid with postmenopausal bleeding
31Changes in the pelvic organs
- 1.UTERUS
- Asymmetrical uterine distortion in most cases,
but uniform at times - Myohyperplasia
- Normal endometrium or features of anovulation
with hyperplasia - Dilatation and congestion of the myometrium and
endometrial venous plexuses
32- Thick,congested and oedematous endometrium
- Part of the endometrium over the submucosa
fibroid becomes thin,and necrotic with evidence
of infection - Elongated and distorted uterine cavity in
intramural and submocous fibroids
33Changes in the pelvic organs ct
- Ovaries
- May be enlarged, congested and studded with
multiple cysts due to hyperoestronism - Ureters
- May be displaced in case of broad ligament tumour
whose compression results in hydroureters and
hydronephrosis - Endometriosis
- There is an increased association of
endometriosis and adenomyosis - Endometrial carcinoma -incidence unaffected
34Clinical features
- Nulliparous or secondary infertility women
- Asymptomatic fibroids (75)
- Position and size of the fibroid determine the
occurrence of symptoms - Site more important than size
- 1.Menstrual abnormalities
- (a)Heavy menstruation (30) classic symptom in
asymptomatic fibroid - Menstrual loss progressively increases with
successive cycles - Conspicuous in submucous or interstitial tumours
35Fibroid Symptoms
- Mostly asymptomatic
- Meavy menstruation
- Heavy regular periods
- Iron deficiency anaemia
- Pressure effects
- Urine frequency
- Pelvic tumour awareness
- Difficulty initiating micturition
- Pain, Infertility Irregular vaginal bleeding
- May be due to other pathology
36Menstrual abnormalities ct..
- Reasons
- Increased surface endometrial area
- Contractility of the uterus is interfered by the
myoma - Endometrial hyperplasia
- Pelvic congestion
- Congestion and dilatation of the subjacent
endometrial plexus due to obstruction of the
tumour - Role of prostanoids
37Menstrual abnormalities ct..
- (b)Irregular menses or irregular bleeding,due to
- Ulceratrion of submucous fibroid or fibroid polyp
- Torn vessels from the sloughing base of a polyp
- Associated endometrial carcinoma
- 2.Dysmenorrhoea
- 3.Infertility
38PREGNANCY RELATED COMPLICATIONS
- High frequency of
- Abortion
- Preterm labour
- IUFGR
- REASONS
- Defective implantation of the placenta
- Poorly developed endometrium
- Reduced space for the growing foetus and placenta
- Red degeneration and torsion of subserous fibroid
common in pregnancy - PPH
39Intramural Submucous Fibroids
40Subserous Fibroid at Laparoscopy
41Fibroid Symptoms
- Mostly asymptomatic
- Heavy menstruation
- Heavy regular periods
- Iron deficiency anaemia
- Pressure effects
- Urine frequency
- Pelvic tumour awareness
- Difficulty initiating micturition
- Pain, Infertility Irregular vaginal bleeding
- May be due to other pathology
42COMPLICATIONS
- Hyaline Degenerations
- Necrosis
- Infection
- Sarcomatous changes
- Torsion of subserous pedunculated fibroid
- Haemorrhage
- Intracapsular
43COMPLICATIONS..
- Rupture surface vein of subserous fibroid-?
intraperitoneal - Polycythemia due to
- Erythropoetic function of the tumour
- Altered erythropoetic function of the
kidney following pressure on the ureters
44Fibroids and Infertility
- In most women the association is a result and not
a cause - Fibroids that change the shape of the uterine
cavity (submucous) or are within the cavity
(intracavitary) decrease fertility by about 70 - And so their removal increases fertility by 70.
- Other types of fibroids, those that are within
the wall (intramural) but do not change the shape
of the cavity, or those that bulge outside the
wall (subserosal) do not decrease fertility,
45Fibroids and Infertility
- The removal of these types of fibroids does not
increase fertility. - Most infertility specialists will recommend
removal of any fibroid with gt50 of its surface
in the uterine cavity - The results from removal of a single submucous
fibroid can be dramatic - And there is evidence that removal of intramural
fibroids gt5 cm diameter will enhance fertility
with IVF
46Fibroids and Pregnancy
- In most women there is no effect of pregnancy on
fibroids - Hence 80 remain unchanged in size
- Rarely rapid growth and red degeneration
- Those that grow depends on
- individual differences in the genetic
changes in each fibroid and - the type and amount of growth factors
that are present in the blood. - Increased risk of bleeding and threatened preterm
delivery - But most deliver at term
47Fibroids and Pregnancy ct.....
- Fibroid in the lower segment can interfere with
vaginal birth - Myomectomy at the time of Caesarean is not wise
- 30 require emergency hysterectomy
- . Almost always, fibroids shrink after delivery
48Can Fibroids Cause Miscarriage?
- Fibroids that bulge into the uterine cavity
(submucous) or are within the cavity
(intracavitary) may sometimes cause miscarriages. - This happens if a submucosal fibroid is located
nearby the implanted embryo, which thins out the
lining and decreases the blood supply to the
developing embryo. - The fibroid may also cause some inflammation in
the lining directly above it. The fetus cannot
develop properly, and miscarriage may result.
49Can Fibroids Cause Miscarriage? Ct.
