obstetrics & gynecology,

1. Fibroid Uterus
Waseem sajjad
08-209

2. Definition
• “A benign(non-caseous) tumor arising from the smooth
muscles layer and accompanying connective tissue of the
uterus”
• fibroid is chiefly composed of smooth muscle fibres & a small
amount of connective tissue.
• The name fibroid is a misnomer, more appropriate term for
this tumor of smooth muscle is Myoma or Leiomyoma.

3. Pathology
• GROSS:
• nodular structures
• Oval or rounded shaped ,firm
in consistency, whorled
appearance on cut section
• single but mostly multiple (up
to 125)
• Size typically size of grape fruit
but varies Tiny seedling to a
huge abdominal mass

4. Uterine leiomyoma ,external surface on left, cut surface on right.

5. Pathology
• Microscopy:
• Smooth muscle cell bundles arranged in whorled pattern with
variable amount of connective tissue
• Predominance of fibrous tissues rarely seen.

6. Epidemiology
• most common tumor of the female body
• Present in 20-30 % of women of reproductive age,only a
fraction of these will require treatment.
• Age : never occurs before menarche , regresses after
menopause ,peak incidence 4th & 5th decades
• Parity : higher in Infertile & women of low parity.
• Race : twice common in black women, African American
women are three times more likely to get fibroids than
Caucasian women.
• Hereditary factor : women with family history , twice more
likely to develop fibroids.

7. Etiology
• Exact aetiology is unknown, current working hypothesis is that
genetic predispositions, prenatal hormone exposure and the
effects of hormones ,growth factors and xenoestrogens cause
fibroid growth.
• 50% cases shows karyotypically detectable chromosomal
abnormalities .
• 70% cases with fibroids have specific mutations MED12
protein.
• Risk factors: African-American descent, nulliparity , obesity
(fat aromatase), polycystic ovary syndrome ,diabetes and
hypertension.
• While pregnancy & smoking decreases risk of fibroids

8. • Fibroid growth is strongly dependent on estrogen and
progesterone , number of observations support the idea that
fibroid is an ovarian hormone dependent tumor.
1. Higher concentration of estrogen and progesterone
receptors in fibroid.
2. GnRH analouges reduces size of fibroid by reducing the
estogens levels.
3. Oral contraceptive pills when taken by women with
fibroids ,increases fibroid size while taken by a female
without fibroids pills reduces the incidence of fibroids.
4. Obese women are at high risk , because of high serum
estrogen levels. Fat aromatase converting
androgen(androstenedione) to estrogen(estradiol)

9. Classification of fibroids
• Intramural fibroids
• Subserosal fibroids
• Submucous fibroids
Within Body of
uterus
Cervical
Intraligamentary

10. • Intramural fibroid :
Within uterine wall ,
surrounded by
myometrium ,
non capsulated but
pseudocapsule form with
growth ,
blood supply is through
nutrient arteries entering
through the
pseudocapsule.

11. • Subserosal fibroid
Originates from outer
myometrium &
projects outwards
from uterus covered
with peritoneum,
attain large size to lack
of surrounding
myometrium.
large subserosal fibroid

12. • Submucous fibroids :
Arises from inner
myometrium, covered
with endometrium .
Projects inwards from
uterine wall into
uterine cavity ,may get
pedunculated.

13. • Cervical fibroid :
Less common(1-2%), arises
from cervix , usually single,
Confined to the supravaginal
portion of cervix,
Either intramural or
intraluminal.
• Intraligamentary fibroids :
Arises from smooth muscles
fibres with in the broad
ligament e.g round ligament
& ovarian ligament

14. Symptomatology
• Fibroids are mostly asymptomatic , particularly when small in
size.
• Menorrhagia is common intramural & sub mucous fibroids,
with increased blood loss but regular cycle.
• Due to :
Increased endometrial surface area.
ulcerated and damaged endometrium over the fibroid.
mechanical compression of venous drainage by fibroid .
• Intermenstrual bleeding in case of submucous fibroid
• Postcoital bleeding caused by pedunculated submucous
fibroid

15. • Subfertility :
30% of patients with fibroid have problems
related to fertility. However Its unclear whether fibroid is a
cause or effect of infertility , possible explanations are
a) delay in child bearing predispose to development of fibroid
b) fibroid causes interference in implantation
• Pain : pain usually start when complications occurs e.g
torsion
red degeneration
sarcomatous degeneration

16. • Urinary symptoms :
cervical fibroid – irritation of bladder – increased frequency
large cervical fibroid – impaction of pelvis – urinary retention
• Pressure symptoms :
Large fibroids causes interference with venous and lymphatic
drainage of the lower limb causing edema and varicosities.
Pressure on pelvic vein may cause hemorrhoids.
• Abdominopelvic mass :
A large fibroid may fill the abdominal cavity causing
dyspepsia due to stomach irritation & dyspnea due to pressure
on lungs.

