1 FIBROIDS

2 MEANING: Fibroids are the tumours composed of smooth muscle and fibrous connective tissue of uterus. These are commonly benign tumours. - D C. Dutta

3 ALTERNATIVE NAMES : Myoma Leiomyoma Fibromyoma Uterine tumour Myomata Fibromyomata

4 TUMOURS OF THE BODY OF UTERUSBENIGN : Adenoma Myoma II. MALIGNANT : 1. Carcinoma 2. Sarcoma 3. Chorio-carcinoma 4. Mesodermal mixed tumour 5. Secondaries

5 INCIDENCE: 20% of women at 30 years of age (asymptomatic)3% of women in OPD (symptomatic) 10% more prevalence in England Higher rate in black race More common in nulliparous or in women having infertility after 1 child Highest prevalence between 35-45years

6 SITES OF FIBROIDS:

7 HISTOGENESIS : Risk factors for fibroids: Increased risk Reduced riskNulliparity Obesity Hyperestrogenic state Black women Age between 35-45 F/h/o tumour Multiparity Smoking

8 ETIOLOGY : Unknown Immature muscle cells present in myometrium Excessive Oestrogens - myomas grow during child bearing age only. - after menopause the growth of tumour stops or regression in size

9 Causes of Neoplastic transformation :ORIGIN: 1. Chromosomal abnormality: About 30% the chromosome abnormality is seen in 6th or 7th chromosome( rearrangement or deletion) Role of polypeptide growth factors: - Epidermal growth factors (EGF), Insulin like growth factor-1( IGF-1), Transforming growth factor (TGF), stimulate the growth of leiomyoma directly or via estrogen

10 GROWTH: Predominantly estrogen-dependent tumuor.Oestrogen dependency evidenced by: Growth potentiality is limited to during child bearing period Increased growth during pregnancy They don’t occur before menarche Following menopause, decrease in size of tumour or cessation of growth. Frequent association of anovulation More of oestrogen receptors than adjacent myometrium

11 Contd… Growth rate is slow & takes about 3-5 years to be felt per abdomen Grows rapidly during pregnancy or pill users Rapid growth can be due to degeneration or malignant change

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13 FEATURES OF TUMOURS: Arise from muscles not from fibresSingle or multiple ( upto 200) Size variable from millimeters to the size of foot ball (filling whole abdomen) Spherical in shape & firm consistency Surrounded by pseudo-capsule Cut surface of the tumour becomes convex & has white whorled appearance Nuclei rod shaped, uniform in size & shape

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15 TYPES OF FIBROIDS: Body (Corporeal) CervicalInterstitial or Intramural Sub-peritoneal or subserous Submucous Pseudo-cervical fibroids

16 TYPES OF FIBROIDS :

17 TYPES OF FIBROIDS :

18 INTERSTITIAL or INTRAMURAL:- In this case the myomas grow & stay in the wall of the uterus Surrounded by myometrial tissue Initially fibroids are intramural subsequently pushed outward or inward 70% persist in position.

19 SUBSEROUS: Fibroid are partitially or completely covered by peritoneumWhen completely covered it attains a pedicle called as ‘Pedunculated subserous fibroid’ If the pedicle is torn then it gets nourishment from omental or mesenteric adhesions called as ‘Wandering’ or ‘Parasitic fibroid’.

20 Contd… - If the fibroid is pushed out in between the layers of broad ligament, called as ‘ Broad ligament fibroid’ ( false or pseudo)

21 SUBMUCOUS: Fibroids grow towards the uterine cavity or cervical canal, may form a polyp in the cavity & covered by the endometrium. They come out through the cervix, may be infected or ulcerated causing metrorrhagia. FATE – Surface necrosis Polypoid change Infection Degerations

22 SUBMUCOUS FIBROID:

23 CERVICAL Rare about 1-2% Seen in supravaginal part of cervix, may be any one above type May be anterior, posterior, lateral or central depending on position Disturb the pelvic anatomy, specially ureter

24 PSEUDOCERVICAL: Fibroid polyp arising from the uterine body when occupies & distends the cervical canal, it is called as Pseudocervical fibroid.

