FibroidsFibroids

Dr. Haresh U. Doshi Dr. Haresh U. Doshi M.D., Diploma (USG), FICOG, PGDMLSM.D., Diploma (USG), FICOG, PGDMLS

Professor & Chief of Unit Professor & Chief of Unit B.J. Med. College , New Civil Hosp. B.J. Med. College , New Civil Hosp.

AhmedabadAhmedabad

FibroidFibroid

Synonyms : Myoma, Leiomyoma, FibromyomaSynonyms : Myoma, Leiomyoma, Fibromyoma

Most common benign neoplasm in the female.Most common benign neoplasm in the female.

Incidence : 20 to 40% of reproductive age women.Incidence : 20 to 40% of reproductive age women.

FibroidFibroid Etiology : Etiology : It arises from smooth muscle cell of It arises from smooth muscle cell of

myometrium. myometrium.

Exact etiology not known. Exact etiology not known.

Monoclonal origin ( arising from single cell Monoclonal origin ( arising from single cell confirmed by G6PD studies. confirmed by G6PD studies.

Genetic basis definite.Genetic basis definite.

Various growth factors like TGFβ , EGF, IGF-1, IGF-Various growth factors like TGFβ , EGF, IGF-1, IGF-2, BFGF are recently implicated in the development 2, BFGF are recently implicated in the development of fibroids.of fibroids.

Fibroid - EtiologyFibroid - Etiology

Epidemiological risk factors :-Epidemiological risk factors :-

Increased risk Increased risk age 35 to 45 years , age 35 to 45 years , nulliparous or low parity , Black women, nulliparous or low parity , Black women, strong family history, obesity, early Menarche, strong family history, obesity, early Menarche, Diabetes, hypertension.Diabetes, hypertension.

Decreased risk Decreased risk ↑↑ parity, exercise, ↑↑intake ↑↑ parity, exercise, ↑↑intake of green vegetables, Prog.only contraceptives, of green vegetables, Prog.only contraceptives, cigarette smokingcigarette smoking

Fibroid - EtiologyFibroid - Etiology

Genetic basis: Responsible for 40 % cases Genetic basis: Responsible for 40 % cases of fibroids of fibroids

Translocation between Chromo. 12 & 14, Translocation between Chromo. 12 & 14,

Trisomy 12, Trisomy 12,

Rearrangement of short arm of Chromo 6 Rearrangement of short arm of Chromo 6

Rearrangement of long arm of Ch. 10, Rearrangement of long arm of Ch. 10,

Deletion of Ch.3 or Ch.7 .Deletion of Ch.3 or Ch.7 .

Fibroid - EtiologyFibroid - Etiology Estrogen although not proved for causing myoma Estrogen although not proved for causing myoma

definitely implicated in its growth. definitely implicated in its growth.

Not detected before puberty & regresses after Not detected before puberty & regresses after menopause.menopause.

May increase during pregnancyMay increase during pregnancy

Estrogen receptors are in higher concent.nsEstrogen receptors are in higher concent.ns

Common fifth decade due to anovulatory cycles Common fifth decade due to anovulatory cycles with high or unopposed estrogen.with high or unopposed estrogen.

FibroidFibroidTypes :Types :

Uterine Uterine Subserous – Sessile pedunculated Subserous – Sessile pedunculated

IntramuralIntramural

Submucous - Sessile pedunculated Submucous - Sessile pedunculated

Cervical : Anterior, posterior lateral Cervical : Anterior, posterior lateral or central or central

IntraligamentousIntraligamentous

ParasiticParasitic

FibroidFibroidSubmucous fibroids are Submucous fibroids are

classified by European societyclassified by European society

for gynec endoscopy ( ESGE ): for gynec endoscopy ( ESGE ):

Type 0 – No intramural extensionType 0 – No intramural extension

Type I – Intramural extension < 50 %Type I – Intramural extension < 50 %

Type II – Intramural extension > 50 %Type II – Intramural extension > 50 %

Fibroid Pathology Fibroid Pathology Multiple, discrete, spherical, pinkish white, firm Multiple, discrete, spherical, pinkish white, firm

capsulated masses . Pseudo capsule is made up capsulated masses . Pseudo capsule is made up of compressed myometrium & areolar tissue.of compressed myometrium & areolar tissue.