17. Examination
General physical examination
• No specific findings
• Excessive loss of blood may cause anemia ,presenting with pallor and in extreme
cases with breathlessness
• Edema and varicosities of limbs are rare findings with large fibroids .
Abdominal examination :
Uterus palpable abdominally after 12weeks size of pregnancy
• Single fibroid -- central uterus with smooth surface
• Multiple fibroids – irregular mass maybe shifted to a side
• Fibroids – firm ,non tender unless undergone degeneration.
Pevic examination :
• Protuding fibroids easily seen
• Speculum examination – patients with mennorrhagia ,intermestrual and
postcoital bleeding.
• Bimanual examination –
• Single fibroid -- central uterus with smooth surface
• Multiple fibroids – irregular mass maybe shifted to a side
• Fibroids – firm ,non tender unless undergone degeneration

18. Complications
1. Related to site of fibroid
• Subserous fibroid : if
pedunculated ,can undergo
torsion or twist in the
pedicle occludes blood
supply leading to ischemic
necrosis presenting with
acute pain.
• Sessile subserous fibroid
may get adherent with the
bowel or omentum ,if
develop its own blood
supply and get separated
from the uterus forming
Parasitic fibroid.

19. • Submucous fibroid : if
pedunculated may prolapse
through cervix causing
Intermenstrual and postcoital
bleeding
Get infected and ulcerated
May cause uterine inversion
• Cervical fibroid : may get
impacted in pelvis causing
ureteric obstruction and urinary
retention.

20. 2. Degeneration :
Blood supply to fibroid is from periphery and the central area is
relatively deprived of circulation so a rapidly growing fibroid
easily undergo degeneration ,these include
• Hyaline degeneration
Soft , on cut section whorled pattern lost & become cystic.

21. • Fatty degeneration :
Fatty change occurs in the fibroid
Require differentiation from uterine lipoma
A longitudinal (a) and transverse (b) image of a 1.46 x 1.16 x
1.56 anterior leiomyoma that has undergone fatty
degeneration.

22. Leiomyoma with fatty degeneration

23. • Red degeneration :
Thrombosis of peripheral
blood vessels , while other
become distended and
engorged with red blood
cells.
Cut section: appear reddish
due to presence of
thrombotic and hemolytic
changes.
• Calcification due to poor
blood supply.
• Rarely sarcomatous
degeneration also occurs
(0.1%)
Leimyoma with extensive red degenration

24. 3. Infections :
Subserous fibroid can acquire infection from
Appendicitis
Diverticullitis
Pyosalpinges
Submural fibroids – after abortion and during perpurium
Submucosal fibroids –after ulceration
4. Hematological complications :
menorrhagia-exessive bleeding -anemia
fibroids--increased erythropoietin production-
polycythemia

25. Investigations
Investigation
of choice
• Ultrasonography
Under special
circumstances
• Hysteroscopy and curettage
• Laparoscopy
Other
investigation
• Hysterosalpingogram
• Modern imaging techniques
• Complete blood picture

26. Ultrasonography
• Investigation of choice
• Typical fibroid appearance :: mild to moderate echogenic mass
in the uterine wall that causes nodular distortion of uterine
outline.
• Small intramural or Submucous fibroid :: recognized by
distortion of the normally linear central endometrial echoes.
• Fibroids with hyaline degeneration :: anechoic area within
fibroid
• Fibroids with cystic degeneration:: will give Snow storm
appearance..

