Uterine fibroid

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1. DEPARTEMNT OF GYNAECOLOGY AND OBSTERTICS UTERINE FIBROIDS DR. D. Y. PATIL HOMOEOPATHIC MEDICAL COLLEGE AND RESEARCH CENTRE - DR . RADHIKA KHANDEWAL -

2. OBJECTIVES Definition Incidence Etiology Risk factors Clinical manifestation Red degeneration Complications of fibroids Management

3. UTERINE FIBROID What is a UTERINE FIBROID ? It is a commonest benign solid tumor of the muscular wall of the uterus composed primarily of smooth muscle and fibrous connective tissue. Also called as uterine leiomyoma, myoma or fibromyoma . Although they can grow to huge size their malignant potential is minimal. Incidence: They are the most common pelvic tumors . It has been estimated 20% women at the age of 30 years have got fibroid in their uterus, out of them 50% remain asymptomatic. In Black women the incidence rate is higher that of White women.

4. ETIOLOGY The aetiology still remains unclear. The prevailing hypothesis are – Chromosomal abnormality Polypeptide growth factors stimulate growth of leiomyoma either directly or via oestrogen . Predominantly an oestrogen – dependent tumor They are not detectable before puberty Progestrone increase mitotic activity & reduce apoptosis in size There may be genetic predisposition

5. RISK FACTORS Nultiparity and infertility. Increasing age . Ethinicity(two fold in african american compared with white women. Increased BMI. Family history. Hyperoestrogenic state

6. CLASSIFICATION

7. CLASSIFICATION

8. TYPES - Body The fibroid are mostly located in the body of the uterus and are usually multiple.

9. TYPES – Interstitial or intramural Initially the f ibroid are intramural in position but subsequently, some are pushed outwards or inwards. Eventually, in about 70% they persist in that position.

10. TYPES – Subperitoneal or subserous The intramural fibroid is pushed outwards towards the peritoneal cavity. The fibroid is either partially or completely covered by peritoneum. PEDUNCULATED SUBSEROUS FIBROID – The fibroid when completely covered by peritoneum. WANDERING/PARASITIC FIBROID – When the pedicle is torn the fibroid gets its nourishment from omental or mesenteric adhesions. BROAD LIGAMENT FIBROID/PSEUDO or FALSE FIBROID – Intramural fibroid may be pushed out in between the layers of broad ligament.

11. TYPES – Submucous The intramural fibroid when pushed towards the uterine cavity, and is lying underneath the endometrium, it is called as submucous fibroid. This variety is least common but produces maximum number of symptoms.

12. TYPES – Cervical Cervical fibroid is rare. In the supravaginal part of the cervix, it may be interstitial or sub-peritoneal variety and rarely polypoidal . Depending on the position it may be – Anterior Posterior Lateral Central

13. PATHOL O GY Frequently multiple May reach 15 cm in size or larger Firm Spherical or irregularly lobulated Have a false capsule Ca n b e easil y en u cleate d from surrounding myometrium

14. MICROSCOPIC STRUCTURE Consists of smooth muscles and fibrous connective tissue of varying proportion. Individual cells are spindle shaped uniform Varying amount of connective tissue are interlaced between muscle fibers Pseudocapsule of areolar tissue & compressed myometrium Arteries are less dense than myometrium & do not have a regular pattern of distribution 1-2 major vesseles are found at the base or pedicle

15. SECONDARY CHANGES

16. DEGENERATION - Hyaline Hyaline degeneration is the most common (65%) type of degeneration affecting all sizes of fibroids except the tiny one. The feel becomes soft elastic in contrast to firm feel of the tumour . Naked eye examination on the cut surface shows irregular homogenous areas with loss of whorl-like appearance.

17. DEGENERATION - Cystic Usually occurs following menopause and is common in interstitial fibroids. It is formed by liquefaction of the areas with hyaline changes. The cystic changes of an isolated big fibroid may be confused with an ovarian cyst or pregnancy.

18. DEGENERATION - Fatty Usually found at or after menopause. Fat globules are deposited mainly in the muscle cells.

19. DEGENERATION - Calcific Seen in 10% of the cases. Usually involves the subserous fibroids with small pedicle or myomas of postmenopausal women. Usually preceded by fatty degeneration. There is precipitation of calcium carbonate or phosphate within the tumor. When the whole of the tumor is converted into a calcified mass it is called as ‘WOMB STONE.’

20. DEGENERATION - Red Also known as carneous degeneration occurs in a large fibroid mainly during second half of pregnancy and puerperium. Naked eye appearance of the tumor shows dark areas with cut section revealing raw-beef appearance often containing cystic spaces. Odor is fishy due to fatty acids and the color is due to presence of haemolysed red cells and haemoglobin . Microscopically, evidence of necrosis are present.

21. DEGENERATION - Red

22. DEGENERATION - Atrophy Atrophic changes occur following menopause dur to loss of support from oestrogen . There is reduction in the size of the tumor. Reduction also occurs following pregnancy enlargement.

