Sehrish fatima

08-172

batch-K

Final year MBBS

uterus Internal anatomy The uterus can be divided into

the body and the cervix. Body – the largest part and has a

rounded superior portion known as the fundus and ends inferiorly at a constriction called the isthmus.

Cervix - this is the inferior portion of the uterus that extends to the vagina. The internal aspect is known as the cervical canal which is a passageway that is bounded between the Internal Os and External os.

Internal anatomy

Uterine wall The wall of the uterus consists of: Endometrium – a thin glandular layer (mucosa) that is shed

every month as part of the menstrual cycle Myometrium – thick smooth muscle layer that contracts

when pushing a fetus out Perimetrium – outermost layer known as serosa which is

covering the fundus and posterior surface of uterine body

Internal anatomy

Definition

Fibroid is a benign tumor arising from the smooth muscles of uterus .Consisting predominantly of smooth muscle fibers admixed with small amount of connective tissue.

It should be more appropriately myoma or leiomyoma.

Incidence

They are the most common pelvic tumors

It is found in 25% of white women & 50% of black women.

Age : greater than 30

Etiology Unknown

Estrogen: It has been implicated in growth of myomas. Studies show that :

1. Myomas contain estrogen receptors in higher concentration than surrounding myometrium.

2. Myomas may increase in size with estrogen therapy & in pregnancy 3. They are not detectable before puberty4. Regress after menopause due to fall in estrogen levels.

Progesterone1. increase mitotic activity & reduce apoptosis in size

Genetic predisposition

Risk Factors AGE-Reproductive age group more common(Thirty & forty)

FAMILY HISTORY-Increases risk

RACE-African & Caribbean –American women

OBESITY-Higher risk

EATING HABITS-Red meat & ham

PARITY-Develop in women who have no children, with genetic determinant.

AppearanceGROSS

Nodular outgrowth causing enlargement and distortion of uterus.

May occur singly but more commonly multiple

Round or oval in shape.

Firm in consistency.

Whorled appearance on cut surface.

Gross features

microscopy

Smooth muscle bundles

Arranged in whorls.

Variable amount of connective tissue.

Classification

Intramural/Interstitial Fibroids Within uterine walls ,surrounded by myometrium , non capsulated but pseudocapsule form with growth , blood supply is through nutrient arteries entering through the pseudocapsule.

Originates from outer myometrium & projects outwards from uterus covered with peritoneum, attain large size to lack of surrounding myometrium

Subserosal Fibroids

Pedunculated fibroids Further extrusion outwards with the development

of pedicle makes it a pedunculated fibroid If such a tumor gets attached to a vascular organ

and is cut off from its origin- Parasitic fibroid

Uterine contractions may force the myoma towards the cavity where it is covered only by endometrium it is called submucous fibroid

Submucous fibroids

…Contd• .CERVICAL FIBROID;

1-2% OF CASES.

SINGLE.

SITE: SUPRAVAGINAL PART OF CERVIX.

a.Intramural

b.Subserous

3.INTRALIGAMENTARY FIBROID;

Arising from smooth muscle fibers with in broad ligament.

..

Clinical findings

symptoms Symptomatic in only 35-50% of Pt

Symptoms depend on location, size, changes & pregnancy status

1-Abnormal uterine bleeding

The most common 30%

Heavy / prolonged bleeding (menorrhagia) iron deficiency anemia

…Contd Submucous myoma produce the most pronounced

symptoms of menorrhagia, pre & post-menstrual spotting

Bleeding is due to increase in size of endometrium , venous stasis and ulceration of the overlying endometrium

Pedunculated submucousal fibroids intermenstrtual bleeding

…Contd

Pain : pain usually start when complications occurs e.g

torsion

red degeneration

sarcomatous degeneration

• Pressure symptoms :

Large fibroids causes interference with venous and lymphatic drainage of the lower limb causing edema and varicosities.

Pressure on pelvic vein may cause hemorrhoids.

Urinary symptoms Cervical fibroid – irritation of bladder – increased

frequency

large cervical fibroid – impaction of pelvis – urinary retention

A large fibroid may fill the abdominal cavity causing dyspepsia due to stomach irritation & dyspnea due to pressure on lungs.

Abdominal Mass

ExaminationGeneral physical examination No specific findings Excessive loss of blood may cause anemia ,presenting with

pallor and in extreme cases with breathlessness Edema and varicosities of limbs are rare findings with large

fibroids .Abdominal examination :Uterus palpable abdominally Single fibroid -- central uterus with smooth surface Multiple fibroids – irregular mass maybe shifted to a sidePelvic examination : Protuding fibroids easily seen

Investigations

Investigation of choice

• Ultrasonography

Under special circumstances

• Hysteroscopy and curettage

• Laparoscopy

Other investigation

• Hysterosalpingogram

• Modern imaging techniques

• Complete blood picture

Ultrasonography Investigation of choice

Typical fibroid appearance :mild to moderate echogenic mass in the uterine wall that causes nodular distortion of uterine outline.

