Uterine fibroids
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fibroids, newer techniques in fibroid, fibroid in pregnancy, types of fibroid, HIFU, myomectomy, fertility conservation surgery,
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Uterine fibroids
- 1. FIBROIDS DR. PREKSHA JAIN DR. PRACHI DIXIT
- 2. Contents • Introduction • Incidence • Etiology • Risk factors • Symptoms • Natural history • Secondary changes & complications • Diagnosis & Types • Fibroids in Pregnancy • Treatment (Medical & surgical) • Recent advances
- 3. Introduction • Definition • Myoma, leiomyoma, fibromyoma • Derived from smooth muscle cell rests from vessel wall or uterine musculature
- 4. Incidence • M/c benign tumors of myometrium • 77% of hysterectomy specimen • 60% in 35-49 yrs • 80% in >50 yrs • 40% in 35 yrs • 70% in 50 yrs Afro american White women
- 5. Etiology • Genetic (40%) • Hormonal • Growth factors
- 6. Genetics • Cellular, atypical & large fibroids • Translocations 12 & 14 chrm • Deletion of 7 chrm • Trisomy of 12 chrm • Leiomyosarcoma have different origin
- 7. Hormones • E & P increase in receptors no. & responsiveness. • Hyperestrogenic states- Obesity, Ca endometrium, early menarche, anovulatory infertility. • Highest mitotic counts encountered in peak progesterone production. • Before puberty & after menopause – less incidence
- 8. Growth Factors • TGF-β, bFGF, EGF, PDGF, IGF, VEGF, PRL
- 9. Risk Factors INCREASE DECREASE NO EFFECT Age Green veg OCP Endogenous hormone Exercise IUCD Family history (2.5 times) Parity STI, CMV, HSV, EBV Afro American Smoking Weight
- 10. Classification
- 11. UTERINE FIBROIDS BODY CERVIX INTERSTITIAL SUBSEROUS SUBMUCOUS SUBSEROUS BROAD LIGAMENT PARASITIC • ANTERIOR • POSTERIOR • CENTRAL • LATERAL • SESSILE • PEDUNCULATED 75% 15% 10% OTHERS- • Intravenous leiomyomatosis • Leiomyomatosis peritonalis disseminata • Bizzare leiomyoma
- 14. Symptoms Asymptomatic 50% (<5cm size & uterus <12cm) Abnormal uterine bleeding – 30% Menorrhagia (intramural & submucous) Metrorrhagia (submucous & endometrial cancer) Polymenorrhea (cystic ovaries & PID) Purulent discharge (infected fibroid polyp)
- 15. Symptoms Pain- • Congestive & spasmodic dysmenorrhea • Acute pain - torsion, hemorrhage & red degeneration. • Chronic Pelvic pain • Rapidly growing sarcoma
- 16. Symptoms Pressure symptoms – • Retention of urine premenstrual • Hydroureter & hydronephrosis • Constipation • Intestinal obstruction
- 17. Symptoms Infertility – 30% • >4cm • Distortion of cavity • PID, endometriosis, anovulation • Fertility rate – Submucous type Subserosal type- No effect Intramural type - slightly decrease
- 18. Symptoms Abdominal lump – • Rapid growth • Pseudo Meig’s syndrome Others – • Secondary to anemia • Vaginal discharge
- 19. Natural History • Grow slowly 9% over 1 year • Regress after menopause • Rapid growth in Premenopausal- indicates pregnancy not sarcoma • Postmenopausal with pain & bleeding- Sarcoma • Secondary or degenerative changes
- 20. Secondary changes & complications • Hyaline 65%, cystic, fatty, calcareous 10% & red degeneration, necrosis • Atrophy • Sarcomatous change • Torsion, Inversion, Hemorrhage, Infection • Association with endometrial cancer(3%), adenomyosis/ endometriosis 30%, salpingoophoritis 15%, Anovulation
- 23. RED DEGENERATION
- 26. Diagnosis • History • Pelvic Examination – enlarged irregularly, firm, non tender, mobile, arising from uterus. • FIGO classification • Imaging
- 27. Imaging IMAGING SENSITIVITY SPECIFICITY MRI 100% 91% TVS 83% 90% SIS 90% 90% Hysteroscopy 82% 87%
- 28. MRI
- 29. TAS
- 30. TVS
- 31. SIS
- 32. Differential diagnosis • Pregnancy • Hematometra • Adenomyosis • Bicornuate uterus • Ovarian cysts & tumors • Ectopic pregnancy • Pelvic kidney • Chronic inversion
- 33. Management Routine investigations Others – IVP, Laparoscopy Treatment- • Conservative- 1. Observation 2. Medical 3. Non-invasive- MRgFUS 4. Minimally invasive- UAE, Myolysis 5. Invasive- Thermal Ablation • Surgical –Polypectomy, Myomectomy, Hysteroscopic resection, Hysterectomy
- 34. • INDICATIONS for intervention: 1. Infertility 2. Recurrent pregnancy losses 3. Asymp >12wk/pedunculated 4. Pressure symptoms 5. Rapidly growing fibroid/ growth after menopause 6. Symptomatic- AUB
- 35. Medical Management • Temporary palliation- 1. Menorrhagia 2. Before surgery- Correction of anemia, decrease size & vascularity 3. Postpone surgery • Alternative to surgery 1. Perimenopausal 2. Desiring fertility 3. Unfit for surgery