23. DEGENERATION - Necrosis Circulatory inadequacy may lead to central necrosis of the tumor. This is present in submucous polyp or pedunculated subserous fibroid.

24. DEGENERATION - Infection The infection gains access to the tumour through the thinned and sloughed surface epithelium of the submucous fibroid. This usually happens following delivery or abortion. Intramural fibroid may also be infected following delivery.

25. DEGENERATION – Vascular changes Dilatation of the vessels or dilatation of the lymphatic channels inside the myoma may occur. The cause is unknown.

26. CHANGES IN PELVIC ORGANS UTERUS – Shape – distorted Myohyperplasia is a constant finding Endometrium normal Anovulation Dilatation and congestion of myometrial and endometrial venous plexuses. Uterine cavity may be elongated and distorted in intramural and submucous varieties. OVARIES – Enlarged, congested and studded with multiple cysts.

27. CHANGES IN PELVIC ORGANS URETER – Displacemment of the anatomy of the ureter in broad ligament fibroid. ENDOMETRIOSIS – Increased association of pelvic endometriosis and adenomyosis . ENDOMETRIAL CARCINOMA.

28. CLINICAL FINDINGS

29. SYMPTOMS Symptomatic in only 30% of Patient. Symptoms depend on location, size, changes & pregnancy status Menstrual abnormality – Menorrhagia, metrorrhagia . Dysmenorrhea Dyspareunia Infertility Recurrent abortion Lower abdominal or pelvic pain Abdominal enlargement

30. SYMPTOMS MENSTRUAL ABNORMALITIES – Submucous myoma produce the most pronounced symptoms of menorrhagia, pre & post-menstrual spotting Bleeding is due to interruption of blood supply to the endometrium, distortion & congestion of surrounding vessels or ulceration of the overlying endometrium Pedunculated submucous areas of venous thrombosis & necrosis on the surface i nter - menstrtual bleeding

31. SYMPTOMS DYSMENORRHOEA – The congestive variety may be due to associated pelvic congestion or endometriosis. Spasmodic type is associated with extrusion of polyp and is expulsion from the uterine cavity. INFERTILITY – Infertility may be a major complaint. The cause may be uterine, tubal, ovarian, peritioneal .

32. SYMPTOMS PREGNANCY RELATED PROBLEMS – Abortion, preterm labour , IUGR. PAIN – Fibroids are usually painless, but it may be due to some complications of the tumor or due to associated pelvic pathology. Due to tumour – Degeneration Torsion of subserous pedunculated fibroid Extrusion of polyp Assosiated pathology – Endometriosis PID

33. PRESSURE SYMPTOMS If large may distort or obstruct other organs like ureters, bladder or rectum u rinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edema Rarely a posterior fundal tumor extreme retroflexion of the uterus distorting the bladder base urinary retention Parasitic tumor may cause bowel obstruction Cervical tumors causes vaginal discharge, bleeding, dyspareunia or infertility SYMPTOMS

34. COMPLICATIONS

35. COMPLICATIONS IN PREGNANCY 2/3 of women with fibroids & unexplained infertility conceive after myomectomy Red degeneration In the 2 nd or 3 rd trimester of pregnancy rapid in size vascular deprivation degeneration Causes pain & tenderness May initiate preterm labor After the acute phase pregnancy will continue to term

36. COMPLICATIONS IN PREGNANCY DURING LABOR Uterine inertia Malpresentation Obstruction of the birth canal Cervical or isthmeic myoma necessitate CS PPH

37. COMPLICATIONS IN NONPREGNANT WOMEN Heavy bleeding with anemia is the most common Urinary or bowel obstruction from large parasitic myoma is much less common Malignant transformation is rare Ureteral injury or ligation is a recognized complication of surgery for myoma Postmenopausal women on hormonal therapy must be followed up with pelvic exam or USG every 6 months.

38. MANAGEMENT O F FIBR O ID

39. EXAMIN A TION Most myoma are discovered on routine bimanual pelvic exam or abdominal examination Retroflexed retroverted uterus obscure the palpation of myomas LABORATORY FINDINGS Anemia Depletion of iron reserve Rarely erythrocytosis pressure on the ureters back pressure on the kidneys erythropoietin Acute degeneration & infection ESR , leucocytosis, & fever

40. IMAGING Pelvic USG is very helpful in confirming the Dx & excluding pregnancy / Particularly in obese . Saline hysterosonography can identify submucous myoma that may be missed on USG HSG will show intrauterine leiomyoma MRI highly accurate in delineating the size, location & no. of myomas , but not always necessary IVP will show ureteral dilatation or deviation & urinary A nomalies . HYSTROSCOPY for identification & removal of submucous myomas

41. DIFFERENTIAL DIAGNOSIS Usually easily diagnosed Exclude pregnancy Exclude other pelvic masses -Ovarian Ca -Tubo-ovarian abscess -Endometriosis -Adenexa, omentum or bowel adherent to the uterus Exclude other causes of uterine enlargement: -Adenomy osis -Myometrial hypertrophy -Congenital anomalies -Endometrial Ca

