UTERINE FIBROIDS (LEIOMYOMATAS)
• Smooth Muscle Tumor of the Uterus
• The most common uterine tumor
– Occurring in about 30% of women above the age of 30 years.
• Occurs up to 75% of hysterectomy specimens
• Symptomatic in 1/3 of cases
What are they?
Patient Characteristics• Age:
– 30-40 years.
– Rare before 30 or after 40 years
• Parity: – Common in nulliparas, patients with low parity.
– It is rare in multiparas.
• Race: – 3-9 times more common in negroids.
• Family history: – Usually positive.
• Hyper-estrenemia: – Estrogen receptors (ER) more than the surrounding myometrium but less
than those in the endometrium• Common in low parity.
• Atrophies and shrinks after menopause.
• Common association with other hyper-estrenic conditions as endometriosis, endometrial hyperplasia and endometrial carcinoma.
Fibroids
Uterine [99%] Extrauterine [1%]
Corporeal [95%] Cervical [4%]
Interstitial [60%]
Submucous [ 20%]
Subserous [15%]
Genital Extragenital
Parasitic Fibroid
Others
[15%]
[20%]
[60%]
Submucous leiomyomaPedunculatedsubmucousIntramural or interstitialSubserous or subperitonealPedunculatedabdominalParasiticIntraligmentaryCervical
Signs of fibroid
• General examination:
– signs of chronic anemia.
• Abdominal examination:
– large pelvi-abdominal swelling in huge fibroids.
• Pelvic examination:
– symmetrically or asymmetrically enlarged uterus.
• Speculum examination
– fibroid polyp.
Differential Diagnosis• Causes of symmetrically enlarged uterus:
– Pregnancy– Subinvolution of the uterus.– Submucous or interstitial fibroid.– Metropathia hemorrhagica.– Adenomyosis uteri.– Carcinoma or sarcoma of the uterus.– Pyo, hemato, or physometra.
• Causes of asymmetrically enlarged uterus:– Subserous fibroid.– Localized adenomyosis.– Ovarian, tubal, or broad ligamentary swelling.– Pregnancy in a rudimentary horn.
Management
• Conservative Management
– small asymptomatic fibroid,
– fibroid in pregnancy or puerperium.
• Just keep observation every 6 months.
• Beware of underlying and/or associated pathology
Medical Treatment:
• Pre-operative till the time of surgery.
• Patient near the menopause, or newly married with minimal symptoms.
• Red degeneration with pregnancy.
• Lines of treatment:– Symptomatic:
• Correction of anemia,
• haemostatics,
• analgesics, and anti-spasmodics (anti-PG).
– Anti-estrogens: • large dose of progesterone,
• Tamoxifen, Danazol,
• LH-RH analogues – useful in decreasing the size and vascularity of the tumor by 50%
which is beneficial before myomectomy
Surgical Management
Myomectomy vs. Hysterectomy
??!!
•Indications:•Symptomatic cases or uterus larger than 12 weeks size.•Suspected malignancy (rapidly enlarging or post-menopausal growth).•Multiple huge fibroids liable to complications.•Infertility.
Myomectomy
• Abdominal Myomectomy
• Vaginal Myomectomy
• Endoscopic Myomectomy
– Hysteroscopic
– Laparoscopic
• Embolization techniques ( Interventional Radiology)
Secondary Changes in Fibroids
• Degenerative
• Vascular
• Inflammatory
• Malignant Changes