Fibroid uterus
- 2. Fibroid • Synonyms : Myoma, Leiomyoma, Fibromyoma • Most common benign neoplasm in the female. • Incidence : 20 to 40% of reproductive age women.
- 3. Fibroid Etiology : It arises from smooth muscle cell of myometrium. * Exact etiology not known. * Monoclonal origin ( arising from single cell) * Genetic basis definite. * Various growth factors like TGFβ , EGF, IGF-1, IGF- 2, BFGF
- 4. Fibroid - Etiology Epidemiological risk factors :- • Increased risk age 35 to 45 years , nulliparous or low parity , Black women, strong family history, obesity, early Menarche, Diabetes, hypertension. • Decreased risk ↑↑ parity, exercise, ↑↑intake of green vegetables, Prog.only contraceptives, cigarette smoking
- 5. Fibroid - Etiology Genetic basis: Responsible for 40 % cases of fibroids • Translocation between Chromo. 12 & 14, • Trisomy 12, • Rearrangement of short arm of Chromo 6 • Rearrangement of long arm of Ch. 10, • Deletion of Ch.3 or Ch.7
- 6. Fibroid - Etiology Estrogen although not proved for causing myoma definitely implicated in its growth. • Not detected before puberty & regresses after menopause. • May increase during pregnancy • Estrogen receptors are in higher concent.ns • Common fifth decade due to anovulatory cycles with high or unopposed estrogen.
- 7. Site of origin Corporeal fibroid (97% ) Cervical fibroid (3%)
- 8. Fibroids are often described according to their location in the uterus
- 9. Fibroid Submucous fibroids are classified by European society for gynec endoscopy ( ESGE ): Type 0 – No intramural extension Type I – Intramural extension < 50 % Type II – Intramural extension > 50 %
- 11. Pathology Well circumscribed white firm mass with a whorled appearance - surrounded by false capsule formed by compressed by uterine muscle
- 13. Symptoms
- 15. It is the most common symptom. Menorrhagia Intermenstrual bleeding postmenopausal bleeding are not characteristic of myomas except if
- 16. Secondary pathological degenerative changes and complications of fibroids
- 17. 1) Atrophy. 2) Necrosis. 3) Degeneration. 4) Malignancy. 5) Infection. 6) Torsion. 7) Incarceration. 8) Inversion of the uteruss.
- 18. Risk of Malignancy 0.1% in reproductive age group 1.7% after age of 60 years
- 19. Fibroid Signs G/E – Pallor P/A – If > 12 weeks size , firm, nodular, arising from pelvis, lower limit can’t be reached, relatively well defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen P/S – Cervix pulled higher up P/V – Uterus enlarged, nodular. D/D from ovarian tumour Uterus not separately felt , transmitted movement present, notch not felt.
- 20. Fibroid Diagnosis • Clinical : From symptoms & signs • USG : Well defined hypoechoic lesions. Peripheral calcification with distal shadowing in old fibroids
- 21. TAS&TVS size, site and number of fibroids differentiates the tumour from other swellings as ovarian tumour
- 22. Fibroid USG
- 24. (3) HysteroscopyTo visualize a sub mucous fibroid or a small fibroid polyp.
- 25. (4) Intra venous pyelogram (IVP) In cervical and broad ligament fibroid - Course of ureter. - Hydroureter & hydroneprosis - Kidney function.
- 26. Fibroid Diagnosis 5. MRI : Most accurate imaging modality for diagnosis of fibroid. It does precise fibroid mapping & characterization Detects all fibroids accurately D/D from adenomyosis D/D from adnexal pathology Ovaries are easily seen Detects small myomas(0.5 cm) 6. H S G : Not done for diagnosis , Done for infertility evaluation filling defects may be seen.
