1. Desabandu Dr. G.H.K.K. Gunawardana
M.B.B.S.,M.S.(Obs & Gyn), F.R.C.O.G.,F.C.O.C.(S.L )
Consultant Obstetrician and Gynaecologist
Teaching Hospital,
Peradeniya.

2. Contents
 Introduction
 Epidemiology
 Pathology
 Classification
 Clinical features
 Differential Diagnoses
 Complications
 Diagnosis
 Treatments
 Prevention

3. Leiomyomas (fibroids)
 Benign smooth muscle tumors of the uterus
 Commonly called “fibroids”
 Estrogen dependent
 Rarely occur before menarche or after menopause
 Grow larger during pregnancy
 Rarely malignant
 Most common indication for pelvic surgery in
women

4. Epidemiology of Leiomyomas
 Develop from smooth muscle cells by means of
hyperplasia
 Occurs in 20% of women of reproductive age
 Most often occurs among
 Nulliparous women
 Women older than 35
 Nonsmokers
 Oral contraceptive or IUD users
 Obese
 Positive family history
 African American women

5. Classification of Leiomyomas
 Submucous - Protrude into the uterine cavity
Sessile submucous
Pedunculated submucous
 Intramural - Within the myometrial wall
 Subserous - Growing toward the serous surface of the
uterus
Sessile Subserous
Pedunculated Subserous
 Intraligamentous - Located in the cervix or in between
the folds of the broad ligament
 Parasitic fibroid – No connection with uterus

6. Pathology
 Macroscopy
Firm
Composed of fibrous tissue and myometrial tissue
If myometrial tissue high - Myoma
If fibrous tissue high - Fibromyoma
 Growing fibroid Myometrium compressed and
atrophied
False capsule

8. Leiomyomas:Symptoms
 Usually asymptomatic
 Symptoms increase as tumors grow
 Common symptoms
 Menstrual disturbance Pressure symptoms
Menorrhagia Feeling of “heaviness”
Dysmenorrhea Bloating
Spotting between periods Pelvic congestion, Varicose veins
Urinary retention, frequency,
dysurea
 Dyspareunia
 Back pain
 A lump or swelling in the lower abdomen
 Subfertility

9. Leiomyomas
Physical Examination
 Abdomino pelvic lump
Firm
Non tender
Irregular
Mobile in transverse direction
Mobility restricted in longitudinal direction except
in pedunculated fibroids
 Absence of ascites
 Normal bowel sounds
 May be mistaken for adnexal mass if situated laterally
 If mass moves with the uterus, likely to be a leiomyoma

10. Leiomyomas:
Differential Diagnoses
 Ovarian neoplasm
 Tubo-ovarian inflammatory mass
 Diverticular inflammatory mass
 Pregnancy
 Ectopic pregnancy
 Adenomyosis
 Pelvic kidney
 Malignancy

11. Complications
 Anaemia - Excessive menstrual blood loss can cause
anaemia
 Urinary tract obstruction
 Infertility
 Red degeneration - Very painful and tender
 Infection
 Malignant change ( < 1% )

12. Complication in pregnancy
Antenatal Intra-Natal Post-Natal
Ectopic
Miscarriage
premature
delivery
Placenta praevia
Placental
abruption
IUGR
Red degeneration
Anaemia
Unstable lie
Malpresentation
Obstructed
labour
Primary PPH
Difficult LSCS
Secondary PPH
Necrosis and
infection
Poor uterine
involution

13. Fibroid in pregnancy

14. Diagnosis
 USS
Characteristically appears hypoechogenic and well
defined lesions
 Hysteroscopy
Pedunculated and submucous myomas can be
identified
 Laparoscopy
 Operative diagnosis

15. HysteroscopyUSS

16. Uterus with big
Myoma
laparoscopic view
Laparoscopy

17. Management
 Depends on
Symptoms
The location of fibroids
Size and number of the fibroid
Fertility wishes
Patient’s wishes
Facilities of the unit and the experience of the
operator

18. Management cont…
1. Monitoring
If the fibroids are causing no symptoms and are
not large,
‘wait and see’ approach
Re-evaluate every 3-6 months
Pelvic ultrasound as needed
Monitor Hb frequently

19. Management cont…
2.Medical treatment
Drugs
 Oral contraceptive pills, either combination pills or
progestin-only, in an effort to manage symptoms
 Hormones, used in combination to shrink the
fibroids prior to surgery
Long term progesterone
GnRH - analogues
Danazole
Gestrinone
Mifepristone
Letrazole

20. Management cont…
3.Arterial embolisation
 Under local anaesthesia, a fine tube is passed via an
artery in the arm or leg into the main artery
supplying the fibroid with blood
 The whole process is monitored by x-ray
 Fine particles (like sand) are injected into the artery
to block the blood supply to the fibroid
 The fibroid slowly dies and symptoms should settle
over a few months

21. Arterial Embolisation

22. Management cont…
4.Ablation Therapy
 HIFU (High intensity focused ultrasound), (Magnetic
Resonance guided Focused Ultrasound)
Non-invasive intervention
Uses high intensity focused ultrasound waves
to ablate (destroy) tissue in combination with
Magnetic Resonance Imaging (MRI)
 Laser ablation

23. Management cont…
5.Surgical management
Myomectomy Hysterectomy
Only the fibroid is
removed
1. Hysteroscopic
myomectomy
2. Laparoscopic
myomectomy
3. Open
myomectomy
Entire uterus is
removed
1. Abdominal
hysterectomy
2.Vaginal
hysterectomy

24. Management cont…
 Myomectomy is indicated when,
 Solitary pedunculated myoma
 Nature or location of the myoma
appears to be interfering with fertility – sub
serous myoma or myomatous polyps
 Myoma is causing pregnancy loss
 Preservation of fertility is required

25. Myomectomy
 Hysteroscopic myomectomy
Fibroids are removed via the cervix, using a hysteroscope
Recommended for submucosal fibroids
 Laparoscopic myomectomy
Myomectomy through laparoscopy
 Open myomectomy (Laparotomy & myomectomy)
Larger fibroids removed via an abdominal incision.
This weakens the uterine wall and makes Caesarean
sections for subsequent pregnancies more likely
Management cont…

26. Vaginal
Myomectomy
Laparoscopic
myomectomy
Open
myomectomy

27. Management cont…
Hysterectomy
Hysterectomy will indicated in,
 Rapid enlargement of the uterus may mean possible
malignancy
 Abnormal uterine bleeding not responding to other
methods of treatment and that may lead to anaemia
 Pelvic pain
 Secondary dysmenorrhea
 Urinary symptoms
 Uterine growth after menopause
 Patient has completed childbearing

28. Management cont…
Hysterectomy
Abdominal Vaginal
hysterectomy hysterectomy
Type of hysterectomy depend on
The size of the lump
Previous abdominal surgeries

29. Fibroids — prevention
 As the cause of fibroids is still unknown, there are no clear
guidelines for preventing them
There are some things you could do that may help to
reduce the risk
 Keep your weight in check. This will minimize oestrogen
levels in body
 Eat green vegetables and fruit, and avoid red meat
 Some studies suggest the combined pill may protect
against fibroids by keeping hormone levels from peaking
and falling