Small intramural or Submucous fibroid recognized by distortion of the normally linear central endometrial echoes.

Fibroids with hyaline degeneration : anechoic area within fibroid

Fibroids with cystic degeneration: will give Snow storm appearance

U/S

Hysteroscopy & Curettage Hysteroscopy provides a direct view of uterine cavity,

& is indicated during

1. Abnormal uterine bleeding

2. Small submucous fibroids missed during ultrasound

…Contd Curettage may help to diagnose a co existing

endometrial pathology ,which may be the actual cause of menorrhagia.

Other investigations Hysterosalpingogram : carried out as a part of

infertility investigation and can pick small submucousfibroids.

…Contd Modern Imaging

Technique : CT scan and MRI are more accurate in describing pelvic mass but too expensive for routine examination.

• Complete Blood Picture In severe menorrhagia hemoglobin will be low and polycythemia can also be diagnosed.

Treatment .

Conservative Treatment Asymptomatic fibroid of size less than 12 weeks

pregnancy in a patient of 42 years of age is left alone in a hope that It would regress after menopause.

An asymptomatic fibroid of size more that 12 weeks of pregnancy does not justify prophylactic removal as risk of sarcomatous change is less than 0.1%.

Only management required is a regular follow up till menopause.

Removal only indicated in case of a very large fibroid or a rapidly increasing in size due to concern about the nature of the mass .

Medical Treatment GnRH analogues is the only drugs which has shown

promising results .

GnRH analogues :

Monthly IM depot injection

Daily Nasal spray

prescribed for 3 months

improved 80% cases of menorrhegia,

50% of the fibroid size is reduced

Disadvantages: expensive , effects only last during therapy , cause post menopausal symptoms (hot flushes , night sweats , psychological disturbance)

…contd

Therefore only given when reduction in size and vascularity is required prior to myomectomy & hysterectomy.

Long term use (6months or more) only allowed when patient is unfit for surgery ( obese ,extensive adhesions) or approaching her menopause.

Other drugs : these shows reduction in size of fibroids up to some extent

Danazol

Gestrinone

Surgical treatment Surgical treatment is present in the form of Myomectomy Hysterectomy

Myomectomy term myomectomy is used for an operation where the uterus is

conserved and fibroid is removed. Preferred treatment in following conditions, Symptomatic fibroids in young patient, Infertile patients when fibroids are only pathology, Patients wishing to have more children, Patients with recurrent abortion ,fibroids likely to be the underlying

cause, Patients wishing to conserve her uterus.

Hysterectomy It is the treatment of choice when

1. Patient is above 40

2. Multiple fibroids

3. Family is completed

4. Symptoms are more severe

.

Complications

DEGENERATION ATROPHIC (decrease in size, but do not disappear)

due to estrogen withdrawl

HYALINE ( loses typical whorl appearance, tumourlook homogenous & glossy area microscopically)

CYSTIC (hyaline cystic)

Fatty degeneration

Red generation (seen during pregnancy ,similar to ischemic necrosis ,fibroid appears reddish due to thrombotic and haemolytic changes in blood vessles)

SARCOMATOUS CHANGE Very rare

0.1% of cases

Starts in the center of tumour

Any size or type of myoma can undergo sarcomatouschange

Malignant change suspected when:

Rapid increase in size

Painful

tender

INFECTION Submucous or subserous myoma if lies near an

inflammed organ… Infection

More common in the ones that have undergone necrosis

Infection occurs:

During puerperium

After abortion

Inflammed appendix

Diverticulum

TORSION

Pedunculated Subserous Myoma…. Torsion

Sudden attack of pain

Tenderness

Difficult to differentiate from red degeneration or torsion of ovarian cyst

.

Differential diagnosis

.

Pregnancy Other pelvic masses1. -Ovarian Ca2. -Tubo-ovarian abscess 3. -Endometriosis4. -Adenexa, omentum or bowel adherent to the uterus Other causes of uterine enlargement:1. -Adenomyosis2. -Myometrial hypertrophy3. -Congenital anomalies4. -Endometrial Ca

.

Other causes of abnormal bleeding

1. Endometrial hyperplasia

2. Endometrial or tubal Ca

3. Uterine sarcoma

4. Ovarian Ca

5. Polyps

6. Adenomyosis

7. DUB

8. Endometriosis

9. Exogenouse estrogens

10. Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Ca

.

Pregnancy and myomas

Effects of Myomas on pregnancy

• Myomas are rarely seen associated with pregnancy (3%)• Commonly seen in an elderly primigravida

ABORTION (risk is high) PREMATURE LABOUR MALPRESENTATIONDuring labour: Abnormal uterine action Cervical dystocia ( interference in dilation of cervix) Obstructed labourDuring puerperium: Puerperal sepsis Delayed involution of uterus

Effects of Pregnancy on Myomas

Increase in size

Change in consistency: Become Soft due to congestion & oedema

Red degeneration

Torsion ( in a pedunculated fibroid )

Infection

Thank You