Microscopically nonstriated muscle fibres are Microscopically nonstriated muscle fibres are arranged in interlacing bundles of varying size & arranged in interlacing bundles of varying size & running in different directions ( whorled running in different directions ( whorled appearance ) Varying amount of connective appearance ) Varying amount of connective tissue is intermixed with smooth muscle fibres. tissue is intermixed with smooth muscle fibres.

Fibroid Pathological variantsFibroid Pathological variants

Microscopic variants Microscopic variants Cellular myoma, Cellular myoma, mitotically active myoma, bizarre myoma, mitotically active myoma, bizarre myoma, lipoleiomyoma, lipoleiomyoma,

Intravenous leiomyomatosisIntravenous leiomyomatosis

LPD – leiomyomatosis peritonealis LPD – leiomyomatosis peritonealis dissemination dissemination

LeiomyosarcomaLeiomyosarcoma

Fibroid SymptomsFibroid Symptoms

AsymptomaticAsymptomatic

- Abnormal uterine bleeding – 30-50% of - Abnormal uterine bleeding – 30-50% of patients . It is due to ↑↑ surface area, patients . It is due to ↑↑ surface area, ↑↑vascularity, endometrial hyperplasia, venous ↑↑vascularity, endometrial hyperplasia, venous obstruction, interference with contractions .obstruction, interference with contractions .

- Anemia due to excessive blood loss- Anemia due to excessive blood loss

- Dysmenorrhoea – Spasmodic as well as - Dysmenorrhoea – Spasmodic as well as congestivecongestive

Fibroid SymptomsFibroid Symptoms

- pelvic pain in 1/3rd patients, backache.pelvic pain in 1/3rd patients, backache.

- Acute pain due to torsion, infection, expulsion, Acute pain due to torsion, infection, expulsion, red degeneration, vascular complicationred degeneration, vascular complication

- Pressure symptoms : - Pressure symptoms :

- Lump in abdomen- Lump in abdomen

- Infertility – 2 to 10 % casesInfertility – 2 to 10 % cases

* Rare symptoms : Ascites, polycythemia, * Rare symptoms : Ascites, polycythemia,

Effects of fibroid on pregnancy :Effects of fibroid on pregnancy : Pregnancy : AbortionPregnancy : Abortion Pressure symptomsPressure symptoms MalpresentationMalpresentation Retrodisplacement of uterusRetrodisplacement of uterus Labour : Preterm labour MalpresentationLabour : Preterm labour Malpresentation Uterine inertia PPHUterine inertia PPH Dystocia MRPDystocia MRP Puerperium : SubinvolutionPuerperium : Subinvolution Sec. PPHSec. PPH Puerperal sepsisPuerperal sepsis Inversion Inversion

Effects of fibroid on pregnancy :Effects of fibroid on pregnancy : Increase in size & softening occurs . Increase occurs Increase in size & softening occurs . Increase occurs

mainly in the 1st trimester & in 22 to 32 % cases.mainly in the 1st trimester & in 22 to 32 % cases. Red degeneration in 2nd trimester – due to rapid Red degeneration in 2nd trimester – due to rapid

growth there is congestion with interstitial hemorrhage growth there is congestion with interstitial hemorrhage & venous thrombosis & venous thrombosis

Impaction in pelvisImpaction in pelvis TorsionTorsion InfectionInfection ExpulsionExpulsion Injury- Pressure necrosis during deliveryInjury- Pressure necrosis during delivery Rupture of subserous vein Rupture of subserous vein Internal hemorrhage Internal hemorrhage

