uterine fibroids

1
Uterine Fibroids

• Dr.Makanda
• May 2022

2
Uterine fibroids
3
Uterine Fibroid

• The commonest benign tumour of the uterus
• The commonest benign solid tumour in female
• Histologically composed of smooth muscle and
  fibrous connective tissue,hence called,uterine
  leiomyoma,myoma,or fibromyoma.

4
Uterine Fibroids

• Usually multiple
• Various sizes
• Genetic predisposition
• more common in black races
• More common in the obese
• Less common in smokers
• Accounts for 30 of hysterectomies

5
Incidence

• At least 20-25 of women at their 30 have fibroid
  which remain asymptomatic
• Symptomatic fibroid at OPD is 3
• Common in nulliparous or one child infertility
• Highest prevalence between the age of 35-45

6
ORIGIN

• AETIOLOGY still unknown
• Hypothesis is that it arises from the neoplastic
  single smooth muscle cell of the myometrium

7
Theories

• 1.Chromosomal abnormality-in about 40 there is a
  chromosomal abnormality esp.chromosome six or
  seven(rearrangement,deletions)
• This leads to abnormal cellular proliferattion

8
ORIGIN ct.

• 2.Role of polypeptide growth factors
• Epidermal growth factors (EGF)
• Insulin-like growth factor-1(ILGF-1)
• Transforming growth factor(TGF)
• These growth factors stimulate fibroid either
  directly or through oestrogen
• A positive family history is often present

9
Growth

• Oestrogen dependent tumour as evidenced by
• Growth potentiality limited during child bearing
  period
• Increased growth during pregnancy
• Do not occur premanarche
• Cessation of growth post menopause and no new
  tumours at all
• Seem to have more oestrogen receptors as compared
  to the adjacent myometrium
• Frequent association of anovulation

10
Growth ct

• Usually the fibroids are multiple and of
  different sizes
• They grow at different paces i.e some grow faster
  more than others and they grow to abdomen
  detectable size for about 3-5 years
• They grow rapidly during pregnancy or amongst
  pill users(high dose pills)
• Rapid growth also due to degeneration or
  malignant change.

11
RISK FACTORS

• High risk
• Nulliparity
• Obesity
• Hyperoestrogenic state
• Black women
• Less risk
• Multiparity
• Smoking

12
Fibroid Locations(Types)

• 1.Subserous or subperitoneal (15)
• Project from the uterus into the peritoneal
  cavity
• Sometimes pedunculated
• Least likely to cause symptoms
• Either partially or completely covered by the
  peritoneum
• Penduculated fibroids whose pedicle become
  torn,wandering or parasitic fibroid,gets
  nourishment from the mesentery or omental
  adhesions

13
Fibroid Locations(Types)..

• 2.Submucous (5 of all fibroids)
• Project into the uterine cavity
• Sometimes pedunculated
• Most likely to cause symptoms
• Can distort the uterine cavity
• They may be penduculated come out of the through
  the cervix

14
Fibroids locations ct

• May become infected or ulcerated to cause
  menorrhagea
• They are most symptomatic fibrois
• Fate of submucous fibrois
• Surface necrosis
• Polypoid change-following pedicle formation
• Infection
• Degenerations including sarcomatous change

15
Fibroid Locations(Types)..

• 3.Intramural or interstitial (75)
• Most common
• Usually multiple
• 4.Cervical (1-2)
• May be interstitial or subperitoneal,rarely
  polypoidal
• Interstitial fibroid may displace or expand the
  cervix
• They all disturb the pelvic anatomy esp. the
  ureters

16
Fibroid locations ct.

• 5.Pseudocervical fibroid
• This is a fibroid polyp arising from the uterine
  body which occupies the and extends the cervical
  canal

17
PATHOLOGY

• NAKED EYE APPEARANCE
• The uterus is distorted by multiple nodules of
  various sizes
• A single fibroid can cause a uniform enlargement
• They feel firm in consistency
• Cut surface of the tumour is smooth and whitish

18
PATHOLOGY

• Naked eye appearance ..
• False capsule is formed compressed adjacent
  myometrium
• The capsule is separated from the growth by a
  thin areolar tissue
• The blood vessels run through this plane to
  supply the tumour

19
PATHOLOGY.

• NAKED EYE APPEARANCE ct
• More vascular in the periphery with the growth
  potentiality
• Less vascular in the centre with high
  potentiality of degenertation

20
PATHOLOGY..

• Microscopic appearance
• Consists of smooth muscles and fibrous connective
  tissue in different proportions
• Originally muscle elements,later on fibrous
  tissues mixed with muscle bundles
• Hence the name myomata,or fibromyomata

