Fibromyoma uterus by Dr H.K.Cheema

details of fibromyoma uterus

1. Fibro-myoma Uterus
Dr. H.K.Cheema
Professor & Head
OBG-PIMS

3. 2.5cm
0.5cm
5.0cm
2.5cm

4. Uterus-three layers

5. Length of uterus

6. Lesions of the Uterus
Benign lesions
❑Leio-myoma/ Fibro-myoma uterus
❑Uterine Polyps
❑1. endometrial polyp
❑2. fibroid polyp
❑3.Adenomatous polyp
❑4. placental polyp
Malignant lesions
❑Leio-myo-sarcoma
❑Uterine sarcoma
❑Endometrial carcinoma of uterus

7. Leio-myoma Uterus

8. Fibro-myoma
❑Synonyms:Myoma,Leiomyoma,Fibromyoma
❑It is most common benign neoplasm in the female.
❑Common benign solid tumorin females
❑Average age is 35-45 years.
❑Incidence : 20 to 40% of reproductiveage women.

11. Fibromyoma
Etiology:
It arises from smooth muscle cell ofmyometrium.
❑Exact etiology notknown.
❑Monoclonal origin ( arising from singlecell)
❑Various growth factors like TGFβ , EGF, IGF-1, IGF-2, BFGF
(Oestrogen dependent Tumor)

12. Fibromyoma-Etiology
Multiple chromosomal abnormalities-detected in 50% of fibroid patients
❑Translocation between Chromo. 12 &14,
❑Trisomy12,
❑Rearrangement of short arm of Chromo6
❑Rearrangement of long arm of Ch.10,
❑Deletion of Ch.3 orCh.7or long arm of Y chromosome.

13. Fibromyoma-Etiology
Increase state of Estrogen in the body-
Hyper-oestrogenismhas been proved for causing myoma
❑Not detected before puberty
❑Theyregresses after menopause
❑Never arise in menopause.
❑May increase duringpregnancy
❑Estrogen receptors are in higherconcentration
❑Commonin Obesity, PCOS, DUB,Endometrialcarcinoma
❑Less in smokers
❑Regresses with OCPs.

14. Fibromyoma-Epidemiological risk factors
Decreased risk
❑↑↑ parity,
❑white Race,
❑Post menopausal phase,
❑Progestroneonly contraceptives,
❑cigarettesmoking
Increased risk
❑age 35 to 45 years ,
❑nulliparous or low parity ,
❑Black women,
❑obesity,
❑early Menarche,

16. Etiology
❑Rapid Growth
❑Pregnancy
❑Nulliparous
❑Black women
❑Hyper-oestrogenic states
❑Slow Growth
❑Mutiparous
❑smoking

17. Sitesoforigin
Corporeal
fibroid
97%)
Cervical
fibroid
(3%)

18. Fibroids are often described according to their location in
theuterus

19. Locations
Uterine Body-95%
❑Intramural or interstitial75%,
❑Submucous15% (sessile /
Pedunculated )
❑Subserous10%( pedunculatd
–torsion/parasitic).
Cervical.<5%
❑Primarycervical.
❑Ligamentary-true/ false
broad ligamentfibroids,
round orsacral-ovarian

20. Origin-Fibromyoma
-

21. Different locations-fibromyoma

25. Gross examination
❑Enlarged Uterus
❑Distorted shape
❑Multiple, nodular growths of variable sizes
❑Feels firm
❑Some sessile, some pedunculated
❑If Pedunculated
❑Fibro-myomatousPolyp

26. Fibromyoma
Submucous fibroids are further classified
by European society for gynec endoscopy ( ESGE
Type0 –No intramural extension
TypeI –Intramural extension < 50 %
TypeII –Intramural extension > 50%

28. Pathology
Wellcircumscribedwhite
firmmasswithawhorled
appearance
-surrounded by false
capsuleformedby
compressed by uterine
muscle

29. Pathology
1.well circumscribed tumor
2.Pseudo-capsule.
3.Cutsurfaceispinkishwhite
4. whorledappearance.
5.Capsuleconsistsofconnectivetissuewhichfixestumorwith
myometrium.
6.VesselsthatsupplyBloodtotumorlieincapsuleandsendradialbranchto
tumorHencecentralpartoftumoriscomparativelylessvascular,thereby
degenerativechangesarenoticeableincenter.
7.Calcificationattheperipheryandspreadsinwardsalongthe
vessels(Wombstone).