Fibroid SignsFibroid Signs G/EG/E – Anemia due to prolonged heavy bleeding . – Anemia due to prolonged heavy bleeding . P/A P/A – If > 12 weeks size , firm, nodular, arising from– If > 12 weeks size , firm, nodular, arising from pelvis, lower limit can’t be reached, relatively wellpelvis, lower limit can’t be reached, relatively well defined, mobile from side to side, nontender, dull defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomenon percussion, no free fluid in abdomen P/SP/S – Cervix pulled higher up – Cervix pulled higher up P/V P/V – Uterus enlarged, nodular.– Uterus enlarged, nodular. D/D from ovarian tumour D/D from ovarian tumour Uterus not separately Uterus not separately

felt , transmitted movement present, notch not felt.felt , transmitted movement present, notch not felt. P/RP/R – May help in difficult cases . – May help in difficult cases .

Fibroid DiagnosisFibroid Diagnosis Clinical :Clinical : From symptoms & signs From symptoms & signs USG : USG : Well defined hypoechoic Well defined hypoechoic

lesions. Peripheral calcification lesions. Peripheral calcification

with distal shadowing in old fibroidswith distal shadowing in old fibroids

Adenomyosis is differentiated by diffuse lesion, Adenomyosis is differentiated by diffuse lesion, less echodense , disordered echogenicity & more less echodense , disordered echogenicity & more prominent at or just after menstruation prominent at or just after menstruation

Hysteroscopy : Hysteroscopy : Submucous fibroidsSubmucous fibroids

Fibroid USGFibroid USG

Fibroid DiagnosisFibroid Diagnosis

MRI :MRI : Most accurate imaging modality for diagnosis of Most accurate imaging modality for diagnosis of fibroid. It does precise fibroid mapping & fibroid. It does precise fibroid mapping & characterization characterization Detects all fibroids accurately Detects all fibroids accurately

D/D from adenomyosisD/D from adenomyosis

D/D from adnexal pathologyD/D from adnexal pathology

Ovaries are easily seenOvaries are easily seen

Detects small myomas(0.5 cm) Detects small myomas(0.5 cm)

H S G : H S G : Not done for diagnosis , Done for infertility Not done for diagnosis , Done for infertility evaluation filling defects may be seen. evaluation filling defects may be seen.

Fibroid MRIFibroid MRI

Fibroid MRIFibroid MRI

Fibroid D/DFibroid D/D

PregnancyPregnancy AdenomyosisAdenomyosis Ovarian tumourOvarian tumour Ectopic pregnancyEctopic pregnancy EndometriosisEndometriosis T O massT O mass

Fibroid PathologyFibroid PathologySecondary changes :-Secondary changes :-

BenignBenign : Atrophy, hyaline, necrosis, cystic, : Atrophy, hyaline, necrosis, cystic,

calcification,red degeneration, calcification,red degeneration,

myxomatous ( fatty) , infectionmyxomatous ( fatty) , infection

Malignant : Malignant : Leiomyosarcoma Leiomyosarcoma

< 1 % in < 50 years < 1 % in < 50 years

< 2 % in > 50 years age< 2 % in > 50 years age

Fibroid ManagementFibroid Management

Expectant :Expectant : asymptomatic , asymptomatic ,

Size < 12 weeks, Size < 12 weeks,

near menopause .near menopause .

Regular follow up every 6 months Regular follow up every 6 months

Recent guidelines suggest upto 16 wks sizeRecent guidelines suggest upto 16 wks size

however difficult to practicehowever difficult to practice

Medical ManagementMedical Management

Not a definitive RxNot a definitive Rx

For symptomatic reliefFor symptomatic relief

Preoperatively to decrease the sizePreoperatively to decrease the size

Progestogens, antiprogestogens Progestogens, antiprogestogens ( Miefpristone ) androgens ( Danazol, ( Miefpristone ) androgens ( Danazol, Gestrinone ) & GnRH analogues are usedGestrinone ) & GnRH analogues are used

GnRH analoguesGnRH analogues Agonists are commonly used drugs :-Agonists are commonly used drugs :- Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75 Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75

mg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 monthsmg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 months Advantages : Decrease in size of myoma by 20 to 50 % Advantages : Decrease in size of myoma by 20 to 50 %