21
SECONDARY CHANGES IN FIBROIDS

• Includes
• Hyaline Degenerations
• Cystic degeneration
• Atrophy
• Necrosis
• Infection
• Vascular changes
• Sarcomatous changes

22
DEGENERATIONS

• 1.Hyaline degenaration
• The most common,accounts for 65
• Affects all sizes of fibroids except the smallest
  ones
• Affects the central part of the fibroid ,the
  least vascular
• The changes feels soft elastic
• Microscopically affects both the muscles and
  firous tissues

23
DEGENERATIONS ct..

• 2.Cystic degeneration
• Occurs following menopause
• Common in interstitial fibroids
• Cystic changes are lined by ragged walls
• Cystic changes of an isolated fibroid can be
  confused with an ovarian cyst or pregnancy

24
DEGENERATIONS ct..

• 3.Fatty degenaration
• Usually seen at or after menopause
• Fat globules are deposited mainly in the muscles
  cells

25
DEGENERATIONS ct..

• 4.Calcific degeneration
• Involves subserous fibroids with small pedicle,
  or postmenopausal women
• Usually proceeded by fatty degenaration
• There is precipitation of calcium carbonate or
  phosphate within the fibroid
• The completely calcified fibroid is called a
  womb stone

26
DEGENERATIONS ct..

• 5.Red degeration(carneous degeneration)
• Cause is unknown,probably vascular and not
  infection
• Occurs in a large fibroid mainly in second half
  of pregnancy and puerperium
• Partial recovery, and therefore called
  necrobiosis
• Microscopically-evidence of necrosis,thrombosed
  vessels but no extravassation of blood

27
DEGENERATIONS ct..

• 6.Atrophy
• Occur following menopause due to loss of
  oestrogen support
• Tumour regresses in size
• The reduction also occurs following pregnancy
  enlargement

28
DEGENERATIONS ..

• 7.Necrosis
• Central necrosis due to inadequate circulation
• Common in the submucous polyps or penduculated
  subserous fibroids

29
DEGENERATIONS ct..

• 8.Infection
• Follows delivery or abortion
• Infection gets access through the thinned and
  sloughed surface epithelium of the submucous
  fibroid
• Can also occur in intramural fibroid after
  delivery
• Vascular changes
• Dilatation of vessels(telengictasis),or
  dilatation of lymphatics (lympangiectasis) in the
  myoma may occur.
• Cause-unknown

30
DEGENERATIONS ct..

• 9.Sarcomatous changes (0.1)
• Usual type is leiomyosarcoma
• Suspision raised by
• Reccurence of fibroid polyp
• Sudden enlargement
• Fibroid with postmenopausal bleeding

31
Changes in the pelvic organs

• 1.UTERUS
• Asymmetrical uterine distortion in most cases,
  but uniform at times
• Myohyperplasia
• Normal endometrium or features of anovulation
  with hyperplasia
• Dilatation and congestion of the myometrium and
  endometrial venous plexuses

32

• Thick,congested and oedematous endometrium
• Part of the endometrium over the submucosa
  fibroid becomes thin,and necrotic with evidence
  of infection
• Elongated and distorted uterine cavity in
  intramural and submocous fibroids

33
Changes in the pelvic organs ct

• Ovaries
• May be enlarged, congested and studded with
  multiple cysts due to hyperoestronism
• Ureters
• May be displaced in case of broad ligament tumour
  whose compression results in hydroureters and
  hydronephrosis
• Endometriosis
• There is an increased association of
  endometriosis and adenomyosis
• Endometrial carcinoma -incidence unaffected

34
Clinical features

• Nulliparous or secondary infertility women
• Asymptomatic fibroids (75)
• Position and size of the fibroid determine the
  occurrence of symptoms
• Site more important than size
• 1.Menstrual abnormalities
• (a)Heavy menstruation (30) classic symptom in
  asymptomatic fibroid
• Menstrual loss progressively increases with
  successive cycles
• Conspicuous in submucous or interstitial tumours

35
Fibroid Symptoms

• Mostly asymptomatic
• Meavy menstruation
• Heavy regular periods
• Iron deficiency anaemia
• Pressure effects
• Urine frequency
• Pelvic tumour awareness
• Difficulty initiating micturition
• Pain, Infertility Irregular vaginal bleeding
• May be due to other pathology

36
Menstrual abnormalities ct..

• Reasons
• Increased surface endometrial area
• Contractility of the uterus is interfered by the
  myoma
• Endometrial hyperplasia
• Pelvic congestion
• Congestion and dilatation of the subjacent
  endometrial plexus due to obstruction of the
  tumour
• Role of prostanoids