25 CORPOREAL FIBROIDS

26 PATHOLOGY OF FIBROIDS:Secondary changes in fibroids: Degeneration Atrophy Necrosis Infection Vascular changes Sarcomatous change

27 1.DEGENERATION: Hyaline degeneration- common type, firm feel of tumour becomes soft elastic. Cystic degeneration- after the menopause, in interstitial fibroids. Liquefaction of areas with hyaline changes, if becomes big may be confused with ovarian cyst or pregnancy Fatty degeneration- at or after menopause, fat globules get deposited in muscle cells

28 Red (carneous) degeneration- occur in 2nd half of pregnancy or puerperium. Cut section revealing raw beef appearance, cystic space & fishy odor Calcareous degeneration- common in subserous type followed by fatty degeneration. There is precipitation of calcium carbonate or phosphate then whole tumour is converted into calcified mass called ‘Womb stone’

29 2. ATROPHY Following menopause due to loss of oestrogen supportReduction in size of tumour ( as similar to that occurs after pregnancy) 3.NECROSIS : Inadequacy of circulation leads to central necrosis of tumour ( in submucous polyp or subserous)

30 4. INFECTION: Gains way to tumour through the thinned & sloughed surface epithelium of submucous fibroid, following abortion or delivery 5. VASCULAR CHANGES: Dilatation of the vessels (telangiectasis) Dilatation of lymphatic channels occur. 6. SARCOMATOUS CHANGES: Occur in less than 0.1% Usual type is lieomyosarcoma.

31 CHANGES IN THE PELVIC ORGANS:> Uterus- Shape distorted, asymmetrical -Endometrium with features of anovulation with hyperplasia, as result becomes thick, congested & edematous > Uterine tubes- Frequent infection > Ovaries- Enlarged, congested & filled with multiple cysts. > Ureter- Compressed leading to hydroureter or hydronephrosis

32 CLINICAL FEATURES: PATIENT PROFILE: Usually nalliparousChronic secondary infertility Early marriage Frequent child birth Age between years Delayed menopause

33 Contd… SYMPTOMS: Asymptomatic (75%) Symptoms depend on anatomic type & size Symptoms depend on the site than the size Small submucous fibroid may produce more symptoms than big subserous fibroid

34 I. Menstrual abnormalities:Menorrhagia (30%) CAUSES: Increased surface area of endometrium Interference with normal contractility Congestion & dilatation venous plexuses Endometrial hyperplasia due to hyperoestrinism Pelvic congestion Role of prostanoids

35 Contd… 2. Metrorrhagia: CAUSES: Ulceration of submucous fibroid or fibroid polyp Torn vessels from the sloughing base of polyp Associated endometrial carcinoma

36 Contd… 3. Dysmenorrhoea:Congestive variety- may be associated with pelvic congestion or endometriosis Spasmodic type- may be associated with extrusion of polyp & its expulsion from the uterine cavity

37 Contd… II. INFERTILITY:CAUSES: Uterine – > Distortion & or elongation of uterine cavity difficult sperm ascent Prevent rhythmic uterine contraction during intercourse impaired sperm transport Congestion & dilatation of endometrial venous plexuses defctive nidation Atrophy & ulceration of endometrium

38 Contd… 2. Tubal – Conual block due position of fibroidMarked elongation of tubes over big fibroid Association salpingitis with tubal block 3. Ovarian – Anovulation 4. Peritoneal – Endometriosis 5. Unknown

39 III. Pregnancy related problems:Abortion Preterm labour IUGR PPH Causes: Defective implantation of placenta Poorly developed endometrium Reduced space for the growing fetus

40 IV. Pain lower abdomen Usually painless CAUSES:Due to tumour degeneration Torsion subserous pedunculated fibroid Extrusion of polyp Associated pathology like PID, endometriosis

41 V. Abdominal swelling Heaviness in lower abdomen VI. Pressure symptoms: Constipation Dysuria Retention of urine Hydroureter Hydronephrosis Infection Pyelitis

42 SIGNS: Pallor Enlargement of abdomen Firm feel on palpationRestricted mobility Dullness on percussion bimanul findings Irregular uterus Cervix moves with movement of tumour

43 INVESTIGATIONS: History Pelvic examination USG & Colour doppler (TVS)Uterine contour enlarged & distorted Echogenecity vary Vascularisation at periphery Central vascularisation indicate degeneration

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46 Contd… 4. MRI 5. Laparoscopy 6. Hysteroscopy or HSG7. Uterine currettage 8. Straight x-ray 9. IVF 10. Blood tests 11. Urine analysis

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49 DIFFERENTIAL DIAGNOSISPregnancy Full bladder Adenomyosis Myohyperplasia Ovarian tumour TO mass

50 COMPLICATIONS: Persistent menorrhagia, metrorrhagia or vaginal bleeding leading to severe anaemia Severe intraperitoneal haemorrhage Severe infection leading to peritonitis or septicaemia Sarcoma

51 MANAGEMENT PROTOCOL: Cervix Body vaginal Supravaginal AsymptomaticRegular supervision Surgery Medical Surgery vaginal Endoscopic resection Hysterectomy Supravaginal Size increases Size stationary Myomectomy Myomectomy Hysterectomy Surgery Follow up Myomectomy Polypectomy