- Next pregnancy, when the egg settles in another
location, pregnancy may proceed without problems.
- However, if you do have a miscarriage and a
fibroid is found bulging into the uterine cavity,
it is advisable to have it removed
50Can Fibroids Cause Miscarriage? Ct.
- Although many women will have fibroids during
their lifetime, the fibroids most often occur in
women in their late thirties and forties, - Only 2 of pregnant women are found to have
fibroids when examined with ultrasound. - Also, the vast majority of women who are
pregnant and do have fibroids encounter no
problems. - They go on to have full-term, healthy babies
without difficulty.
51Can Fibroids Cause Miscarriage? Ct.
- No differences in the risk of
- Premature delivery,
- Fetal growth problems,
- Fetal abnormalities,
- Placental problems, or
- Heavy bleeding after delivery.
- NOTE The need for caesarean section, however, is
more common among women who have fibroids - Indicated when a large fibroid located in the
cervix obstructs labour.
52PATHOGENESIS OF DEGENARATION
- During pregnancy, the placenta makes large
amounts of female hormones which may rarely cause
fibroids already present to grow. - Very rarely, if they grow too quickly the blood
vessels supplying them may not be able to get
enough oxygen to the tissue and degeneration of
the fibroid cells can then occur. - This process of degeneration can cause pain, but
usually resolves in a short time without
treatment and without harm to the baby. - Some women may have mild contractions during
this time, but it is extremely rare for premature
labor to actually begin
53PATHOGENESIS OF DEGENARATION ct
- . RX Bed rest,
- heat, and pain medication
- medications to inhibit premature labor
54PRESENTATION
- Lower abd.swelling/ lump
- lower abd heaviness
- Constipation posterior fibroid pressing the
rectum - Hydroureteric and hydronephrotic changes-broad
ligament tumour?infection?pyelitis - Signssome degree of pallor
55Examination
- P/A- when enlarged to 14 wks
- Firm to hard or cystic in cystic degeneration
- Well-defined margins except lower pole that cant
be easily reached - Nodular surface
- Mass cant be moved from side to side
56EXAMINATION.
- Pve
- Bimanual palpation shows irregularly enlarged
tumour - Uterine tumour by
- Uterus is not separately felt and no groove
between the uterus and the mass - The cervix moves with the movement of the tumour
felt per abd. - A subserous pedunculated tumour is confused with
an ovarian tumour
57Investigations
- Aims
- 1.Confirm the diagnosis
- 2.Preopertive preparation
- Confirmation
- Ultrasound
- A useful tool for the diagnosis and the location
of the tumour.differentiaates fibroid from
pregnancy and ovarian mass - Pedunculated tumour can be confused with a solid
ovarian tumour - Transvaginal uss shows the myoma
location,dimensions and ovarian pathology - Multiple small fibroids is usually irrelevant
58Investigations ct...
- Heterogenous echolucency is normal in a parous
uterus - Adenomyosis can look the same
- Size and location important
- Can be a contraction wave in pregnancy
- MRI better than CT Imaging
- Laparoscopy and Hysteroscopy
- Saline infusion-useful to detect a submucous
fibroid or polyp
59PREOPERATIVE ASSESSMENT
60DDX
- Pregnancy
- Full bladder
- Adenomyosis
- Myohyperplasia
- Ovarian mass
- Tom
61Investigating a Submucous Fibroid
62Treatment Options for Fibroids
- Hysterectomy
- If the uterus is gt10w size
- Or symptoms that are due to the fibroids
- Rapid growth
- Abdominal or vaginal
- Myomectomy
- Best for single fibroid in a young woman
- 50 come to hysterectomy within 5 years?
- Hysteroscopic resection
- Uterine artery embolisation (UAE)
- Medical options
- GnRH analogue
- Mirena
63Uterine artery embolization
- UFE does not require general anesthesia. The
procedure is performed under local anesthesia
with the patient conscious, but sedated, and
feeling no pain. The interventional radiologist
makes a tiny nick in the skin in the groin
(femoral artery) or the wrist (radial artery) and
using real-time imaging, the physician guides the
catheter through the artery to the site of the
fibroid and then releases tiny spheres, the size
of grains of sand, into the uterine arteries that
supply blood to the fibroid tumor..
64Uterine artery embolization
- This blocks the blood flow to the fibroid tumor
causing it to shrink and die
65UAE
66Good candidates for UAE
- Are a woman who is over the age of 35
- Are not currently pregnant
- Have been diagnosed with uterine fibroids
- Are experiencing symptoms such as excessive heavy
bleeding, cramping, pelvic pain, bloating or
frequent urination
67Benefits of UFE
- Uterine fibroid embolization is a minimally
invasive outpatient procedure with no incision
needed - Requires only local (rather than general)
anesthesia - Does not cause scarring like surgical techniques
do - While there will be some moderate pain after a
UFE procedure, it is typically less intensive
than post-surgical pain - A good option if you would like to preserve your
uterus vs. a hysterectomy
68Benefits of UAE..
- 85-90 of women experience significant relief of
their symptoms - Faster recovery time compared to surgery
- Same day procedure, typically no overnight stay
needed, so you can recover at home - Reduced risk of infection as compared to surgery
- Easy to make and quickly schedule an appointment
at an outpatient center
69Thank you for your attention