- 36. Drug Dose Advantage Disadvantage ANTIFIBRINOLYTICS Tranexamic Acid 1-4gm/d blood loss Correct anemia Size remain same GnRH AGONIST Goserelin (Zoladex) 3.6mg every 28days 3-6mth s/c 30% size 35% ut vol in 6mth • Hypoestrogenic effect • Rebound size • Loss of plane • Seedling fibroids missed • Expensive GnRH ANTAGONIST Cetorelix, Ganirelix 30% size in 3weeks Under evaluation ANTIANDROGEN Danazol 200-400mg 6-12mth Gestrinone Volume No regrowth Androgenic effect PROGESTERONE ANTAGONIST Mifepristone 25-30mg 3-6mth 25-75% size 50% ut vol Amenorrhea Endometrial hyperplasia Hot flushes, deranged LFT
- 37. • Antiestrogen- Faslox, Raloxifene, fadrozole (aromatase inhibitor) • MIRENA • Others- chinese herbal medicine
- 38. SPRM • Selective progesterone receptor modulator ULIPRISTAL - • Partial agonist & antagonist of Pg receptors ASOPRISNIL – • 10-25mg per day 3mth • Inhibits growth • Decreases uterine artery blood flow & menorrhagia • No effect on endometrial proliferation
- 39. Magnetic Resonance guided Focused Ultrasound • FDA approved Oct 2004 • Selection criteria- 1. 4-10cm fibroids 2. Family completed 3. Perimenopausal 4. Subcut tissue to fibroid <12cm 5. Clearly visible on MRI • Thermal ablation • 31% reduction ut vol in 6mth
- 41. • US is focused either 1. Geometrically via Lens, Curved Transducer 2. Electronically via Phased Array • Adv- 1. No scar 2. Short stay, early resuming of activities 3. Least chances of infection, complications 4. Repetition of procedure with low risk
- 42. Uterine Artery Embolization • Procedure • Indication-Symptomatic fibroid, surgery not feasible • Contraindications- 1. Immunocompromised 2. Genital tract infection or malignancy 3. Vascular disease 4. Contrast allergy/ impaired renal function 5. Infertility
- 44. • Adv- 1. 80% decrease in menorrhagia, 33% reduction of fibroid in 3mth. Success rate 85-95%. 2. Short stay 3. No bleeding, adhesions • Disadv- 1. Postembolization syndrome 2. Early ovarian failure & early menopause 3. Effect on fertility & pregnancy 4. May require hysterectomy 5. Death, sepsis, loss of organs
- 45. Myolysis • Lap procedure • Destroys by laser, cryotherapy, electrosurgical energy • Indications- 1. Perimenopausal 3-10cm 2. Ut size < 14wk
- 46. Surgical Management • I/c- 1. Severe anemia 2. Torsion 3. Pain, urinary symptoms compromising QOL • Preoperative- 1. Correction of anemia 2. Control menorrhagia 3. Control medical problems
- 47. ACOG criteria for Hysterectomy • Confirmation of indication: 1. Asymptomatic 12wk concern to patient 2. Excessive bleeding- Profuse bleeding >8days or anemia 3. Pelvic discomfort- Acute & severe or chronic pain, Pressure symptoms
- 48. Myomectomy I/c : Unexplained infertility with cavity distortion Unexplained RPL Fertility conservation Subserous pedunculated • Prerequisities- 1. Correct Hb, oral iron, GnRH-a, Autotransfusion 2. Other causes of infertility should be ruled out 3. Consent for hysterectomy 4. Perform in preovulatory menstrual cycle 5. Endometrial cancer rule out by D&C
- 49. Myomectomy • Types- 1. Vaginal 2. Hysteroscopic resection of submucous myomata 3. Laparoscopic 4. Abdominal
- 50. Abdominal Myomectomy 1. Examination rectovaginal abdominal bimannual examination under anesthesia 2. Cervical dilatation 3. Maylard incision & retraction 4. Prevent adhesions 5. Prevent blood loss- Hypotensive anesthesia, temporary uterine artery occlusion or vasoconstrictive agents, CO2 laser 6. Planning Uterine incision 7. Dissection & Enucleation 8. Repairing defects - Bonneys hood method, Complete obliteration of cavity 9. Serosal closure - Baseball sutures. 10. Confirm hemostasis.
- 52. Results of Myomectomy • Complications- 1. Intraperitoneal bleeding 2. Infections • 80% menorrhagia controlled • 40-60% pregnancy rate • 5% take home baby rate • 30-50% recurrence • 20-25% relaparotomy
- 55. Radiofrequency Ablation • Halt’s method • Under Phase 3 clinical trials awaits approval • 3 small incisions- 1. Laparoscopic camera 2. Intraabdominal ultrasound probe 3. Halt Device
- 56. Gene Therapy • Recent evidence suggests that, fibroids develop as an over expression of p14Arf Gene. • This drives a negative feedback loop between, p53 & MDM2 genes, which governs the fate of each individual fibroid. • NUTLIN -3, a known MDM2 antagonist, was thus used to oppose the proliferative activity in cell cultures from fibroids. • It also stimulates Senescence Gene- p21 & Apoptosis Gene- BAX, in vitro.