31. PathologyMicroscopically
Smooth muscle
Connectivetissues
Whorled
appearance

32. Symptoms

36. Symptoms
.
1.Mennorhagia—
↑size of cavity,
↑vascularity,
↑ ostrogen,
2.Polymenorrhea—co-existing PCOD/PID
3.Metrorrhagia --sub-mucosal
4.Meno-metrorrhagia ---I/mural, sub-mucosal
5. Poly-menorrhagia--I/mural,Sub-mucosal,PCOD/PID
6.Dysmenorrhea----sub-mucosal-spasmodic,congestive
7.No menstrual disturbance---sub-serosal
8.co-existing Carcinoma endometrium—3%

37. Symptoms---
Infertility
1. fibroid > 4 cm in size
2.distortion of cavity-poor nidation, cornualblockage
3.Recurrent abortions
4.associated PCOS,
endometriosis,
Anovulation

40. Other symptoms--
❑Increased frequency of micturation--
❑Retention of urine---
❑Constipation--
❑Vaginal discharge----
❑Abdominal lump----
❑& Anaemia—
❑Pseudo-Meigsyndrome---(Fibromyoma+ Ascites+ Right Pleural
effusion)

41. Acute Pain in Fibro-myoma
Torsion of pedunculated-------Fibroid
Capsular Haemorrhage
Rapid growth of fibromyoma—Sarcomatouschange(0.5%)
Red degeneration of fibroid---in Pregnancy

42. Shock
❑Capsular haemorrhage
❑Excessive bleeding with anaemia—large sub-mucosal fibroid

43. Fate of Sub-mucosal Fibroid
❑1.Polypoidal changes
❑Surface necrosis
❑Infection
❑Degeneration
❑Sarcomatouschange
❑Symptoms
❑Mennorrhagia
❑Meno-metrorrhagia/metrorrhagia
❑Dysmennorrhea—Congestive & spasmodic
❑Vaginal discharge—blood stained/Foul smelling

44. Secondary pathological
degenerative changes and
complications of fibroids

45. Secondary changes-Degenerations
❑Degenerations
❑Hyaline degeneration
❑Red degeneration
❑Fatty degeneration
❑Calcific degeneration
❑Cystic degeneration
HRFC 2

46. Hyaline degeneration offibro-myoma
Reproductive
age
Soft elastic
instead of firm
Central part of
fibromyoma
Loss of whorled
appearance

47. CYSTICDEGENERATION
menopause
Occurs after
liquefaction with
hyaline degeneration
Common in
intra-mural
fibromyoma
D/D
Pregnancy
Ovarian cyst

48. HAEMORRHAGE & CALCIFICATION
Sub-serosal
Post-
menopausal
age
Calcium
carbonate/phos
phate deposits
Womb stone

49. CALCIFICATIONOFFIBROID-RADIOGRAPH
Womb stone

52. REDDEGENERATIONOFFIBROID-NECROBIOSIS

53. ❑2
nd
half of pregnancy/puerpurium
❑Larger fibroid, vascular in origin
❑Symptoms—
❑-Acute pain in pregnancy(tense, tender),high grade fever.
❑Cut section—
❑Reddish-purple in colour
❑Raw Beef appearance/cooked meat
❑Fishy odour
❑Cause—
❑vessels thrombosed,necro-biosis, haemolysed RBC
❑D/D—
❑Acute appendicitis, Torsion ovarian cyst ,acute pyelitis
❑Investigations---Hb,TLC,DLC,,ESR↑,Treatment-Consevative—Admit,Analgesics,supportivetherapy.

54. Complications…….
A Atrophy
V vascular changes
I Infection
N Necrosis
S sarcomatous change
T Torsion
I Inversion
C Capsular Haemorrhage
A Associated Endometrial carcinoma
AVIN-STICA

55. Complications---
❑Atrophy
❑Vascular changes
❑Infection
❑Necrosis
❑Sarcomatouschange
❑Torsion
❑Inversion uterus
❑Capsular Haemorrhage
❑Associated endometrial carcinoma—3%

56. Risk ofMalignancy
0.1% in reproductive agegroup
1.7% after age of 60years

57. FibromyomaSigns
G/E –Pallor
P/A –If > 12 weeks size , firm, nodular, arising from pelvis, lower
limit can’t be reached, relativelywell
defined, mobile from side to side, nontender, dull on
percussion, no free fluid inabdomen
P/S–Cervix pulled higher up P/V–
Uterus enlarged,nodular.
D/D from ovarian tumour Uterus not separately
felt , transmitted movement present, notch notfelt.