52 MEDICAL MANAGEMENT: Objectives:To improve menorrhagia & correct anemia To minimise size & vascularity of tumour To facilitate endoscopic surgery (infertility) An alternative to surgery When surgery is postponed temporarily

53 DRUGS TO MINIMISE BLOOD LOSS:Progestogens Antifibrinolytics Antiprogesterones Prostanglandin synthetase inhibitors Danazol GnRH analogues Agonists Antagonists

54 Benefits of GnRH analogue therapy:Improvement of menorrhagia & may produce amenorrhoea Improvement of anaemia Relief of pressure symptoms Reduction in size(50%), used for 6months Reduction in vascularity of tumour Reduction blood loss during myomectomy May facilitate laparoscopic or hysteroscopic surgery

55 SURGICAL MANAGEMENT: Myomectomy: Indications:Patient in reproductive age group desirous of having a child Age below Recurrent pregnancy wastage Patient consent to save uterus Nulliparous women

56 Contd… Prerequisites for myomectomy:Examination of husband from fertility point of view Hysteroscopy or HSG to detect fibroid encroaching uterine cavity or polyp or tubal block Diagnostic DC in irregular cycles to detect polyp or endometrial carcinoma

57 Contd… Contraindications: Infertility- if tubes blocked- If azoospermia or oligospermia Associated carcinoma Associated bilateral infective TO mass Infected fibroids Big broad ligament fibroid Too many fibroids Sarcomatous change Associated regnancy

58 MYOMECTOMY:

59 2. ENDOSCOPIC SURGERY: a. Hysteroscopy:- Fibroid 3-4cm diameter or polyp resection - Pedicle or base of fibroid coagulated complications- perforation, fluid overload, haemorrhage, pulmonary oedema, cerebral edema, hyponatraemia, gas embolism, injury to other abdominal organs, Neurological symptoms

60 Contd… Laproscopy: - Subserous & intramural can be removed - Electrocautery, laser, & extra corporeal sutures used for haemostasis Contraindication: fibroid too large, deep intramural, multiple or technically inaccessible. Complications: Extraperitoneal insufflation, omental emphysema, cardiac arrhythmia, injury to blood vessels, injury to other organs, thermal injury, gas embolism etc.

61 3. HYSTERECTOMY: -Indications: Sudden distoration of GC: Associated endometriosis Removal of ovary Advantages of hysterectomy No chance of recurrence Adnexal pathology & unhealthy cervix - Vaginal hysterectomy- If size of weeks of pregnancy with uterine prolapse - Embolisation of uterine arteries to cause avascular necrosis & shrinkage of fibroid

62 HYSTERECTOMY:

63 ASYMPTOMATIC FIBROID:Observation: Perform diagnostic tests Begin expectant therapy Size < 12 wks of pregnancy Diagnosis certain Follow up Periodic examination at 6mth interval Observe the symptoms of fibroids

64 Contd… 2. Surgery: Indications: Size >12 wks of pregnancy Diagnosis not certain Fibroid grows during follow up Subserous pedunculated fibroid Unexplained infertility with distortion of uterine cavity Unexpalined recurrent abortion Present in lower pole of uterus likely to complicate delivery

65 CERVICAL FIBROIDS

66 SYMPTOMS: 1. Anterior cervical: Frequency or retention of urine2. Posterior cervical: Rectal symptoms (constipation) 3. Lateral cervical: Vascular obstruction Haemorrhoids Pedal oedema Ureters pushed laterally & below tumour

67 Contd… 4. Central cervical: Produce bladder symptoms Cervix expanded on all sides Asymptomatic during pregnancy Obstruction during labour. If pedunculated, sensation of something coming out, if infected a foul smelling discharge per vagina

68 TREATMENT: 1. Supravaginal fibroids:Myomectomy – Its not only technically difficult but the anatomic & functional restoration of cervix cannot be adequate to achieve the future reproduction Hysterectomy 2. Vaginal part fibroids: Myomectomy If, pedunculated polypectomy

69 PREGNANCY AND MYOMAS EFFECTS OF MYOMAS ON PREGNANCY: During pregnancyAbortion: distortion pf uterine cavity, defective implantation, interference with accomodation & increase in size, impaction of myoma in pelvis Premature onset of labour Malpresentation

70 contd… 2. During labour: Abnormal uterine action Cervical dystciaObstructed labour Retainned placenta Post partum haemorrhage 3. During puerperium: Puerperal sepsis Delayed involution of uterus

71 Contd… EFFECTS OF PREGNANCY ON MYOMAS: Increase in sizeChange in consistency Red degeneration Torsion & infection

72 REMEMBER: Regular physical check ups Do not neglect growing massDo not neglect irregular cycles Do not postpone the treatment Appropriate age for marriage Follow proper spacing

73 Thank you