- 57. Fibroids in Pregnancy • Incidence – 18%, 1 in 1000 • Effect of pregnancy – 1. Increase in vascularity & size 2. Torsion of subserous 3. Puerperal infection 4. Red degeneration – 5% Presentation Appearance Cause • Effect of fibroid on pregnancy –RPL, Ante, intra, postpartum
- 58. • Indication of removal during CS- 1. Pedunculated subserosal 2. Interfering with delivery or closure 3. Intractable pain 4. Incarcerated fibroid 5. Rapid growth with pressure symptoms
Notas do Editor
- advances
- Benign monoclonal tumors of smooth muscle cells of myometrium& contains large aggregation of extracellular matrix collagen, fibronectin proteoglycan
- Overall incidence is 50% & highest 35 45 yrs
- Smooth ms polifratn, incrs DNA synthesis, promote mito & angiogenesis
- Exposure to endog hormones as in early menarche & late menopause Wt-21% risk increases with each 10 kg rise Smoking contains nicotine wich inhibits aromatase & thus blocks conversion of androgen into estrone Incidence is less in multiparas but there is increase in size during pregnancy coz of increase in blood supply
- Wen fibroid grows symmetrically & remain within the myometrium intramural Grows outward outside peritoneum in subserosal Covered by thin endometrium submucous
- Menorrhagia occurs due to incrsd surface area of the endometrial cavity , may interfere with myometrial contractility and of arteriols in the endometrium thrombosis and sloughing of venous channels ,increase vascularity, endometrial hyperplasia Metrorrhagia in women >40yrs d&c to be done to rule out endom cancer which is associated in 3% cases
- Ant & post wall fibroids cervical fibroid Premenstrual rtention of urine due to increase in size premenstrually
- Removal of submucous fibroid increase fertility, subserosal increase, intramural have no effect
- Rapid growth occurs in pregnancy on ocp malignancy
- incidence
- Mri for size location plannin surgery Usg is readily available least costly reliable in ut <375ml volume & 4 or less fibroids
- Asymptomatic or small Women approaching menopause
- Rapid growth is 6weeks or more size in <1yr
- GNRH AGONIST- sustained pituitary down regulation & supression of ovarian fiunction two phases agonist phase initial flare up followed by desensitisation phase. Creats state of medical hypophysectomy. Aftr discont menses return in 4-8wks while size return to pre t/t level aFter 6mt side effect hotflushes 78% headache 55% vg dryness 32% most significant effect is bone loss after 6mth of therapy so it may be given with low dose estrogn pg as add back therapy E 0.625mg & MPA 2.5mg. Buserelin 300microgm daily Nafarelin 400microgm daily Leuoprolide & triptorelin 3.75mg 28days
- Reduces menorrhagia size of uterus provide contraception
- Highly precise medical procedure that applies high-intensity focused sonic energy to locally heat & destroy the diseased/damaged tissue, via ablation.
- Ultrasound is focused into a small focal zone, like focusing light rays through a magnifying glass to a point.
- Percutaneous cannulation of femoral artery & embolization of uterine artery with PVA, gelatin sponges, trisacryl gelatin microspheres PVA particles 500-700micrometer ischemic necrosis
- fEver pain nausea vomitin malaise leucocytosis
- 1 …by recombinant erythropoetin alfa & epoetin 250 IU/kg wkly for 3 wks increase Hb by 1.6g/dl or parenteral iron or autotransfusion donor blood or Gnrh agonist
- Removal of fibroids & conserving uterus
- 2. Postop drainage 4. Packing placed in plastic bags, 5000 IU heparin in 1000ml RL continuous irrigation & suction, no use of sponges, fine & running sutures, use of absorbable barriers like INTERCEED & non absorbable barrier Gortex/Seprafilm 5. Contolled hypotensive anesthesia target mbp 60mmhg, moderate tredelenburg position, C/I in MI, PVD, Renal or hepatic disease hypovolemia Using Bonneys myomectomy clamp, occlusion by ring forceps, rubber torniquet around cervix via broad lig, rubber shod clamps, loop torniquet, Rumel torniquet, arterial occlusion shud be ensured, higher d bp tighter d torniquet, Vasopressin, 20units in 20ml Ns into supf myom C/I in pt on TCA, Vascular heart diseases 6. Single ant midline vertical incision & removal of as many fibroids as possible & removal of post wall fibroids with incision in uterine cavity
- intra-abdominal ultrasound probe, which can determine the size and location of fibroids. a needle electrode that penetrates the fibroid and burns the cells, which are eventually reabsorbed by the body. The device also cauterizes the incision to minimize bleeding.
- Large veins in capsule & thrombosed small veins in substance, causes fever mod leucocytosis, raised esr, d?D appendicitis, twisted ovarian cyst, aph