58. Fibro-myoma---Diagnosis
•1.Clinical : From symptoms &signs
•2.USG:Well defined hypoechoic
lesions.Peripheral calcification with distal
shadowing in old fibroids

59. ❑3.TAS&TVS
❑size, site and number offibroids
❑differentiates the tumour from other swellings as
ovariantumour

60. Fibromyoma---USG

61. 4-Saline infusionsonography

62. .
5. Hysteroscopy

63. (6) Intra venous pyelogram(IVP)
In cervical and broad ligamentfibroid
-Course ofureter.
-Hydroureter &hydroneprosis
-Kidneyfunction.

64. Fibromyoma-Diagnosis
7. MRI : Most accurate imagingmodality fordiagnosisof fibroid.
It does precise fibroid mapping & characterization
Detects all fibroidsaccurately
D/D fromadenomyosis
D/D from adnexalpathology
Ovaries are easilyseen
Detects small myomas(0.5cm)
8. HSG:Not donefordiagnosis ,Done forinfertility
evaluation filling defects may beseen.

65. Fibromyoma-MRI

66. Fibromyoma--D/D
❑PHOBAE3P
❑Pregnancy
❑Haematometra
❑Benign ovarian tumour
❑Malignant ovarian tumour
❑Bicornuateuterus
❑Adenomyosis
❑Endometriosis
❑Endometrial carcinoma
❑Ectopic pelvic kidney
❑MyomatousPolyp

67. Pregnancy complicating Fibromyoma
Some fibromyomas’---can cause infertility.
During pregnancy, size ↑,can cause hyaline, cystic,
red degeneration-5%
↑size in pregnancy—can cause
Respiratory embrassment
Retention of urine
Obstructed labour

68. Fibro-myomacomplicating Pregnancy
❑Abortion
❑Mal presentation, Malposition
❑IUGR
❑Pre-term labour
❑Prolonged labour
❑P. sepsis
❑Inversion uterus
❑Sub-involution uterus
❑In-co-ordinated uterine action
❑Obstructed labour
❑PROM
❑Accidental haemorrhage
❑Cervical dystocia
❑PPH--

70. Investigations
❑CBC—
❑Hb,BT,CT,ABORH,
❑Platelet count, TLC,DLC
❑USG
❑Diagnosis
❑Pre-opeartive
❑Post-opeartive
❑After GnRhanalogue therapy
❑HSG/Sonosalpingography
❑Hysteroscopy/D&C
❑Laproscopy
❑Laprotomy
❑Pregnancy with Fibromyoma–any doubt in diagnosis, location, size?
❑MRI

71. Fibromyoma; Treatment
❑Expectant:
❑asymptomatic ,
❑Size < 12 weeks,
❑near menopause.
❑Regular follow up every 6months

73. Indications for Medical Management
❑To treat anaemia, recover before surgery
❑To reduce the size & Facilitate surgery
❑Treat women in Peri-menopausal age group to avoid surgery
❑Women who are unfit for surgery
❑For fertility preservation in women with large fibriodsbefore
conservative surgery-myomectomy

74. Medical treatment
❑Iron therapy
❑Purpose---Correct Anaemia, control bleeding,
❑pre-operative, post operative, regular treatment
❑Drugs—[to control mennorrhagia]
❑Tranxemicacid, Mefanemicacid
❑RU-486---(Mifipristone)
❑10-25mg o.d.x3m
❑Danazol—400-800 mg.dailyx3-6 months.
❑GnRhanalogues
❑MirenaIUCD

75. Mnemonic ; Drugs used to decrease the size of fibromyoma
❑2 GynaeM D
❑GnRhagonists
❑GnRhantagonists
❑Mifepristone
❑Danazol

