Uterine Fibroids

By: Fatima Choudary

05/02/13
















The Womb most of us know it as the Uterus and all of us are aware of its
existence. As Nora Roberts the screenplay writer (best known for Sleepless in
Seattle and When Harry Met Sally) says: We lived through an era when happiness
was a warm puppy, and the era when happiness was a dry martini, and now we
have come to the era when happiness is knowing what your uterus looks like. My
presentation today is about uterine fibroids, but I wanted to briefly go through the
anatomy of the normal uterus so that we can better understand the pathology
associated.
So the Uterus is a major female, hormone-responsive reproductive sex organ.
Looking at it from outside to in you first have the Cervix uteri, aka the neck of the
uterus: This is composed of the external orifice of the uterus, the canal of the Cervix
and the Internal orifice of the Uterus. Then you have the Corpus Uteri this is the
body of the Uterus and it consists of the Cavity of the body of the uterus and the
Fundus.
Next we look at the layers of the Uterus. There are three main layers that
comprise the uterus. The Endometrium, myometrium and perimetrium.
The Endometrium is the innermost layer of the uterus. It itself has the
functional endometrium and basal endometrium. Any damage that occurs to the
basal endometrium causes Ashermans Syndrome, which are adhesions and or
fibrosis in the endometrium. The endometrium is the layer that builds up and then
sheds on a monthly basis when no fertilization occurs.
The Myometrium consists of mainly smooth muscle. The innermost layer of
the myometrium is known as the junctional zone; if this part thickens it causes
Adenomyosis. This is also the layer that fibroids originate from.
Last but not least the perimetrium is the smooth connective tissue that
surrounds the uterus.
Now to move on to the topic of discussion, Uterine Fibroids aka
Leiomyomas. This is a benign noncancerous tumor that arises from the smooth
muscle layer (the myometrium) of the uterus. It is the most frequently diagnosed
gynecologic tumor and the leading cause of hysterectomy in the US. It occurs in 20-
50% of women greater than the age of 30 and is more common in blacks than
whites. Leiomyomas are estrogen sensitive tumors so the tumor size increases
during pregnancy and decreases with menopause. It is important to remember
however that leiomyoma is not a precursor to Leiomyosarcoma (the malignant
tumor of the uterus). They can undergo Undergo: Degeneration, Dystrophic
calcification and Hyalinization, which is the reason for the term fibroids. Small
leiomyomas are symptomatic if located within the uterine cavity, whereas large
leiomyomas usually go unnoticed and are located outside the uterus.
The risk factors associated with Leiomyomas are the following: African
American decent, Nulliparity, Obesity, PCOS, Diabetes and Hypertension.
The symptoms that a leiomyoma causes depend on the size and location: The
most common symptom it can cause is menorrhagia when located in the submucosa.
It can also cause painful menstruation, painful sexual intercourse, it can put
pressure on bladder leading to frequency, urgency and incontinence, It can cause
abnormal gynecologic hemorrhage, miscarriages, abdominal discomfort or bloating.
It can put pressure on the colon causing constipation and painful defecation, it can
cause backaches and in some cases infertility. Although infertility only accounts for
3% of cases and in such cases a fibroid is located in the submucosal position and it is
thought that this location may interfere with the functioning of the lining and the
ability of the embryo to implant.
There are different locations that fibroids can occur, and they are named
according to their site of occurrence. You can have Submucosal Fibroids, Intramural
Fibroids, Subserosal Fibroids, Pedunculated Fibroids and Extrauterine fibroids.
Submucosal Fibroids are primarily found on the endometrial side of the
uterus and can protrude into the uterine cavity. They are usually found in muscle
beneath the endometrium of the uterus. They can distort the uterine cavity. It is a
small lesion, which may lead to bleeding and infertility. It can also prolapse through
cervix, leading to labor-like uterine contractions.
Intramural Fibroids are the most common type. They are primarily located in
the uterine muscle. They begin as small nodules in the muscular wall of the uterus
and may expand inwards and cause distortions and elongation of the uterine cavity.
Subserosal Fibroids occur primarily on the outside of the uterus, on the
