UTERINE FIBROIDS - Dr Kihara .A.B.

 Degenerative changes
 Infertility
Epidemiology  Miscarriages and premature delivery
 This is the commonest benign tumor seen in females.  Torsion of sub serous fibroids
 Incidence is highest in nulliparous with prevalence  Polycythemia- Secondary to erythropoietin of tumor or
highest in the reproductive ages of 30 – 45 years. from the kidneys due to ureteric pressure
 Are seen more in the blacks.
 Symptoms are seen in 3 – 10% Management
 Fibroids can be asymptomatic or symptomatic.
Etiology  Principles of management start with history, physical
 Uncertain aetiopathogenesis. examination and investigations.
 However the tumor arises from the smooth muscle of the
myometrium.
 Once a definitive diagnosis is made treatment modalities
must be weighed on the symptomatology, size of the
 Genetics and nulliparity thought to play role. fibroids and desire for fertility.
 Growth of the tumor is Estrogen dependent. This is seen
with the tumor growth spurt noted with pregnancy, use Clinical features
of pills and the regression as seen with menopause  Patient profile
 Nulliparity or multiparous.
Types of tumor seen
 Period of infertility or recurrent pregnancy losses
 Interstitial or intramural. Occurs in 70%.
 Is the client menopausal
 Sub peritoneal or subserosal. These can be pedunculated
or parasitic (wandering) or intraligamentous
Symptoms
 Sub mucous seen in 5% . Are most symptomatic e.g.
 Asymptomatic therefore an incidental finding.
surface necrosis, polypoid change, infection and
 Menstrual abnormalities – Menorrhagia is the commonest,
degenerations
metrorrhagia, dysmenorrhea
 Cervical fibroid rare seen in 1-2%
 Infertility
Pathology  Lower abdominal pain
The uterus outline maybe smooth or irregular and with a firm  Lower abdominal swelling
or cystic feel. The fibroids (myoma) are surrounded by a  Pressure symptoms
false capsule formed by the compression of myometrium and  Sexual problems – deep dyspareunia, post coital bleeding
separated from the growth by thin loose areolar tissue within or discharge
which blood vessels run. The centre of the tumor consists of
whorls of smooth muscle and connective tissues Clinical examination
 Anemia and clinical manifestations as per severity
Degenerative changes  Palpable abdominal mass – mobile and dull to percussion
 Atrophy usually after menopause  BIMANUAL PELVIC EXAMINATION MANDATORY – uterine
 Necrosis especially sub mucous or pedunculated mass felt
 Fatty
 Cystic Differential diagnosis
 Calcific – Calcium carbonate or phosphonate (womb  Pregnancy
stone )  Pyometra
 Hyaline commonest change seen  Haematometra
 Infective  Lochiometra
 Red necrobiosis – occurs in pregnancy and puerperium  Adenomyosis
 Vascular telangiectasis of vessels or lymphatics  TOM
 Sarcomatous rarely seen 0.1%  Ovarian tumor
Associated endometriosis and adenomyosis is seen in 30% and  Cancer of the uterus, Choriocarcinoma, sarcoma
pelvic infections in 15%
Investigations
Associated changes in the pelvic organs  Ultrasonography
 Uterus – Associated distortion. Myohypoplasia secondary  Endoscopic surgery – Laparoscopy, hysteroscopy
to hyperestrogenism, work hypertrophy.  Hysterosalphingogram – shows evidence of filling defects
 The endometrium can be normal or hyperplasic. In sub and uterine distortions
mucous fibroids may thin and necrotic or infected.  Uterine Curettage – May feel pedunculated fibroids
 The uterine tubes may be distorted, blocked or infected  Plain abdominal X-ray – calcified fibroids seen
(15%).  Intravenous pyelography – shows pelvic mass and renal
 Ovaries maybe congested and multicystic. pathology
 Ureters – distorted anatomy and evidence of  Others: PAP Smear and baseline profile – full H’gm, U/E
hydroureter/ hydronephrosis and secondary
pyelonephritis Treatment principles
 Endometriosis and adenomyosis seen in 30%
Supportive therapy:
Complications of fibroids  Drugs to minimize bleeding
 Anemia  Progestogens
 Urinary problems – retention, infections, renal failure  Danazol
  GnRH analogues
 Androgens
 Management of pain
 NSAIDS
 Opoids
 Correction of anemia
 Treatment of infections

Definitive treatment of fibroids: consider the

symptomatology, size of the growth and the desired fertility
of the patient.

A) Medical treatment include GnRh Analogues

B) Radiological treatment – Uterine artery Embolisation
C) The Surgical approaches available include:
 Endoscopic surgery
 Laparatomy
 Transvaginal surgery – TVH, TVH + laparoscopy

The procedures done include:

 Myomectomy
 Hysterectomy

Complications arising from myomectomy include:

 Recurrence in 5-10%
 Persistent menorrhagia 1-5%
 Relaparatomy in 20 -25 %
 Pregnancy rate of 40 – 50%
 Pregnancy must be delivered in the hospital
 Adhesion formation in the uterus and the pelvis
 Injuries to other pelvic viscera NOTES

Complications arising from hysterectomy

 Hemorrhage
 Sepsis
 Prolapse
 Ureteric injuries
 Post anaesthetic complications
 Psychosocial Sexual dysfunctions
 Persistent pelvic pain (Adhesion s)

Management protocol summarized