77. GnRhanalogues
GnRhanalogues
GnRh
Antagonist
GnRhAgonist

78. GnRhanalogues
GnRhagonists
❑Leuprolideacetate
❑Buserelin
❑Goserelin
❑Naferelin
❑Triptorelin
GnRhantagonists
❑Cetrorelix
❑Ganirelix

79. GnRHagonists
❑Agonistsare commonly used drugs :-
❑Triptorelin ( Decapeptyl) 3.75 mg or leuprolidedepot
❑3.75mgI/M for3 months
❑Advantages :
❑Decrease in size of myoma by 20 to 30 %
❑Decrease in bleeding
❑Increasein Hblevel
❑Decreases blood loss during surgery
❑Converts hysterectomy intomyomectomy
❑Converts Abd. hyst into vaginal.hysterectomy

80. GnRhagonists
❑Action
❑Itdecreasesuterinevolume-35%,fibroidvolume-30%.
❑EffectiveBleedingcontrolisalsoseen
❑Dosage
❑MonthlyGnRhAgonistisgivenfor6months.
❑Posteffect
❑FollowingdiscontinuationofGnRhagonist,uterinevolumeandmensesreturnswithin4--8weeks,2/3
rd
womenremainedasymptomaticfor8-12months.
❑95%womendevelopedside-effectsofhypoestrogen---iatrogenicmenopauseandoseoporosis.
❑Addbacktherapy(OCP)givenconcurrentlyreducesthesesideeffcts.
❑GnRH-agonistisrecommended
❑1.astemporarytreatmentforpremenopausalwomenwithheavymenorrhagia.
❑2.Onemonthbeforemyomectomytoreducesizeoffibromyomatoreduceintraoperativebleeding.

81. GnRhagonists
❑Disadvantages :
❑Highcost
❑Hypoestrogenic side effects.
❑Effect isreversible
❑Rarely ↑↑ bleeding due to degeneration
Occasionally difficulty inenucleation
❑

82. Price 5500-6000/Inj
GnRhAgonist-InjLeuprolide 3.75mg

83. Price Rs11,000/Inj
InjLeuprolide 11.25mg

84. ImmediatesuppressionofendogenousGnRh
bydailySCinjection0fGanirelixresultsin30%
reductioninfibroidvolumewithin3wks.
PatientdevelopsHypoestrogenicsymptoms.
Availability of long acting compounds might be
considered for medical treatment prior to
surgery.
GnRhAntagonist→
.

85. Rs2700-3000/Inj
GnRhAntagonist

86. LevonorgestralIUCD-Mirena
❑Progesterone releasing IUCD-
❑Mirena-Levonorgestrel releasing IUCD(Third generationIUCD) maybea
reasonabletreatmentforselected women.
❑Used in child bearing age gp. with fibroids associated with menorrhagia and
women interested to have contraception.
❑Contains Progesterone LNG 60 mg releasing 20ug/day
❑Fibroids decreases in size within 6 –12 months of use.
❑85% of such women returned to their normal bleeding within 3 months and
40% develop reversible amenorrhea at the end of 1.5-2 years.

87. Rs. 4500

88. Indications for Surgical treatment
❑Fibromyoma> 12 weeks size.
❑Patient is symptomatic-decide the mode of treatment
❑Subserous and pedunculated likely to undergo Torsion
❑Unexplained infertility / Recurrent abortions
❑Rapidly growing fibroid
❑If likely to produce complications in future pregnancy
❑If there is doubt about the nature of tumor.

89. SurgicalManagement
❑Myomectomy
❑Abdominal,Vaginal
❑Hysteroscopic
Laproscopic
❑Hysterectomy
❑Abdominal
❑Vaginal
❑LAVH,TLH

90. Hystrectomy—
Routes=abdominal, vaginal (open/laproscopic)
Sub-total hysterectomy= uterus minus cervix is removed
Total hysterectomy= uterus + cervix
Total abdominal hysterectomy with Bilateral salpino-oophorectomy=Pan-
hysterectomy
Werthiem’shysterectomy-
1. Modified Radical = TAH+ B/L S.O + Medial part of parametrium+ Upper vaginal
cuff+ pelvic lymphadenectomy
2. Radical=TAH+ B/L S.O + parametrium up to lateral pelvic wall + Upper vaginal
cuff+ pelvic lymphadenectomy

92. SurgicalManagement
Myomectomy is done in following:-
Indications for surgery→
Infertility caused by cornualfibroidblocking
tube.
Habitualabortionduetosubmucousfibroid.
Pedunculatedfibroid likely to undergotorsion.
Fibroid > 12weeks.
Broad ligament fibroid pressing onureter.
Fibroidpressingoverbladdercausingretentionofurine/
infection.
Rapidly growing uterine fibroid in postmenopausal
women.