serosal surface. They are located underneath the mucosal (peritoneal) surface of the
uterus. They can become very large and can grow out into a papillary manner to
become pedunculated growths. Subserosal fibroids can detach from the uterus and
become parasitic leiomyomata.
Pedunculated Fibroids are intra-cavitary fibroids located on the stalk and
they can be passed through the cervix.
Extrauterine fibroids (aka parasitic myomas.) They are located in other parts
of the body and are related to or identical to metastasizing leiomyoma.
Fibroids can undergo carneous degeneration, which are changes of the
leiomyomata due to rapid growth. This is when the center of the fibroid becomes
red, causing pain. It is synonymous with red degeneration.
The pathophysiology of Fibroids is unknown but it is hypothesized that it may be
due to an increased endometrial surface area or, disruption of hemostatic
mechanisms during menses. Another speculated explanation is ulceration of the
submucosal fibroid surfaces.
The Diagnosis can be made using one of the many following techniques. On
Physical examination you would notice an irregular pelvic mass that is mobile,
midline and moves contiguously with the cervix. Then you can use procedures such
as Transabdominal Ultrasound, a transvaginal Ultrasound, an MRI, a
Hysterosalpingography or Sonohysterography.
Picture of a normal transabdominal ultrasound, the abnormal showing a
posterior uterine fibroid
Picture of normal transvaginal ultrasound, the abnormal showing an intramural
myoma.
An MRI
A Hysterosalpingography is a radiologic procedure done to investigate the shape
of the uterine cavity and the shape and the patency of the fallopian tubes. It is
usually done with radiographic contrast medium dye, which is injected into the
uterine cavity through the vagina and cervix. If the fallopian tubes are open, it can
fill the tubes and spill out into the abdominal cavity. It can be painful so analgesics
can be administered before and/or after the procedure
A Sonohysterography also known as a Gynecologic hysterography or gynecologic
sonography. It is the application of a medical ultrasonography to the female pelvic
organs such as Uterus, ovaries, Fallopian tubes, as well as the bladder. It can be
performed transabdominally with a full bladder (which acts as an acoustic window
to give better visualization of pelvic organs) or, Transvaginally with specifically
designed vaginal transducer. Transvaginal imaging uses a higher frequency imaging
so it gives a better resolution of the ovaries, uterus and endometrium.
Differential Diagnosis includes: Ovarian masses, Tubo-ovarian masses, Pelvic
kidney and Endometrioma
Histologically the tumor cells resemble elongated, spindle-shaped cells with a
cigar-shaped nucleus and form bundles in different directions, which results in the
whorled pattern. An appearance of prominent nucleoli with perinuclear halos
should alert the pathologist to investigate possibility of Hereditary Leiomyomatosis
and Renal Cell Carcinoma.
Treatment: Many uterine fibroids are asymptomatic and only need to be
monitored. Very rarely do uterine leiomyomata degenerate into leiomyosarcoma.
Medication can be given to control symptoms, for example for pain you can give
NSAIDs. Medications may be prescribed to shrink tumors like GnRH agonists such as
Danazol, but often once you stop the treatment the tumors regrow to pretreatment
size thus GnRH agonist therapy is reserved for tumor shrinkage or correction of
anemia prior to operative treatment. A Hysterectomy can be performed for
symptomatic fibroids when future pregnancy is undesired. A Myomectomy for
women who still desire children and last but not least uterine artery embolization.
Uterine Artery Embolization is a technique performed by cannulizing the
femoral artery and catheterizing both uterine arteries directly and infusing
embolization particles that preferentially float to the fibroid vessels. This causes
fibroid infarction and subsequent hyalinization and fibrosis. Initial studies with
follow-up over 5 years shows symptom relief for approximately 75% of women.
However this intervention shouldntt be used in women who want to get pregnant
in the future because there is an increased risk of placentation abnormalities.
This concludes my presentation, just one more quote before I end by Ina May
Gaskin: There is no other organ quite like the uterus. If men had such an organ they
would brag about it. So should we











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