UTERINE FIBROID

LEIOMYOMA

By: Ms. Faizah, Mr. Ng De Lone, Mr. Zulhilmi

OBJECTIVES
To understand the pathogenesis and features of

uterine fibroid
Clinical presentation of uterine fibroid and its
impact on womens health, pregnancy and
reproductive function.
Diagnosis of uterine fibroid by history & physical
examination
Laboratory investigations and imaging modalities.
Management (surgical and non-surgical) according
to age, symptomatology, site and size of fibroid
and wishes for reproductive function.

INTRODUCTION
Definition:

Benign tumors that arise from the

overgrowth of smooth muscle and connective
tissue in the uterus
Commonest benign tumor in women
> 25% of women in reproductive age group
have uterine fibroid.
> 50% of all women will develop at least one
fibroid during their lives
Primary indication for hysterectomies carried
out in US

Factors Associated with development of

Uterine Fibroid

RISK

Reproductive age
Race: Ethnicity ( AfricanAmerican)
Nulliparity
Family history
Obesity
PCOS
DM, HTN

RISK

Smoking
OCP
Injectable progesterone

PATHOGENESIS
Benign smooth muscle tumor of myometrium
Initiating factors are not known; seems to arise from

a single myometrial cell

Growth is dependent on ovarian sex steroid
hormones
Rare before menarche and regress after menopause

Macroscopic features of Fibroid

Spherical, well circumscribed tumour,
Pale-whitish mass, with sheets of whorled

appearance on cut section

Pseudocapsulated
Consistency: firm to hard
Receive blood supply at peripheries and
very few vessels transverse the pseudocapsule to reach the core
As fibroid increase in size, it often outgrows
the
blood
supply
and
undergoes
degenerative changes.

Microscopic Features :
Tumour consists of bundles of plain muscle cells,
separated by varying amount of fibrous strands

DEGENERATIVE CHANGES
1. Hyaline degeneration

Commonest

Smooth muscles are replaced by hyaline tissue

Soft , on cut section whorled pattern lost & become

cystic

Degenerative changes
2. Cystic degeneration

Hyaline substance breakdown

3. Calcification

Common in post-menopausal

Fatty degeneration
Rare

Degenerative changes
5 Red degeneration : Occurs during
pregnancy

Haemorrhage into tumor

Painful

SITES
Commonly start from myometrium and can

attain impressive dimension

Intramural
Sub mucosal
Subserosal
Cervical fibroid
Broad ligament fibroid

Pedunculated fibroid with long stalk or pedicle

mobile

Sub mucosal fibroid which may protrude from

cervical canal
Subserosal fibroid latching on blood supply of
omentum and mesentery losing its uterine
attachment parasitic fibroid
Parasitic fibroid can invade great vein and
migrate up to level of atrium of heart (rare)
Intravenous leiomyomatosis

CLINICAL PRESENTATION
Symptoms:
Mostly

asymptomatic
Depends on:
Site and size
Pressure on other pelvic structure
Pregnancy status
Degenerative changes

Clinical features
Heavy, painful, prolonged vaginal bleeding

(Menorrhagia)

Intramural, subserosal, cervical fibroid

Untreated excessive & prolonged bleeding anaemia
( weakness/ dyspnea/ CCF)

Intermenstrual bleeding (Metrorrhagia)

sub mucosal fibroid ulcerating from endometrium or
protruding from cervical canal
Non-specific symptoms:

Pelvic congestion, lower abdominal bloating, heaviness

Dyspareunia (some)

CLINICAL PRESENTATION
Pain : Uncommon
May occur:
If fibroid is impacted
Undergoes acute torsion
Red degeneration during pregnancy
Pressure effect on surrounding structure

Uncommon
Difficulty in micturition/ defecation
Rapid growth in size especially after
postmenopausal period

Leiomyosarcoma

Symptoms related to pregnancy

Sub fertility
Difficulty in conception/ early pregnancy wastages
Exact mechanism cant be explained
Fibroid distorts endometrial cavity or impedes implantation
Location of fibroid has been shown to affect both fertility &
early pregnancy loss.

Subserosal:

Does not affect fertility outcome.

Abnormal lie/prolonged labour/ delivery of placenta/ PPH/
subinvolution of uterus in puerperium

Intramural & Sub mucosal : fertility &

miscarriage rate

Improvement following myomectomy

SIGNS
Central pelvic mass

; palpable on bimanual

examination as firm, irregularly enlarged uterus with

smooth or bosselated surface.
Those with long stalks ; maybe palpated

abdominally as separated masses from uterus.

A pedunculated submucous fibroid can prolaspe through
cervical canal presenting with heavy menstrual bleeding,
ulcerations on surface, and infection.
Anemia is common in these situations.