93. Myomectomy-Routes
❑Abdominal
❑Vaginal
❑Method
❑Laproscopic
❑Hysteroscopic
❑Open
Myomectomy is enucleationof myoma
from the uterus leaving behind
potentially funtionaluterus capable of
future reproduction.

94. Indications of Myomectomy
❑Persistent uterine bleeding despite medical treatment.
❑Excessive pain or pressure symptoms
❑Size> 12 weeks, woman desriousof having pregnancy
❑Unexplained infertility with distortion of uterine cavity.
❑Recurrent pregnancy loss.
❑Rapidly growing fibro-myoma during follow up
❑Pedunculated Sub-serosal fibromyoma

95. Contra-indications of Myomectomy
❑Infected fibroid
❑Growth of fibroid after menopause
❑Suspected malignant change
❑Parous woman where hysterectomy is a safe choice.
❑Pelvic or endometrial Tuberculosis
❑During prernancy
❑During c. section.

96. Time of myomectomy
❑Immediate Post-menstrual period to reduce blood loss
❑Should not be performed during pregnancy
❑Should not be performed during c.section.
❑Results
❑Pregnancy rate after myomectomy=40-60%
❑Recurrence rate=30-50%
❑20-25% ultimately come for Hystrectomyin later life.

97. Pre-operative management Protocol
❑Anemiashould be corrected.
❑(parentralirontherapyalong withfolicacid,vitaminC,proteinsuplementation.)
❑Arrange for Blood transfusion.( atleast2 units) (Auto transfusion / donor blood
transfusion)
❑Control of bleeding→GnRHagonisttherapy( atleastone month prior to surgery)
❑Control of associated medical problems like hypertension, CHF, Asthma, UTI,
kidney or liverillness.
❑D& C must prior to myomectomy
❑Patient should be investigated prior to myomectomy for complete infertility
investigations including Husband’ seminologyto rule out other causes of infertility.
❑Written consent for hysterectomy has to be taken prior to myomectomy because of
risk of heavy bleeding during surgery.
Before surgery
Hb, BT, CT, ABORh
Platelet count, PTI/INR
TLC,DLC,ESR,PBF
S.TSH,LFT,RFT
RBS,HbA1C
VDRL, Viral Markers
ECG,X-Ray Chest(P-A view)
Urine C/E, Urine C/S
Medical fitness from Physician
PAC by anasthetist

98. Abdominalmyomectomy
Pre-requisites
❑Other factors for infertility should be ruledout
❑Take written consentwith risk ofhysterectomy
❑Cross matched Blood should be ready.
❑Pap smear & endometrial sampling to rule out malignancy.
❑Medical or mechanical means to control blood loss -available
❑Bonney’sMyomectomy 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.

99. Myomectomy specimen

100. Hysteroscopicmyomectomy/Resection
•For submucous myoma causing infertility, Recurrent pregnancy
loss, AUB orpain
•Criteria:-< 5 cm insize
< 50 % intramuralcomponent
< 12 cm
2
uterinesize

101. Laparoscopicmyomectomy
❑In 3 phases
❑excision of myoma, repair ofmyometrium &extraction
❑Suitable for subserous & intramural fibroids upto 10 cm size
❑Complications are those of operative laparoscopy + myomectomy

102. Myomectomy Instruments

103. Abdominalmyomectomy
❑Minimum incisions are kept –preferably single midline
vertical, lower, anterior wall.
❑Removal of as many fibroids as possible through one incision
& secondary tunnellingincisions.
❑Meticulous closure of all deadspace.
❑Properhaemostasis
❑Multiple small fibroids can be removed enbloc by wedge
resection.
❑Measures for adhesion prevention should betaken.

104. OpenMyomectomy

105. Vaginalmyomectomy
❑Submucous pedunculated or small sessile cervical
fibroids are removedvaginally.
❑Ligation of pedicle ifaccessible
❑Twisting off the fibroids if pedicle not accessible in case
of small & medium sizefibroids
❑To gain access to pedicle of higher & big fibroid incision
on the cervix can bemade.

