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thus each myoma is monoclonal (Each myoma would have cells with the same abnormality.) The larger the myoma, the more an abnormal karyotype will be detected
. The regions of chromosome 12 and 7 involve genes that may regulate growth-inducing proteins and cytokines, including transforming growth factor β (TGF-β) epidermal growth factor (EGF), insulin-like growth factors (IGF) 1 and 2, and platelet-derived growth factor (PDGF) ( Fig. 18-34 ).
FOUND IN CERVIX AS WELL
Subserosal myomas give the uterus its knobby contour during pelvic examination. Further growth of a subserosal myoma may lead to a pedunculated myoma wandering into the peritoneal cavity. This myoma may outgrow its uterine blood supply and obtain a secondary blood supply from another organ, such as the omentum, and become a parasitic myoma. Growth of a myoma in a lateral direction from the uterus may result in a broad ligament myoma ( Fig. 18-33 ). The clinical significance of broad ligament myomas is that they are difficult to differentiate on pelvic examination from a solid ovarian tumor. Large, broad ligament myomas may produce a hydroureter as they enlarge.
Grossly, a myoma has a lighter color than the normal myometrium
. On cut surface the tumor has a glistening, pearl-white appearance, with the smooth muscle arranged in a trabeculated or whorled configuration. smooth muscle cells are markedly elongated and have eosinophilic cytoplasm and elongated, cigar-shaped nuclei.
Ground glass fibrous tissue proliferation
Red degeneration; the ghosts of the muscle cells and their nuclei remain
The most common symptoms related to myomas are pres-sure from an enlarging pelvic mass, pain including dysmenorrhea, and abnormal uterine bleeding. The severity of symptoms is usually related to the number, location, and size of the myomas. However, over two thirds of women with uterine myomas are asymptomatic.
Symptoms depend on location, size, changes & pregnancy status One of three women with abnormal bleeding and submucous myomas also has endometrial hyperplasia, which may be the cause of the symptom. explanation is straightforward when there are areas of ulceration over submucous myomas. However, ulceration is a rare finding. The most popular theory is that myomas result in an abnormal microvascular growth pattern and function of the vessels in the adjacent endometrium.
Vascular occlusion necrosis, infection Torsion of a pedunculated fibroid acute pain Myometrial contractions to expel the myoma 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
Occasionally, myomas are the only identifiable abnormality after a detailed infertility investigation.
NEXT SLIDE …. VICTOR BONNEY
HE GOES ON TO DESCRIBE THE LATER ORDEAL IN HIS LIFE….
WENT ON TO REMOVE 130 FIBROIDS FROM A UTERUS CONSIDERED A FEAT IN 1930
TORSION is extremely rare ….. Only situation which necessitates a laprotomy and removal of myoma from the pregnant uterus….
Submucous fibroids can lead to miscarriage both due to defective implantation and as there is less space for the foetus to grow
Fibroid uterus in detail ..... odstetrics and gynecolgy
• Disease is prevalent in one among every
four women as per studies
The commonest benign tumour of uterus
Commonest benign solid tumour in
Terminology & Definition
• “womb stone”
Benign tumors Arising from the
myometrium or muscles of its vessel walls
Composed of smooth muscles
interspersed with varying amounts of
myoma, fibromyoma, leiofibromyoma,
fibroleiomyoma, and fibroma
Aetiology & Pathogenesis
origin of uterine leiomyomas is incompletely
But cytogenetic studies have yielded some clues
Each tumor develops from a single muscle cell
– a progenitor myocyte
Cytogenetic analysis has demonstrated that myomas
have multiple chromosomal abnormalities.
• Twenty percent of abnormalities involve translocations
between chromosomes 12 and 14.
• Seventeen percent involve a deletion of chromosome 7.
• Twelve percent involve a deletion of chromosome 12.
• oestrogen and progesterone receptors are found in higher
concentrations in uterine myomas.
• There also appear to be similarities between fibroids and
Red (carneous) degeneration
Commonly occurs during pregnancy
Edema & hypertrophy impede blood supply
aseptic degeneration & infarction with venous
thrombosis & hemorrhage
Painful but self-limiting
May result in preterm labor & rarely DIC
Transformation to leiomyosarcomas occurs in 0.1-0.5%
Abnormal uterine bleeding---- 30%
Pain abdomen ---
Mass per abdomen
Abnormal uterine bleeding
• The most common symptom is menorrhagia
• Heavy / prolonged bleeding (menorrhagia) iron deficiency anemia
• But intermenstrual spotting and disruption of a normal pattern are
other frequent complaints
• location of the myomas, submucous versus intramural, is not
related to bleeding symptoms
• symptoms of bleeding were related to the size of myomas
• The older theory that the amount of menorrhagia is directly
related to an increase of endometrial surface area has been
• Dull aching pain of Feeling a mass
• RED DEGENERATION
• TORSION HAEMORRHAGE,
• ACUTE INFECTION
• EXPULSION OF A SUBMUCOUS FIBROID
• Back pain radiating to the lower extremities
• 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
“Woman postpones her pregnacy later fibroid postpones it”
• The relationship is uncertain
• Myomectomy is indicated only in long-standing
infertility and recurrent abortion after all other potential
factors have been investigated and treated.
• submucous myomas that distort the uterine cavity are
the myomas that may affect reproduction
INVENTOR: MYOMECTOMY CLAMP AND SCREW
“ …in my early years as a
gynaecological surgeon, a
case occurred which
profoundly affected my
outlook. A lady, recently
married, wishing above all
things to have a child,
underwent a subtotal
hysterectomy on account of a
single sub‐mucous fibroid.”
Master pelvic surgeon and pioneer of
conservative surgery for the ovary and
Clinically, the diagnosis of uterine myomas is
usually confirmed by physical examination. Upon
palpation, an enlarged, firm, irregular uterus may
The three conditions that commonly enter into the
differential diagnosis include pregnancy,
adenomyosis, and an ovarian neoplasm.
The discrimination between large ovarian tumors
and myomatous uteri may be difficult on physical
examination, because the extension of myomas
laterally may make palpation of normal ovaries
impossible during the pelvic examination.
The mobility of the pelvic mass and whether the
mass moves independently or as part of the uterus
may be helpful diagnostically.
INCIDENCE OF CLINICALLY DETECTABLE FIBROIDS IN
PREGNANCY VARIES FROM 1 IN 500 TO 1 IN 1000.
INCREASE IN SIZE– oestrogen and progestrone
RED DEGENERATION – charecterised by rapid
enlargement of fibroid, acute onset of pain
over the fibroid, mild pain and
INFECTION of the fibroid in peuperium
TORSION OF A PEDUNCULATED FIBROID
Position size and type of fibroid determine
their effect on pregnancy
Most complications occur when the fibroid is
submucous and close to the placental
Miscarriage and preterm labour.
Both in first and second trimester
Non-engagement of head
PPH and retained placenta
Difficulty at CS