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Title: uterine fibroids


1
Uterine Fibroids
  • Dr.Makanda
  • May 2022

2
Uterine fibroids
3
Uterine 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.

4
Uterine 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

5
Incidence
  • 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

6
ORIGIN
  • AETIOLOGY still unknown
  • Hypothesis is that it arises from the neoplastic
    single smooth muscle cell of the myometrium

7
Theories
  • 1.Chromosomal abnormality-in about 40 there is a
    chromosomal abnormality esp.chromosome six or
    seven(rearrangement,deletions)
  • This leads to abnormal cellular proliferattion

8
ORIGIN 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

9
Growth
  • 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

10
Growth 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.

11
RISK FACTORS
  • High risk
  • Nulliparity
  • Obesity
  • Hyperoestrogenic state
  • Black women
  • Less risk
  • Multiparity
  • Smoking

12
Fibroid 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

13
Fibroid 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

14
Fibroids 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

15
Fibroid 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

16
Fibroid locations ct.
  • 5.Pseudocervical fibroid
  • This is a fibroid polyp arising from the uterine
    body which occupies the and extends the cervical
    canal

17
PATHOLOGY
  • 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

18
PATHOLOGY
  • 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

19
PATHOLOGY.
  • NAKED EYE APPEARANCE ct
  • More vascular in the periphery with the growth
    potentiality
  • Less vascular in the centre with high
    potentiality of degenertation

20
PATHOLOGY..
  • 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

21
SECONDARY CHANGES IN FIBROIDS
  • Includes
  • Hyaline Degenerations
  • Cystic degeneration
  • Atrophy
  • Necrosis
  • Infection
  • Vascular changes
  • Sarcomatous changes

22
DEGENERATIONS
  • 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

23
DEGENERATIONS 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

24
DEGENERATIONS ct..
  • 3.Fatty degenaration
  • Usually seen at or after menopause
  • Fat globules are deposited mainly in the muscles
    cells

25
DEGENERATIONS 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

26
DEGENERATIONS 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

27
DEGENERATIONS ct..
  • 6.Atrophy
  • Occur following menopause due to loss of
    oestrogen support
  • Tumour regresses in size
  • The reduction also occurs following pregnancy
    enlargement

28
DEGENERATIONS ..
  • 7.Necrosis
  • Central necrosis due to inadequate circulation
  • Common in the submucous polyps or penduculated
    subserous fibroids

29
DEGENERATIONS 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

30
DEGENERATIONS ct..
  • 9.Sarcomatous changes (0.1)
  • Usual type is leiomyosarcoma
  • Suspision raised by
  • Reccurence of fibroid polyp
  • Sudden enlargement
  • Fibroid with postmenopausal bleeding

31
Changes 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

33
Changes 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

34
Clinical 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

35
Fibroid 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

36
Menstrual 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

37
Menstrual 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

38
PREGNANCY 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

39
Intramural Submucous Fibroids
40
Subserous Fibroid at Laparoscopy
41
Fibroid 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

42
COMPLICATIONS
  • Hyaline Degenerations
  • Necrosis
  • Infection
  • Sarcomatous changes
  • Torsion of subserous pedunculated fibroid
  • Haemorrhage
  • Intracapsular

43
COMPLICATIONS..
  • 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

44
Fibroids 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,

45
Fibroids 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

46
Fibroids 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

47
Fibroids 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

48
Can 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.

49
Can 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

50
Can 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.

51
Can 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.

52
PATHOGENESIS 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

53
PATHOGENESIS OF DEGENARATION ct
  • . RX Bed rest,
  • heat, and pain medication
  • medications to inhibit premature labor

54
PRESENTATION
  • 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

55
Examination
  • 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

56
EXAMINATION.
  • 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

57
Investigations
  • 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

58
Investigations 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

59
PREOPERATIVE ASSESSMENT
  • IVP
  • FBP
  • Urinalysis

60
DDX
  • Pregnancy
  • Full bladder
  • Adenomyosis
  • Myohyperplasia
  • Ovarian mass
  • Tom

61
Investigating a Submucous Fibroid
62
Treatment 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

63
Uterine 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..

64
Uterine artery embolization
  • This blocks the blood flow to the fibroid tumor
    causing it to shrink and die

65
UAE
66
Good 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

67
Benefits 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

68
Benefits 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

69
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