Bengin tumors arising from the smooth muscle cells of the myometrium

They are the most common pelvic tumor in women.

20% of women >of 35 years .

PathologyPathology

Well circumscribed white firm mass with a whorled appearance

- surrounded by false capsul formed by compressed by uterine muscle

PathologyPathology MicroscopicallyMicroscopically

Smooth muscle

& Connective

tissues

.

Pathology Of FibroidPathology Of Fibroid

SizeSizeVaries from very small fibroidsVaries from very small fibroids

(seedlings) to huge tumours (seedlings) to huge tumours

ShapeShapeStarts as a small spherical tumourStarts as a small spherical tumour

but as it enlarges its shape may bebut as it enlarges its shape may be

changed by compression.changed by compression.

ConsistencyConsistencyFirm unless affected by degenerationFirm unless affected by degeneration

connective tissueconnective tissue

Secondary pathological

degenerative changes and

complications of fibroids

1)1) Atrophy. Atrophy.

2)2) Necrosis.Necrosis.

3)3) Degeneration. Degeneration.

4)4) Malignancy.Malignancy.

5)5) Infection.Infection.

6)6) Torsion.Torsion.

7)7) Incarceration.Incarceration.

8)8) Inversion of the uterusInversion of the uterus..

Loss of worled appearance if Loss of worled appearance if degenration occurred degenration occurred

Risk of MalignancyRisk of Malignancy

Incidence of leiomyosarcoma in

hysterectomy specimens of women

receiving surgical treatment for

fibroid

0.1% in reproductive age group

1.7% after age of 60 years

Early menarche (<10 years old) is associated with an increased risk of developing fibroids.

Early menarche (<10 years old) is associated with an increased risk of developing fibroids.

Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation.

Early age at first birth decreases risk and a longer interval since last birth increases risk

Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation.

Early age at first birth decreases risk and a longer interval since last birth increases risk

No definit risk with oral contraception

No association of fibroid growth with agents for ovulation induction

No definit risk with oral contraception

No association of fibroid growth with agents for ovulation induction

A relationship between fibroids and increasing body mass. The relationship is complex and is likely modified by other

factors

A relationship between fibroids and increasing body mass. The relationship is complex and is likely modified by other

factors

Site of originSite of origin

Corporeal

fibroid

(97% )

Cervical

fibroid

(3%)

Fibroids are often described according Fibroids are often described according to their location in the uterusto their location in the uterus

Anatomic LocationsAnatomic Locations

SymptomsSymptoms

It is the most common symptom.

Menorrhagia is the typical bleeding pattern with myomas .

Intermenstrual bleeding and

postmenopausal bleeding are NOT characteristic of myomas EXCEPT IF

Bulk-related symptoms —

urinary frequency, difficulty emptying the bladder,urinary obstruction

Piles &constipation

Hydrourter &hydronephrosis

.

Dysmenorrhea — Dysmenorrhea is also reported by many women with fibroids.

Leiomyoma degeneration or torsion — fibroids cause acute pain from degeneration (eg, red degeneration)

or torsion of a pedunculated tumor.

submucosal or intramural with an intracavitary component) result in:

difficulty conceiving a pregnancy

Increase risk of abortion

leiomyomas have been associated with adverse pregnancy outcomes eg, placental abruption, fetal growth restriction, and preterm labor and birth

Signs of cervical fibroid Signs of cervical fibroid

A firm fixed pelvic mass A firm fixed pelvic mass with the with the

uterus lying on its top.uterus lying on its top.

Barrel-shapedBarrel-shaped enlargement of the enlargement of the

cervix.cervix.

A cervical polyp.A cervical polyp.

Pelvic ExamPelvic Exam

AA pelvi-abdominal Or pelvic mass.pelvi-abdominal Or pelvic mass.

symmetrical enlargement of the uterus.symmetrical enlargement of the uterus.

A symmetrical enlargement of the uterus. A symmetrical enlargement of the uterus.

