Uterine fibroid

1

Fifth stage 

Gynecology 

Lec-3

.د

  اسماء

13/4/2016

UTERINE FIBROIDS

LEIOMYOMA: 

What is a leiomyoma? 

It is a benign neoplasm of the muscular wall of the uterus composed primarily of smooth 
muscle . 

Although they can grow to huge size their malignant potential is minimal. 

Incidence: 

They are the most common pelvic tumors  

It is found in 25% of white women & 50% of black Women. 

More than 45% of women have leiomyomas by the fifth decade of life. 

They are primary indication for about 200000 Hysterectomies in united state each year 

ETIOLOGY: 

  Unknown 
  Each individual myoma is unicellular in origin  
  Estogens



 no evidence that it is a causative factor , it has been implicated in growth of 

myomas 

  Myomas contain estrogen receptors in higher concentration than surrounding 

myometrium 

  Myomas may increase in size with estrogen therapy & in pregnancy & decrease after 

menopause 

  They are not detectable before puberty 
  Progestrone increase mitotic activity & reduce apoptosis 



 in size 

  There may be genetic predisposition  

Risk factors: 

  Nultiparity and infertility. 
  Increasing age . 
  Ethinicity(two fold in african american compared with white women. 

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  Increased BMI. 
  Family history. 
  Reduced incidence with COCP and DMPA user. 

PATHOLOGY: 

  Frequently multiple 
  May reach 15 cm in size or larger 
  Firm  
  Spherical or irregularly lobulated 
  Have a false capsule 
  Can be easily enucleated  from surrounding myometrium 

CLASSIFICATION: 

  Submucous leiomyoma 
  Pedunculated submucous 
  Intramural or interstitial 
  Subserous or subperitoneal 
  Pedunculated abdominal 
  Parasitic 
  Intraligmentary 
  Cervical  

MICROSCOPIC STRUCTURE: 

  Whorled appearance nonstriated muscle fibers arranged in bundles running in 

different directions 

  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 

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SECONDARY CHANGES: 

1-BENIGN DEGENERATION 

  Atrophic. 
  Hyaline  yellow, soft gelatinous areas  
  Cystic liquefaction  follows extreme hyalinization 
  Calcific circulatory deprivation precipitation of ca carbonate & phosphate 
  Septic circulatory deprivation necrosis  inection 
  Myxomatous (fatty) uncommon, follows hyaline or cystic degenration 

Red (carneous) degeneration 

  Commonly occurs during pregnancy  
  Edema & hypertrophy impede blood supply aseptic degenration & infarction with 

venous thrombosis & hemorrhage 

  Painful but self-limiting 
  May result in preterm labor & rarely DIC 

2-MALIGNANT TRANSFORMATION is rare: 

  Transformation to leiomyosarcomas occurs in 0.1-0.5% 

CLINICAL FINDINGS: 

1-SYMPTOMS 

  Symptomatic in only 35-50% of Patient. 
  Symptoms depend on location, size, changes & pregnancy status 

1-Abnormal uterine bleeding 

  The most common 30% 
  Heavy / prolonged bleeding (menorrhagia)  iron deficiency anemia 
  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 

intermenstrtual bleeding 

2-PAIN 

  Vascular occlusion  necrosis, infection 
  Torsion of a pedunculated fibroid acute pain 
  Myometrial contractions to expel the myoma 

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  Red degenration acute pain 
  Heaviness fullness in the pelvic area  
  Feeling a mass 
  If the tumor gets impacted in the pelvis pressure on nerves back pain radiating to 

the lower extremities 

  Dysparunea if it is protruding to vagina 

3-PRESSURE EFFECTS 

  If large may distort or obstruct other organs like ureters, bladder or rectum urinary 

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 serosanguineous vaginal discharge, bleeding, dyspareunia or 

infertility 

4-INFERTILITY 

  The relationship is uncertain  
  27-40% of women with multiple fibroids are infertile  but other causes of infertility 

are present 

  Endocavitary tumors affect fertility more 

5- SPONTANEOUS ABORTIONS 

  ~2X N  incidence before myomectomy 40% 

                                   after myomectomy 20% 

  More with intracavitary tumors 

2- EXAMINTION 

  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 

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IMAGING 

  Pelvic U/S is very helpful in confirming the Dx & excluding pregnancy / Particularly in 

obese . 

