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Degeneration

Fibroids Fibroids may undergo atrophy, internal haemorrhage,


Definition fibrosis and calcification.
Benign tumours of the uterus primarily composed of Types of degeneration:
smooth muscle & fibroids connective tissue
leiomyomata (monoclonal). 1. Red degeneration**
Presents with acute abdo pain
Epidemiology Risk factors
Occurs in 20 50% of women >30y.o. o Pregnancy
Most common solid tumour of the female o PCOS
pelvis o Hormone supplement (e.g. OCP, HRT)
In ~85% of cases, fibroids occur in multiples Due to haemorrhagic infarction

Risk factors/Aetiology 2. Hyaline degeneration (~60%)


Focal or generalised hyalinisation
BMI
Advanced maternal age
3. Cystic degeneration (~5%)
Black ethnicity
Fibroid outgrows vascular supply oedema
Exposure to sex hormones (e.g. contraceptive,
HRT)
4. Myxoid degeneration
Hypertension
Filled with gelatinous material
High intake of beef/red meat
Appear as complex cystic masses
Smoking
Can mimic malignant leiomyosarcoma
Pathophysiology
Signs & symptoms
Arise from the myometrial layer of the uterine
Commonly asymptomatic
corpus (intramural)
Irregular firm, central pelvic mass
o Protrudes outward = subserosal
o Protrudes inward = submucous O&G
Symptoms associated with distortion of
endometrial lining more common in Abnormal PV bleed (due to distortion of
submucous endometrial lining most common with
Growth accelerates during pregnancy (due to submucous fibroids)
elevated hormones) Heavy periods (menorrhagia)
Involutes at menopause Infertility
Dyspareunia (if on cervix)
Classification
Space-occupying
1. Intra-uterine
o Subserosal Recurrent 2nd trimester loss
o Intramural (most common) Obstructed labour
o Submucosal (least common) Dysmenorrhoea (obstruction of menstrual
flow)
2. Extra-uterine
Pressure:
o Cervical within the cervix
o Broad ligament located between 2 Bloating
layers of the ligament Pelvic pressure
o Parasitic (likely pedunculated Urinary frequency/urgency
subserosal leiomyoma that twists off Urinary & faecal incontinence
and latches on to adjacent structures, Pedunculated submucous fibroids can dilate
with neo-vascularisation) cervix prolapse into vagina risk of
infection
3. Diffuse uterine leiomyomatosis
Pain: Complication

Acute or chronic pain 2 degeneration Recurrent uterine fibroid growth


Menorrhagia Labour & delivery complications
Dysmenorrhoea Acute torsion
Significant haemorrhage
Bleed:
Anaemia
Abnormal PV bleed Degenerative changes

Diagnosis

Test Findings
Abdominal Heterogenous hypoechoic masses
U/S 1st line +/- cystic areas
Hysteroscopy Direct visualisation of space-
occupying lesions
Laparoscopy + Visualisation of irregular
histology protrusion from uterine
gold standard surface

MRI For evaluation of atypical cases of


pelvic/abdo masses

Gross pathology: firm, round, well-


circumscribed nodules located either:
o Subserosal (under the uterine serosa)
o Intramural (within myometrium)
o Submucosal (just below the
endometrium)

Micropathology: spindle-shaped cells with no


mitotic activity or remarkable nuclear atypia

Management

Conservative: if fibroids are asymptomatic and not


causing any complications, simply monitor for any
changes

Medical (pre-operative adjunct)

Mifepristone
Mirena

Surgical

1st line: myomectomy

The only surgical procedure that preserves


fertility
Complications
o Recurrence
o Haemorrhage

Alternative: UAE (uterine artery embolization)

Definitive: Hysterectomy