Decrease in bleedingDecrease in bleeding increases Hb level increases Hb level

Decreases blood loss during surgeryDecreases blood loss during surgery

Converts hysterectomy into myomectomyConverts hysterectomy into myomectomy

Converts Abd. hyst into vag. hysterectomy Converts Abd. hyst into vag. hysterectomy

Makes hysterectomic resection possible Makes hysterectomic resection possible

GnRH analoguesGnRH analogues Disadvantages : High costDisadvantages : High cost

Hypoestrogenic side effectsHypoestrogenic side effects

Effect is reversibleEffect is reversible

Rarely Rarely ↑↑ ↑↑ bleeding due to degenerationbleeding due to degeneration

Occasionally difficulty in enucleationOccasionally difficulty in enucleation AntagonistAntagonist

Cetrorelix is usedCetrorelix is used

60 mg I/M repeated after 3-4 months if necessary60 mg I/M repeated after 3-4 months if necessary

Initial flare up does not occurInitial flare up does not occur

Medical - Newer TherapyMedical - Newer Therapy

SERM – RaloxifenSERM – Raloxifen

60 mg /day is tried for 6 to 12 mths.60 mg /day is tried for 6 to 12 mths.

Higher doses ( 180 mg) are required for Higher doses ( 180 mg) are required for

effective decrease in size.effective decrease in size.

Better if combined with GnRH analogsBetter if combined with GnRH analogs

Medical - Newer TherapyMedical - Newer Therapy

SPRM - AsoprisnilSPRM - Asoprisnil

5 to 25 mg/day is used5 to 25 mg/day is used

Mechanism of inhibitory action is not knownMechanism of inhibitory action is not known

Possible risk of endometrial hyperplasia is not Possible risk of endometrial hyperplasia is not studiedstudied

Medical - Newer TherapMedical - Newer TherapyyMifepristoneMifepristone

5 – 10 mg is tried 5 – 10 mg is tried

No loss of bone densityNo loss of bone density

Promising resultsPromising results

Steinaure et al reviewed 6 trialsSteinaure et al reviewed 6 trials

Decrease in myoma volume by 26-74 %.Decrease in myoma volume by 26-74 %.

No effect on bone densityNo effect on bone density

Endometrial hyperplasia may limit its longterm use. Endometrial hyperplasia may limit its longterm use.

Medical - Newer TherapyMedical - Newer Therapy

Aromatase inhibitorsAromatase inhibitors

Directly inhibit estrogen synthesis & rapidly Directly inhibit estrogen synthesis & rapidly produce hypoestrogenic state.produce hypoestrogenic state.

FadrozoleFadrozole is tried in couple of studies is tried in couple of studies

71 % reduction occurred in 8 weeks71 % reduction occurred in 8 weeks

Appears to be promising therapy.Appears to be promising therapy.

Surgical ManagementSurgical Management

* * HysterectomyHysterectomy Abdominal Abdominal

VaginalVaginal

LAVH, TLHLAVH, TLH

* * MyomectomyMyomectomy Abdominal Abdominal

VaginalVaginal

HysteroscopicHysteroscopic

LaproscopicLaproscopic

Surgical ManagementSurgical Management

Vaginal hysterectomy is favoured in following if Vaginal hysterectomy is favoured in following if

Uterus < 16 wks, preferably < 14 wksUterus < 16 wks, preferably < 14 wks

No associated pathology like endometriosis , No associated pathology like endometriosis , PID, adhesionsPID, adhesions

Uterus mobile & adequate Uterus mobile & adequate

lateral space in pelvislateral space in pelvis

Experienced vaginal surgeonExperienced vaginal surgeon

Surgical ManagementSurgical ManagementMyomectomy is done in following :-Myomectomy is done in following :-

Infertility Infertility

Recurrent pregnancy loss & Recurrent pregnancy loss & no other cause no other cause

Young patients Young patients

Patients who wish to preserve Patients who wish to preserve their uterus their uterus