- 27. Fibroid MRI
- 28. Fibroid MRI
- 29. Fibroid D/D • Pregnancy • Adenomyosis • Ovarian tumour • Ectopic pregnancy • Endometriosis • T O mass
- 30. Fibroid Management Expectant : asymptomatic , Size < 12 weeks, near menopause . • Regular follow up every 6 months • Recent guidelines suggest upto 16 wks size however difficult to practice
- 32. Medical Management • Not a definitive Rx • For symptomatic relief • Preoperatively to decrease the size • Progestogens, antiprogestogens ( Miefpristone ) androgens ( Danazol, Gestrinone ) & GnRH analogues are used
- 33. GnRH analogues • Agonists are commonly used drugs :- • Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 months • Advantages : Decrease in size of myoma by 20 to 50 % Decrease in bleeding increases Hb level Decreases blood loss during surgery Converts hysterectomy into myomectomy Converts Abd. hyst into vag.hysterectomy
- 34. GnRH analogues • Disadvantages : High cost Hypoestrogenic side effects Effect is reversible Rarely ↑↑ bleeding due to degeneration Occasionally difficulty in enucleation • Antagonist Cetrorelix is used 60 mg I/M repeated after 3-4 months if necessary Initial flare up does not occur
- 35. Surgical Management * Hysterectomy Abdominal Vaginal LAVH, TLH * Myomectomy Abdominal Vaginal Hysteroscopic Laproscopic
- 36. Surgical Management Vaginal hysterectomy is favoured in following if • Uterus < 16 wks, preferably < 14 wks • No associated pathology like endometriosis , PID, adhesions • Uterus mobile & adequate lateral space in pelvis • Experienced vaginal surgeon
- 37. Surgical Management Myomectomy is done in following :- • Infertility, • Recurrent pregnancy loss & no other cause • Young patients • Patients who wish to preserve their uterus
- 38. Hysteroscopic myomectomy • For submucous myoma causing infertility, Recurrent pregnancy loss, AUB or pain • Criteria :- < 5 cm in size < 50 % intramural component < 12 cm2 uterine size
- 39. Laparoscopic myomectomy • In 3 phases excision of myoma, repair of myometrium & extraction • Suitable for subserous & intramural fibroids upto 10 cm size • Complications are those of operative laparoscopy + myomectomy
- 40. Abdominal myomectomy • Other factors for infertility should be ruled out • Consent for hysterectomy • Blood cross matched & ready • Pap’s smear & endometrial sampling to rule out malignancy • Medical or mechanical means to control blood loss Bonney’s Myomectomy clamp, rubber tourniquet, manual ( finger compression) pressure at isthmic region or use of vasopressin 10 – 20 units diluted in 100ml saline infiltrated before putting the incision .
- 41. Abdominal myomectomy • Minimum incisions are kept – preferably single midline vertical, lower, anterior wall . • Removal of as many fibroids as possible through one incision & secondary tunnelling incisions. • Meticulous closure of all dead space. • Proper haemostasis • Multiple small fibroids can be removed enbloc by wedge resection. • Measures for adhesion prevention should be taken.
- 42. Open myomectomy
- 43. Vaginal myomectomy • Submucous pedunculated or small sessile cervical fibroids are removed vaginally. • Ligation of pedicle if accessible • Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids • To gain access to pedicle of higher & big fibroid incision on the cervix can be made.
- 44. Surgical Management Laparoscopic myolysis : • By ND-YAG laser or long bipolar needle electrode through laparoscope, blood supply of myoma is coagulated. • Without blood supply, myoma atrophies. • Applicable to 3 -10 cm size & myomas < 4 in number * Cryomyolysis is under investigation
- 45. Uterine artery embolization • By interventional radiologist • Catheter is passed retrograde thro. Right femoral artery to bifurcation of aorta & then negotiated down to opposite uterine artery first. • Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or gelfoam are used for embolization. • 60 – 65 % reduction in size of fibroid • 80 – 90 % have improvements in menorrhagia & pressure symptoms
- 47. Uterine artery embolization • High vascularity & solitary fibroid are associated with greater chance of long term success. • Pregnancy, active infection & suspicion of malignancy are absolute C I . • Desire for fertility is also a contraindication • The risk of ovarian failure must be counselled • Post embolization syndrome ( fever, vomiting, pain) can occur
- 49. Fibroid Newer Management Mirena : • Third generation IUCD • Contains Progesterone LNG 60 mg releasing 20 ug /day • Fibroids decreases in size 6 – 12 months of use. Future research in fibroid Rx : • MRI guided focused ultrasound therapy • SPRM –Selective progesterone Receptor modulator Asoprisnil • Somatostatin analogues Lanreotide
- 50. MRI-guided Focused Ultrasound (MRI- FUS)
- 51. MCQs in Fibroid • Most common type of uterine leiomyoma . a) Intramural. b)Subserosal. c) Submucosal. d)Broad ligament. • Which of the following is for symptomatic treatment of fibroid. a) OCPs b)Testosterone. c) GnRH agonist. d)GnRH antagonist.
- 52. MCQs • Most common symptom of fibroid a) Abnormal uterine bleeding. b) Pelvic pain. c) Mass in abdomen. d) Abdominal discomfort • Most common pelvic tumor of reproductive age group is a) Uterine fibroid b) Dermoid cyst . c) Ovarian cysts. d) Ovarian tumor.
- 53. Thank You