42. DIFFERENTIAL DIAGNOSIS Exclude other causes of abnormal bleeding Endometrial hyperplasia Endometrial or tubal Ca Uterine sarcoma Ovarian Ca Polyps Adenomyosis DUB Endometriosis Exogenouse estrogens Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Ca

43. TREATMENT

44. TR E ATMENT DEPENDS ON: Age Parity Pregnancy status Desire for future pregnancy General health Symptoms Size Location

45. MANAGEMENT BODY CE R V IX ASYMPTOMATIC SYMP T O M A TI C S UR GI C A L  Si z e < 12 w eeks.  Diagnosis certain. REGULAR S U PE R VISION  Size >12weeks. MEDICAL  Diagnosis uncertain.  Unexplained infertility.  H/o abortion.  Pedunculated SURGERY  Size increases.  Symptoms appear. o Size s t a t ion ar y . o Symptom less. S UR G E R Y FO L L O W UP

46. SY M P T OM A TI C MED I C A L S UR G I C A L INDICATIONS 1.Symptomatic pt. 2.Perimenopausal female 3.Women desiring children & retaining uterus. 4.For correction of anemia before surgery. 5.To decrease size & vascularity of tumors. TREATMENT  Treat anaemia- Haematinics.  Fib r inol y t i cs - T ra n exe m i c a c i d .  Antiprogesterone- Mifepristone ( RU 486)  - Danazol.  G nr h ago n ist- G o s e rlin, L u p o r e li n Naferelin, Buserelin.  G nr h antago n i s t - Ce t r o re li x , G a ni re li x .  P g s y n t h e t as e inh- N S A I D ’ s.  P r og es t er on e re l eas in g I UD .

47. S UR GI C A L OP T I O N S MYOMEC T O MY HYSTERE C T O MY MYO L YS I S EMBOLOTHERAPY E ND O S C O P Y LAPAROTOMY L A PROSCOPIC MYOM E C T OMY HYSTEROSCOPI C RESECTION OF SUBMUCOUS MYOMA 1. Electrocautery 2 . L a s e r . 3 . C r y o

48. CERVIX SUPRAVAGINAL VAGINAL Myomectomy Hysterectomy Polypectomy Myomectomy

49. MANAGEMENT OF UTERINE FIBROID No treatment is required for asymptomatic small fibroid , unless if cause 12 week uterine enlargement or is the cause of infertility. For excessive heavy cycle . Progesterone only therapy: Oral Progesterone only pills. LNG releasing IUD.

50. C ombined oral contraceptive pills : used cyclically to reduce menstrual blood loss or continueously to eliminate the cycle . Dysmenorrhoea is also improved . MANAGEMENT OF UTERINE FIBROID

51. EMERGENCY MEASURES Blood transfusion/ PRBC to correct anemia . Emergrncy surgery indicatd for: - infected myoma -acute torsion -intestinal obstruction Myomectomy is contraindicated during pregnancy .

52. SPECIFIC MEASURES Most cases asymptomatic no treatment Postmenopausal no treatment Other causes of pelvic mass must be excluded Initial follow up every 6 months to determine the rate of growth of the myoma Surgery is contraindicated in pregnancy The only indication for myomectomy in pregnancy is torsion of a pedunculated fibroid Myomectomy is not recommended during CS ⚫ Pregnant women with previous multiple myomectomy / especially if the cavity was entered 🡆 should be delivered by CS to risk of scar rupture in labor

53. SUPPORTIVE MEASURES PAP smear & endometrial sampling for all Pt with irregular bleeding Before surgery -Correct Hb -Prophylactic antibiotics -Mechanical & antibiotic bowel preparation if difficult surgery is anticipated Prophylactic heparin postoperative

54. SURGICAL MEASURES

55. Operative treatment Myomectomy : Indications Women who wish to maintain fertility SM fibroid distorting the uterine cavity Fibroids > 5 CM Multiple fibroids

56. Open myomectomy The route of choice for : Large SS or IM fibroids >7 cm Mulitple fibroids >5 cm When entry in to uterine cavity is expected

57. Hystroscopic myomectomy The route of choice for SM fibroids. for removing SM fibroids >2 cm

58. Laproscopic myomectomy Mostly done in subserosal type. R emove the mass through a small abdominal incision.

59. H ysterectomy Old age Completed her family Multiple fibroids

60. Non invasive procedures 1.Uterine artery embolization The ideal patient for UAE : Pre-menopausal pt not desiring fertility. Post-menopausal pt with failure of spontaneous regression. Patient has failed medical management. Absolute contraindication to surgery.

61. 2. MRGFUS : Non invasive procedure Fo c use d ultr a soun d wav e conv e r t e d in p a thol o g y to heat under guide of MRI. Slection criteria: 4-10 cm family completed perimenopausal Non invasive procedures