37
Menstrual abnormalities ct..

• (b)Irregular menses or irregular bleeding,due to
• Ulceratrion of submucous fibroid or fibroid polyp
• Torn vessels from the sloughing base of a polyp
• Associated endometrial carcinoma
• 2.Dysmenorrhoea
• 3.Infertility

38
PREGNANCY RELATED COMPLICATIONS

• High frequency of
• Abortion
• Preterm labour
• IUFGR
• REASONS
• Defective implantation of the placenta
• Poorly developed endometrium
• Reduced space for the growing foetus and placenta
• Red degeneration and torsion of subserous fibroid
  common in pregnancy
• PPH

39
Intramural Submucous Fibroids
40
Subserous Fibroid at Laparoscopy
41
Fibroid Symptoms

• Mostly asymptomatic
• Heavy menstruation
• Heavy regular periods
• Iron deficiency anaemia
• Pressure effects
• Urine frequency
• Pelvic tumour awareness
• Difficulty initiating micturition
• Pain, Infertility Irregular vaginal bleeding
• May be due to other pathology

42
COMPLICATIONS

• Hyaline Degenerations
• Necrosis
• Infection
• Sarcomatous changes
• Torsion of subserous pedunculated fibroid
• Haemorrhage
• Intracapsular

43
COMPLICATIONS..

• Rupture surface vein of subserous fibroid-?
  intraperitoneal
• Polycythemia due to
• Erythropoetic function of the tumour
• Altered erythropoetic function of the
  kidney following pressure on the ureters

44
Fibroids and Infertility

• In most women the association is a result and not
  a cause
• Fibroids that change the shape of the uterine
  cavity (submucous) or are within the cavity
  (intracavitary) decrease fertility by about 70
• And so their removal increases fertility by 70.
• Other types of fibroids, those that are within
  the wall (intramural) but do not change the shape
  of the cavity, or those that bulge outside the
  wall (subserosal) do not decrease fertility,

45
Fibroids and Infertility

• The removal of these types of fibroids does not
  increase fertility.
• Most infertility specialists will recommend
  removal of any fibroid with gt50 of its surface
  in the uterine cavity
• The results from removal of a single submucous
  fibroid can be dramatic
• And there is evidence that removal of intramural
  fibroids gt5 cm diameter will enhance fertility
  with IVF

46
Fibroids and Pregnancy

• In most women there is no effect of pregnancy on
  fibroids
• Hence 80 remain unchanged in size
• Rarely rapid growth and red degeneration
• Those that grow depends on
• individual differences in the genetic
  changes in each fibroid and
• the type and amount of growth factors
  that are present in the blood.
• Increased risk of bleeding and threatened preterm
  delivery
• But most deliver at term

47
Fibroids and Pregnancy ct.....

• Fibroid in the lower segment can interfere with
  vaginal birth
• Myomectomy at the time of Caesarean is not wise
• 30 require emergency hysterectomy
• . Almost always, fibroids shrink after delivery

48
Can Fibroids Cause Miscarriage?

• Fibroids that bulge into the uterine cavity
  (submucous) or are within the cavity
  (intracavitary) may sometimes cause miscarriages.
• This happens if a submucosal fibroid is located
  nearby the implanted embryo, which thins out the
  lining and decreases the blood supply to the
  developing embryo.
• The fibroid may also cause some inflammation in
  the lining directly above it. The fetus cannot
  develop properly, and miscarriage may result.

49
Can Fibroids Cause Miscarriage? Ct.

• Next pregnancy, when the egg settles in another
  location, pregnancy may proceed without problems.
  
• However, if you do have a miscarriage and a
  fibroid is found bulging into the uterine cavity,
  it is advisable to have it removed

50
Can Fibroids Cause Miscarriage? Ct.

• Although many women will have fibroids during
  their lifetime, the fibroids most often occur in
  women in their late thirties and forties,
• Only 2 of pregnant women are found to have
  fibroids when examined with ultrasound.
• Also, the vast majority of women who are
  pregnant and do have fibroids encounter no
  problems.
• They go on to have full-term, healthy babies
  without difficulty.

51
Can Fibroids Cause Miscarriage? Ct.

• No differences in the risk of
• Premature delivery,
• Fetal growth problems,
• Fetal abnormalities,
• Placental problems, or
• Heavy bleeding after delivery.
• NOTE The need for caesarean section, however, is
  more common among women who have fibroids
• Indicated when a large fibroid located in the
  cervix obstructs labour.