IMAGING MODALITIES
Ultrasonography (transvaginal or transabdominal probe)

- Useful in imaging and locating fibrioids.

- Delineates the site and size and demonstrates any distortions of
endometrial lining.
Doppler assesment
- Blood flow at the peripheries of a fibroid is a characteristic finding.
MRI
- Employed if fibroid dimension and site needs to be assessed
accurately.
Hysteroscopy
- Essential imaging tool in submucosal fibroid.
- Hysteroscopic myomectomy through a resectoscope maybe
warranted in symptomatic small submucous fibroids.
Transvaginal sonohysterography
- Endometrial cavity distended with saline infusion and imaged with
a transvaginal ultrasonography.
- This delineates the submucosal fibroid well.

Transvaginal sonohysterography
- Endometrial cavity distended with saline infusion and imaged with
a transvaginal ultrasonography.
- This delineates the submucosal fibroid well.

Diagnostic Laparoscopy

Hysteroscopy
- Recognizes a sub mucous myoma
- Also allows its excision under direct vision

Treatment

Management options

Medical
Surgical
Interventional
radiology

Medical
Management of uterine fibroids depends largely on

the site of fibroids, age of patient, symptoms and

how it affects the quality of life and need for
continued reproductive function.
For e.g., iron deficiency anemia resulting from

menorrhagia is optimized with hematinics and

sometimes with blood transfusions

Anti-fibrinolytic
Menorrhagia can be managed medically.

- Recommended 1st line therapy is tranexamic acid

(anti-fibrinolytic) which reduces blood loss by 50%.

It should be used in preference to NSAIDs

Danazol and Gestrinone

Reduces fibroid size and amount of blood loss
Prolonged use of danazol is limited by significant

androgenic side-effects.
This is contrary to gestrinone where the side effects

are less and fibroid re-growth after cessation of

therapy is gradual.

Mifepristone
Effective in reducing blood loss and uterine size at

various doses with minimal side effects

50% reduction in size is observed when 25 mg

Mifepristone is administered over three months

GnRH Analogues
It suppress the ovaries and induce a milieu of hypoestrogenism.
It controls the symptoms, but causes amenorrhea, vasomotor side-

effects.
Prolonged used; bone dimineralization resulting in osteoporosis
Use prior to surgery (myomectomy or hysterectomy) with concomitant

administration of hematinic effectively optimizes perioperative IDA.

Fibroid size is reduced significantly, making it possible for a transverse

scar on the abdomen or even a vaginal approach during surgery

Leuprolide: 3.75 mg once a month for 3 months

Myomectomy
Surgical removal of fibroid alone, by laparotomy or laparoscopy
Performed if fibroid is the cause of sub fertility or
Preservation of fertility is desired.
Heavy blood loss may occur during surgery
To control bleeding, techniques like:

- Intra myometrial vasopressin injection

- Occlusive clamps
- Tourniquets
Recurrence rate after surgery is 27%

Abdominal myomectomy

Cervical fibroid in a nulliparous woman

Myomas removed in piecemeal

Laparoscopic myomectomy
Feasible in :
- Pedunculated fibroid
- Sub serous fibroid not exceeding 10 cm, not more than four in number

Patient must be counselled for hysterectomy too

if the need arises

Indications of Myomectomy
1.

Persistent uterine bleeding despite medical therapy

2. Excessive pain or pressure symptoms

3. Size >12 weeks, woman desirous to have a baby
4. Unexplained infertility with distortion of the uterine

cavity
5. Rapidly growing leiomyoma during follow up
6. Sub serous pedunculated fibroid

Hysterectomy
Surgical procedure
Definitive treatment and is performed when medical

therapy fails, especially in presence of significant

symptoms affecting quality of life.
3 approaches of hysterectomy
Total

Abdominal hysterectomy

Vaginal

hysterectomy

Laparoscopic

Total Hysterectomy or LAVH

Hysterectomy
Open laparotomy: large fibroids or when the locations, access and

surgery itself poses great difficulties.

Vaginal approach is reserved for smaller one.
Supracervical hysterectomy adv:
1.

Shorter operating time

2. Less risk of injury

3. Better sexual function (since the vaginal length and cervix are

preserved)
4. Lesser risk of vault prolapse. The risk of malignant change in cervical

stump is negligible (<1%)

Uterine Artery Embolization

Injecting polyvinyl alcohol particles into uterine artery (via

femoral artery catheterization) to embolize uterine vascular bed.

Severe Cx are uncommon.
Effective in reducing blood loss and the fibroid size gradually.
Severe post-procedural ischemic pain is often encountered.
UAE can reduce the size of fibroids by up to 50%, with relief of

abnormal bleeding and pressure symptoms. Women report being

very satisfied by the treatment. Although longer term information
is more limited, many women will have a sustained improvement.