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