- A pedunculated subserous- A pedunculated subserous

- A broad ligament fibroid. - A broad ligament fibroid.

speculum exam speculum exam cervical polypcervical polyp

CERVICAL POLYPCERVICAL POLYP

TAS&TVSTAS&TVS

size, site size, site and and numbernumber of fibroids of fibroids

differentiates differentiates the tumour from the tumour from

other swellings as other swellings as ovarian tumour ovarian tumour

2-Saline infusion sonogRaphy2-Saline infusion sonogRaphy

(3) Hysteroscopy(3) Hysteroscopy

To visulize a sub

mucous fibroid or

a small fibroid

polyp.

(4) Intra venous pyelogram (IVP)(4) Intra venous pyelogram (IVP)

In In cervicalcervical and and broad ligament fibroid broad ligament fibroid

- Course of ureter.Course of ureter.

- Hydroureter & hydroneprosis Hydroureter & hydroneprosis

- Kidney function.- Kidney function.

Asymptomatic Asymptomatic

Fibroid small (<12 wk gestational size)Fibroid small (<12 wk gestational size)

Near menopauseNear menopause

Treatment is not necessary if….Treatment is not necessary if….(follow up every 6 months )(follow up every 6 months )

Hormonal ttt Hormonal ttt

COCPsCOCPs

DanazolDanazol

Gonadotrophin releasing hormone analogueGonadotrophin releasing hormone analogue (agonist) (agonist)

Mifepristone: Mifepristone: a progesterone receptor a progesterone receptor antagonist It reduces the size of myomas by antagonist It reduces the size of myomas by 50%. 50%.

MirenaMirena coil treats menorrhagia, and reduces coil treats menorrhagia, and reduces

the size of fibroids + contraception)the size of fibroids + contraception)

MyomectomyMyomectomy

Removal of fibroids from the uterus Removal of fibroids from the uterus

Indications:Indications:

Young age below 40 years Young age below 40 years

Single myoma Single myoma

Contraindication of Myomectomy Contraindication of Myomectomy

Age Age > 40.> 40.

Multiple fibroids (leave Multiple fibroids (leave behind a useless behind a useless

organ). organ).

Cervical fibroidCervical fibroid

If If malignancymalignancy is suspected. is suspected.

presence of other lesions in the uterus as presence of other lesions in the uterus as

adenomyosis.adenomyosis.

Open myomectomy Open myomectomy

LaparoscopicLaparoscopic MyomectomyMyomectomy

HysteroscopicHysteroscopic MyomectomyMyomectomy

How to decrease blood loss How to decrease blood loss during myomectomy ?during myomectomy ?

Pre operative correction of anemia: Pre operative correction of anemia: – Iron supplementation,Blood transfusionIron supplementation,Blood transfusion

Pre operative GnRH agonists treatmentPre operative GnRH agonists treatment

Vasopressin(20U in 20 ml NS) Vasopressin(20U in 20 ml NS) - - as effective as as effective as

vascular occlusion for controlling blood lossvascular occlusion for controlling blood loss

Tourniquets : Tourniquets : Bonney’s myomectomy clampBonney’s myomectomy clamp

Ring forcepsRing forceps

Elastic rubber catheter(around cervix)Elastic rubber catheter(around cervix)

HysterectomyHysterectomyIndication:Indication:

1)1)Multiple myomaMultiple myoma

2)2)Cervical fibroid Cervical fibroid

3)3)Uncontrollable bleeding Uncontrollable bleeding

during myomectomy during myomectomy

Cervical fibroid Cervical fibroid

Smooth muscle tumors of the uterus are often multiple. Seen here Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the utare submucosal, intramural, and subserosal leiomyomata of the uteruserus

Embolization of both uterine arteriesEmbolization of both uterine arteries

Indicated when patient is unfit or refuse Indicated when patient is unfit or refuse

hysterectomy . hysterectomy .

< tumour size about < tumour size about 50%. 50%. endometritis and pyometra endometritis and pyometra

infection of the necrotic fibroids. infection of the necrotic fibroids.

MRI-guided Focused Ultrasound MRI-guided Focused Ultrasound (MRI-FUS(MRI-FUS))

Management Clinical effect\ Method of Treatment

Observation MostSerial Pelvic Exams

Pre-surgical Shrinkage Size by 50%GnRH analog 3-6months; regrowth after stopping

Myomectomy Preserves fertilityLaparotomy, laparoscopy

Embolization Preserves the uterusInvasive radiotherapy

Hysterectomy Fertility completedTAH,TVHDefinitive tx