Hysteroscopic myomectomyHysteroscopic myomectomy For submucous myoma causing infertility, RPL, AUB or For submucous myoma causing infertility, RPL, AUB or

painpain Criteria :- Criteria :- < 5 cm in size< 5 cm in size

< 50 % intramural component< 50 % intramural component

< 12 cm< 12 cm22 uterine size uterine size Gn RH analogue may be given preoperativelyGn RH analogue may be given preoperatively Suspicion of malignancy, infection & excessive mural Suspicion of malignancy, infection & excessive mural

component contraindicates surgerycomponent contraindicates surgery Advantages are short procedure , rapid recovery & all Advantages are short procedure , rapid recovery & all

disadvantages of laprotomy avoided.disadvantages of laprotomy avoided.

Laproscopic myomectomyLaproscopic myomectomy

In 3 phases In 3 phases excision of myoma, repair of excision of myoma, repair of myometrium & extractionmyometrium & extraction

Suitable for subserous & intramural fibroids upto Suitable for subserous & intramural fibroids upto 10 cm size 10 cm size

Complications are those of operative laproscopy + Complications are those of operative laproscopy + myomectomymyomectomy

Fibroid excised are remoyed by electronic morcellators Fibroid excised are remoyed by electronic morcellators or through posterior colpotomy incision vaginally.or through posterior colpotomy incision vaginally.

Abdominal myomectomyAbdominal myomectomy- Other factors for infertility should be ruled out- Other factors for infertility should be ruled out

- Consent for hysterectomy- Consent for hysterectomy

- Blood ‘X’ matched & ready- Blood ‘X’ matched & ready

- Pap’s smear & endometrial sampling to rule out - Pap’s smear & endometrial sampling to rule out malignancymalignancy

- Medical or mechanical means to control blood loss - Medical or mechanical means to control blood loss Bonney’s Myomectomy clamp, rubber tourniquet, Bonney’s Myomectomy clamp, rubber tourniquet, manual ( finger compression) pressure at isthmic manual ( finger compression) pressure at isthmic region or use of region or use of vasopressin 10 – 20 unitsvasopressin 10 – 20 units diluted in diluted in 100ml saline infiltrated before putting the incision .100ml saline infiltrated before putting the incision .

Abdominal myomectomyAbdominal myomectomy Minimum incisions are kept – preferably single midline Minimum incisions are kept – preferably single midline

vertical, lower, anterior wall .vertical, lower, anterior wall .

Removal of as many fibroids as possible through one Removal of as many fibroids as possible through one incision & secondary tunnelling incisions.incision & secondary tunnelling incisions.

Meticulous closure of all dead space.Meticulous closure of all dead space.

Proper haemostasis Proper haemostasis

Multiple small fibroids can be removed enbloc by Multiple small fibroids can be removed enbloc by wedge resection.wedge resection.

Measures for adhesion prvention should be taken.Measures for adhesion prvention should be taken.

Abdominal myomectomyAbdominal myomectomy Morcellation – Deeply embedded Morcellation – Deeply embedded

tumours are best removed bytumours are best removed by

cutting them into bits. cutting them into bits. Bonney’s hood – for posterior fundal Bonney’s hood – for posterior fundal

large fibroid transverse fundal large fibroid transverse fundal incision posterior to tubal insertion is made & uterine incision posterior to tubal insertion is made & uterine wall after enucleation is sutured anteriorly covering the wall after enucleation is sutured anteriorly covering the fundus as a hood.fundus as a hood.

Complications of myomectomy like hemorrhage & Complications of myomectomy like hemorrhage & infection are less in modern times. infection are less in modern times.

Vaginal myomectomyVaginal myomectomy

Submucous pedunculated or small sessile Submucous pedunculated or small sessile cervical fibroids are removed vaginally.cervical fibroids are removed vaginally.

Ligation of pedicle if accessibleLigation of pedicle if accessible

Twisting off the fibroids if pedicle not accessible Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids in case of small & medium size fibroids

To gain access to pedicle of higher & big fibroid To gain access to pedicle of higher & big fibroid incision on the cervix can be made.incision on the cervix can be made.