52
PATHOGENESIS OF DEGENARATION

• During pregnancy, the placenta makes large
  amounts of female hormones which may rarely cause
  fibroids already present to grow.
• Very rarely, if they grow too quickly the blood
  vessels supplying them may not be able to get
  enough oxygen to the tissue and degeneration of
  the fibroid cells can then occur.
• This process of degeneration can cause pain, but
  usually resolves in a short time without
  treatment and without harm to the baby.
• Some women may have mild contractions during
  this time, but it is extremely rare for premature
  labor to actually begin

53
PATHOGENESIS OF DEGENARATION ct

• . RX Bed rest,
• heat, and pain medication
• medications to inhibit premature labor
  

54
PRESENTATION

• Lower abd.swelling/ lump
• lower abd heaviness
• Constipation posterior fibroid pressing the
  rectum
• Hydroureteric and hydronephrotic changes-broad
  ligament tumour?infection?pyelitis
• Signssome degree of pallor

55
Examination

• P/A- when enlarged to 14 wks
• Firm to hard or cystic in cystic degeneration
• Well-defined margins except lower pole that cant
  be easily reached
• Nodular surface
• Mass cant be moved from side to side

56
EXAMINATION.

• Pve
• Bimanual palpation shows irregularly enlarged
  tumour
• Uterine tumour by
• Uterus is not separately felt and no groove
  between the uterus and the mass
• The cervix moves with the movement of the tumour
  felt per abd.
• A subserous pedunculated tumour is confused with
  an ovarian tumour

57
Investigations

• Aims
• 1.Confirm the diagnosis
• 2.Preopertive preparation
• Confirmation
• Ultrasound
• A useful tool for the diagnosis and the location
  of the tumour.differentiaates fibroid from
  pregnancy and ovarian mass
• Pedunculated tumour can be confused with a solid
  ovarian tumour
• Transvaginal uss shows the myoma
  location,dimensions and ovarian pathology
• Multiple small fibroids is usually irrelevant

58
Investigations ct...

• Heterogenous echolucency is normal in a parous
  uterus
• Adenomyosis can look the same
• Size and location important
• Can be a contraction wave in pregnancy
• MRI better than CT Imaging
• Laparoscopy and Hysteroscopy
• Saline infusion-useful to detect a submucous
  fibroid or polyp

59
PREOPERATIVE ASSESSMENT

• IVP
• FBP
• Urinalysis

60
DDX

• Pregnancy
• Full bladder
• Adenomyosis
• Myohyperplasia
• Ovarian mass
• Tom

61
Investigating a Submucous Fibroid
62
Treatment Options for Fibroids

• Hysterectomy
• If the uterus is gt10w size
• Or symptoms that are due to the fibroids
• Rapid growth
• Abdominal or vaginal
• Myomectomy
• Best for single fibroid in a young woman
• 50 come to hysterectomy within 5 years?
• Hysteroscopic resection
• Uterine artery embolisation (UAE)
• Medical options
• GnRH analogue
• Mirena

63
Uterine artery embolization

• UFE does not require general anesthesia. The
  procedure is performed under local anesthesia
  with the patient conscious, but sedated, and
  feeling no pain. The interventional radiologist
  makes a tiny nick in the skin in the groin
  (femoral artery) or the wrist (radial artery) and
  using real-time imaging, the physician guides the
  catheter through the artery to the site of the
  fibroid and then releases tiny spheres, the size
  of grains of sand, into the uterine arteries that
  supply blood to the fibroid tumor..

64
Uterine artery embolization

• This blocks the blood flow to the fibroid tumor
  causing it to shrink and die

65
UAE
66
Good candidates for UAE

• Are a woman who is over the age of 35
• Are not currently pregnant
• Have been diagnosed with uterine fibroids
• Are experiencing symptoms such as excessive heavy
  bleeding, cramping, pelvic pain, bloating or
  frequent urination

67
Benefits of UFE

• Uterine fibroid embolization is a minimally
  invasive outpatient procedure with no incision
  needed
• Requires only local (rather than general)
  anesthesia
• Does not cause scarring like surgical techniques
  do
• While there will be some moderate pain after a
  UFE procedure, it is typically less intensive
  than post-surgical pain
• A good option if you would like to preserve your
  uterus vs. a hysterectomy

68
Benefits of UAE..

• 85-90 of women experience significant relief of
  their symptoms
• Faster recovery time compared to surgery
• Same day procedure, typically no overnight stay
  needed, so you can recover at home
• Reduced risk of infection as compared to surgery
• Easy to make and quickly schedule an appointment
  at an outpatient center

69
Thank you for your attention