27. Uterine fibroid (arrow)

28. Hysteroscopy & Curettage
• Hysteroscopy provides a direct veiw of uterine cavity, & is
indicated during
Abnormal uterine bleeding
Small submucous fibroids missed during ultrasound
Investigation under special circumstances

29. Curettage may help to diagnose a co existing endometrial
pathology ,which may be the actual cause of menorrhagia.

30. • Indication
when the mass cannot be differentiated on the ultrasound
fibroid associated with infertility or pelvic pain
laparoscopy

31. Other investigations
1. Hysterosalpingogram : carried out as a part of infertility
investigation and can pick small submucous fibroids.
Hysterosalpingogram showing two
submucous leiomyoma(arrow)
Hysterosalpingogram

32. 1. Modern Imaging
Technique : CT scan
and MRI are more
accurate in describing
pelvic mass but too
expensive for routine
examination.
1. Complete Blood
Picture : In severe
menorrhagia
hemoglobin will be low
and polycythemia can
also be diagnosed.
A very large (9cm) fibroid of the uterus
seen on CT

33. Treatment
conservative treatment
Medical treatment
Surgical treatment

34. Conservative Treatment
• Asymptomatic fibroid of size less than 12 weeks pregnancy in
a patient of 42 years of age is left alone in a hope that I would
regress after menopause.
• Even an asymptomatic fibroid of size more that 12 weeks of
pregnancy does not justify prophylactic removal as risk of
sarcomatous change is less than 0.1%.
• Only mangment required is a regular follow up till menopause.
• These days, Removal only indicated in case of a very large
fibroid or a rapidly increasing in size due to concern about the
nature of the mass .
•

35. Medical Treatment
• Ideal drug – complete regression of fibroids
• GnRH analogues is the only drugs which has shown promising
results .
• GnRH analogues :
Monthly IM depot injection
Daily Nasal spray
prescribed for 3 months
improved 80% cases of menorrhegia,
50% of the fibroid size is reduced
Disadvantages: expensive , effects only last during therapy ,
cause post menopausal symptoms (hot flushes , night sweats ,
psychological disturbance)

36. • Therefore only given when reduction in size and vascularity is
required prior to myomectomy & hysterectomy.
• Long term use (6months or more) only allowed when patient
is unfit for surgery ( obses ,extensive adhesions) or
approaching her menopause.
• Other drugs : these shows reduction in size of fibroids up to
some extent
• Danazol
• Gestrinone

37. Surgical treatment
• Surgical treatment is present in the form of
a) Myomectomy
b) Hysterectomy
Myomectomy
term myomectomy is used for an operation where the
uterus is conserved and fibroid is removed.
Preferred treatment in following conditions,
1. Symptomatic fibroids in young patient,
2. Infertile patients when fibroids are only pathology,
3. Patients wishing to have more childrens,
4. Patients with recurrent abortion ,fibroids likely to be the
underlying cause,
5. Patients wishing to conserve her uterus.

38. Routes of Myomectomy
• Abdominal myomectomy
Most common method,
perform through abdomen.
• Vaginal myomectomy
For pedunculated
submucosal fibroids
protruding through cervix
removed vaginally by ligating
its pedicle with cautery.
• Endoscopic myomectomy

39. Disadvantages of Myomectomy
• Hemorrhages
Patient hemoglobin less than 11 gm/dl , two pints of cross
matched blood should be kept for transfusion
Uncontrolled hemorrhages may lead to hysterectomy.
• Early post operative complications
Post operative oozing from the uterine wound causes pyrexia
and paralytic ileus thus prolonging post operative recovery
• Delayed complications
Intraperitoneal adhesions causing infertility and intestinal
obstruction.
• Recurrence
15% risk

40. Hysterectomy
• Removal of uterus
• Mostly through abdomen
although small fibroids can
be removed through vaginal
hysterectomy
• Advantages :
a) Low post operative
morbidity
b) No risk of recurrence
Hysterectomy specimen:deformed
uterus with one isthmic fibroid

41. • Its preferred over
myomectomy under
theses circumstance
1. Patients above 40 years
of age
2. Presence of multiple
fibroids
3. Patients with complete
family
4. Patients experiencing
severe symptoms

42. Differential diagnosis
• Adenomyosis :
Also called adenomyoma
Disease of multiparous
women
Menorrhagia is associated
with severe dysmenorrhea
Uterus : uniformly enlarged
,tender
Ultrasound findings :
thickened myometrium with
swiss chees appearance
Cut surface : lacks whorled
appearance and capsule.
• Ovarian tumors :
Confused with pedunculaed
sub serous fluid
Menorrhagia often absent
Mass feels separate from the
uterus while fibroids has
limited mobilty.
Ultrasound may be helpful
but diagnosis is not
confirmed until laproscopy or
laprotomy is performed..

43. thank you