  Saline hysterosonography can identify submucous myoma that may be missed on 

U/S 

  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 anomalies 

HYSTROSCOPY  for identification & removal of submucous myomas 

DIFFERENTIAL DIAGNOSIS: 

  Usually easily diagnosed 
  Exclude pregnancy 
  Exclude other pelvic masses 

o  Ovarian Ca 
o  Tubo-ovarian abscess  
o  Endometriosis 
o  Adenexa, omentum or bowel adherent to the uterus  

  Exclude other causes of uterine enlargement: 

o  Adenomyosis 
o  Myometrial hypertrophy 
o  Congenital anomalies 
o  Endometrial Ca 

  Exclude other causes of abnormal bleeding: 

o  Endometrial hyperplasia  
o  Endometrial or tubal Ca 
o   Uterine sarcoma  
o   Ovarian Ca 
o  Polyps 
o  Adenomyosis 
o  DUB 
o  Endometriosis 
o  Exogenouse estrogens 

Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to 
exclude endometrial Ca 

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COMPLICATIONS: 

1-COMPLICATIONS IN PREGNANCY 

  ≥  2/3  of women with fibroids & unexplained infertility conceive after myomectomy 

Red degeneration  

  In the 2nd or 3rd trimester of pregnancy rapid  in size  vascular deprivation  

degeneration  

  Causes pain & tenderness 
  May initiate preterm labor 
  Managed conservatively with bedrest & narcotics + tocolytics if indicated 
  After the acute phase pregnancy will continue to term 

DURING LABOR 

  Uterine inertia 
  Malpresentation 
  Obstruction of the birth canal 
  Cervical or isthmeic myoma  necessitate CS 
  PPH 

2- 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 Cx myoma 
  No evidence that COCP  the size of myomas 
  Postmenopausal women on HRT must be followed up with pelvic exam or U/S every 6 

M   

TREATMENT: 

DEPENDS ON: 

  Age 
  Parity 
  Pregnancy status 
  Desire for future pregnancy 
  General health 
  Symptoms 
  Size  
  Location 

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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 
  Injected MPA. 
  Progesterone only pills. 
  LNG releasing IUD. 
  COCP:used cyclically to reduce menstrual blood loss or continueously to eliminate the 

cycle 

  Dysmenorrhoea is also improved   

GNRH AGONISTS: 

RX results in: 

 1- size of the myomas 50% maximum 

 2- This shrinkage is achieved in 3months of RX 

 3-Amenorrhea & hypoestrogenic side-effects occur 

 4-Osteopososis may occur if Rx last > 6M 

It is indicated for 

 1-  bleeding from myoma except for the polypoid submucous type 

 2-Preoperative to  size  allow for vaginal hysterectomy 

 myomectomy 

 laparoscopic myomectomy  

A-EMERGENCY MEASURES: 

  Blood transfusion/ PRBC to correct anemia 
  Emergrncy surgery indicatd for: 

 - infected myoma 
 -acute torsion 
 -intestinal obstruction 

  Myomectomy is contraindicated during pregnancy   

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B-SPECIFIC MEASURES: 

  Most cases asymptomatic  no treatment 
  Postmenopausal  no treatment 
  Other causes of pelvic mass must be excluded 
  The Dx must be certain 
  Initial follow up every 6 M  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 

C-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 

D-SURGICAL MEASURES: 

1-Evaluation for other neoplasia 

2-Myomectomy 

  For symptomatic Pt who wish to preserve fertility  
  Open myomectomy :for large myoma 
  Laparoscopic myomectomy:pedunculated,subserous,some  intramural fibroid 
  Hysteroscopic myomectomy:submucos 

3-Hysterectomy:if no desired fertility nor uterine preservation especially if rapidly 
expanding tumors (uterus is doubled after 6months) ,it’s the desired definitive surgery. 

  Vaginal hysterectomy 
  Abdominal hysterectomy 

4-Uterine artery embolisation available and surgery is difficult.