Surgical ManagementSurgical Management

Laproscopic myolysis :-Laproscopic myolysis :-

By ND-YAG laser or long bipolar needle By ND-YAG laser or long bipolar needle electrode thro. Laproscope blood supply of electrode thro. Laproscope blood supply of myoma is coagulated.myoma is coagulated.

Without blood supply myoma atrophies.Without blood supply myoma atrophies.

Applicable to 3 -10 cm size & myomas < 4 in Applicable to 3 -10 cm size & myomas < 4 in numbernumber

* Cryomyolysis is under investigation * Cryomyolysis is under investigation

Uterine artery embolizationUterine artery embolization By interventional radiologistBy interventional radiologist

Catheter is passed retrograde thro. Right femoral Catheter is passed retrograde thro. Right femoral artery to bifurcation of aorta & then negotiated artery to bifurcation of aorta & then negotiated down to opposite uterine artery first.down to opposite uterine artery first.

Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or Polyvinyl alcohol ( PVA ) particles ( 500-700 um) or gelfoam are used for embolization.gelfoam are used for embolization.

60 – 65 % reduction in size of fibroid60 – 65 % reduction in size of fibroid

80 – 90 % have improvements in menorrhagia & 80 – 90 % have improvements in menorrhagia & pressure symptomspressure symptoms

Uterine artery embolizationUterine artery embolization

Uterine artery embolizationUterine artery embolization

High vascularity & solitary fibroid are associated High vascularity & solitary fibroid are associated with greater chance of longterm success.with greater chance of longterm success.

Pregnancy, active infection & suspicion of Pregnancy, active infection & suspicion of malignancy are absolute C I .malignancy are absolute C I .

Desire for fertility is also a contraindication to UAIDesire for fertility is also a contraindication to UAI

The risk of ovarian failure must be counselledThe risk of ovarian failure must be counselled

Post embolization syndrome ( fever ,vomiting, Post embolization syndrome ( fever ,vomiting, pain) can occur pain) can occur

Uterine artery embolizationUterine artery embolization

Fibroid Newer ManagementFibroid Newer ManagementMirenaMirena : :

Third generation IUCDThird generation IUCD

Contains Progesteron LNG 60 mg releasing 20 ug /dayContains Progesteron LNG 60 mg releasing 20 ug /day

Fibroids decreases in size 6 – 12 mths of use.Fibroids decreases in size 6 – 12 mths of use.

May have variable effects on uterine myomas May have variable effects on uterine myomas depending upon balance of growth factorsdepending upon balance of growth factors

Couple of studies have shown beneficial resultsCouple of studies have shown beneficial results

Suitable for those who also desire contraceptionSuitable for those who also desire contraception

Newer Management- MRGFUSNewer Management- MRGFUS

Permitted by FDA since Permitted by FDA since 20042004

MRI guidance is used to MRI guidance is used to direct ultrasound to direct ultrasound to tissues to elicit tissues to elicit coagulative necrosis via coagulative necrosis via thermal ablation.thermal ablation.

Newer Management- MRGFUSNewer Management- MRGFUS Fasting overnightFasting overnight

Shaving of lower abdomenShaving of lower abdomen

Foley’s catheterFoley’s catheter

Sonications of 20 to 40 Sonications of 20 to 40

seconds interval with seconds interval with

80 – 90 seconds cooling80 – 90 seconds cooling

ResearchResearchLanreotide a long acting somatostatin Lanreotide a long acting somatostatin analog reduces GH secretion 30 mg analog reduces GH secretion 30 mg depot reduced fibroid size by 41.6 %depot reduced fibroid size by 41.6 %

Targetting growth factors that areTargetting growth factors that are involved in angiogenesis or fibrosis involved in angiogenesis or fibrosis Pirfenidone an antifibrotic agent is Pirfenidone an antifibrotic agent is under trial under trial

Thank YouThank You