106. Important considerations-Myomectomy
❑It should be done to preserve the reproductive function.
❑It is more risky operation than hysterectomy when fibroids are too many or too big.
❑Risk of recurrence is about 30-50%
❑Risk of persistence of menorrhagia is 1-5%
❑Risk of re-laparotomy is about 20-25%
❑Pregnancy rate after myomectomy is 40-60%
❑Pregnancy after myomectomy should be done in hospital to avoid chances of scar rupture during labour.
❑Complications-hemorrhage during operation, within 24 hrs( reactionary),>24hrs-secondary Hge
❑Trauma to bladder, ureter, Gut, Rectum
❑Infection-wound sepsis,
❑Complications of anaesthesiainclude aspiration Pneumonia, Paralytic ileus etc.

107. Radical SurgicalManagement
❑Abdominal or Vaginal hysterectomy
❑Vaginal hystrectomyis favoured in following;
❑If Uterus< 14wks
❑With no associated pathology like endometriosis , PID, adhesions
❑Uterus mobile & adequatelateralspaceinpelvis
❑Experienced vaginal surgeon

108. Uterine arteryembolization

109. Uterine arteryembolization
❑By interventionalradiologist
❑Catheter is passed retrograde thro. Right femoral artery to bifurcation of
aorta & then negotiated down to opposite uterine arteryfirst.
❑Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or gelfoamareused
forembolization.
❑60 –65 % reduction in size offibroid
❑80 –90 % have improvements in menorrhagia & pressuresymptoms

110. .

111. Uterine artery
embolization

112. AdvantagesOf UAE
❑No majorsurgery.
❑No intra-operativebleeding.
❑Short hospitalstay.
❑No abdominaladhesions.
❑75-80% women suffering from menorrhagia aresatisfied.

113. Uterine arteryembolization
•High vascularity & solitary fibroid are associated with greater chance of
long termsuccess.
•Pregnancy, active infection & suspicion of malignancy are absolute C I.
•Desire for fertility is also acontraindication
•The risk of ovarian failure must becounselled
•Post embolization syndrome ( fever, vomiting, pain) canoccur

114. Latest SurgicalManagement
❑Laparoscopic myolysis:
❑By ND-YAG laser or long bipolar needle electrode through laparoscope,
blood supply of myoma iscoagulated.
❑Without blood supply, myomaatrophies.
❑Applicable to 3 -10 cm size & myomas < 4 in number
❑Cryomyolysisis underinvestigation

115. Leio-myosarcoma
❑Incidence=0.2-0.5%
❑Age= usually Post-menopausal.
❑When fibroid starts growing rapidly with acute pain in Post-menopausal woman
with tenderness. Always suspect leio-myosarcoma.
❑Most common in sub-mucous, followed by intra-mural fibroid.
❑Average 6-9 cm.
❑The malignant change starts from the centre.
❑Soft, fleshy, poorly defined margins, non encapsulation of tumour.
❑Cut surface= greyish yellow, with areas of hemorrhage & necrosis.
❑Poor prognosis=5 yrsurvival rate is 15-25%

116. Typeequationhere.

118. 5-10 mitosis/10 HPF
With cellular atypia
> 10 mitosis/10 HPF
With/without cellular
atypia

119. 15-20%

121. Uterine Polyps

128. Questions
32 yrs.F, MF=10 yrs, infertile
H/O progressive mennorhagia
Pallor ++
A non-tender, hard mass, arising from pelvis, movable from side to
side
Diagnosis ?
How will u manage the case?

129. Question
47 yrs, Para 2,progressive meorrhagia, with foul smelling, blood
stained discharge in between
Pallor++
Non-tender hard mass ,irregular in shape, size>16 weeks, arising
from pelvis
P/S ulcerated pedunculatedmass seen coming out of external osof
cervix
Diagnosis?
Management?

130. Questions
Case based Questions
Types of Fibro -myoma
Fate Of sub-mucosal fibro-myoma
Symptoms of fibro-myoma
Menstrual problems in fibro-myoma
S.N --Degenerations in fibro-myoma
Complications of fibro-myoma
Myomectomy, polyps
Specimens
Short case
Grand Viva