Scenario no 1:

34yrs old female, P4+0,

presented with HMB and
dysmenorrhea. On P/V, uterus is
bulky. Most likely diagnosis is
a) Fibroid uterus
b) Adenomyosis
c) Pelvic inflammatory
disease
d) Endometriosis

Scenario no 2:
A

38yrs old female, P1,

presented with HMB and
dyspareunia. Pelvic
examination is tender & a
mass is felt. Most likely
diagnosis is?

Scenario no 3:
A

32yrs old female,

nullipara, presented with
HMB & dysmenorrhea. On
p/v, a mass of 16wks
size felt in midline.
Diagnosis?

Scenario no 4:
A

35yrs old female, M/F

9yrs, P0, presented with
dysmenorrhea &
dyspareunia. On P/V,
uterus is fixed
retroverted. Diagnosis?

Fibroid
uterus
Dr Afsheen Bilal
FCPS II Trainee
PGR III, Unit V

Most

common benign
tumour of female
genital tract
Arise from neoplastic
transformation of single
smooth muscle cells.

Classification:
According

to there location

Submucous
Intramural
Subserosal
Cervical
Others
Pedunculated
Parasitic

Incidence
Clinically.20-30%

of
women during reproductive
life
Hysterectomy
specimens.70%

Risk factors:
Nulliparity
Obesity
Positive

family Hx
Afro-caribbean
race(3-9x)

Protecting factors:
Multiparity
Prolonged

smoking

use of OCPs

Aetiology
Poorly

understood

Alteration

in apoptosis-Bcl-2 increase

Cytogenetic

abnormalities

Abnormalities

in uterine blood vessels

& angiogenic growth factors

Growth

is dependent on sex steroids

Malignant

1:200

transformation is rare

Symptoms:

Aysmptomatic 50%
Menstrual upset-menorrhagia & dysmenorrhea
Abdominal discomfort
Pelvic pressure or backache

CONT
Abdominal

distension
Urinary frequency, difficulty in
micturation, incomplete bladder
emptying or incontinence
Bowel problems
Reproductive dysfunction- difficulty
in conceiving, pregnancy loss, PPH

Diagnosis:
Clinical

exam
USG-TVS first line
MRI

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

20092010

US Images of fibroids

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

20092010

Treatment:
Depends

on the symptoms &

their effects on general
health and lifestyle
Medical
Surgical
UAE

Medical Rx:

GnRH

Agonists.
M/A. Downregulation of pituitary receptors
Formulations.
1 or 3-mon
thly depot injections
Nasal spray
Indications.
Unsuitable for surgery
Prior to surgery with severe anemia

Cont.
Disadvantages.
Fibroids

regrow when Rx stop

Postmenopausal S/E. hot flushes,
vaginal dryness, bone loss
Mask the cleavage b/w fibroid &
surrounding myometrium
Not cost effective

Mirena.if cavity is normal & not enlarged.

Progesterone receptor modulators

Asoprisnil

Surgical Rx:
Hysterectomy.
Uterine

sparing options.

Myomectomy
Abdominal

Laproscopic

Hysteroscopic

Cont
Disadvantages;
Often

multiple fibroids-difficult to
remove them all
Excessive intraoperative blood loss
Emergency hysterectomy may be
required
Difficult to secure hemostasis
Postoperative adhesions formation
Rapture of uterus in labour if cavity
is breached

Endometrial

ablation

Uterine artery
embolization.

Minimally invasive radiological

technique

Procedure. Under conscious sedation,

UAE involves cannulation of femoral
artery with a small plastic tube
which is fed around the aortic arch
through iliac vessels & thereafter
into contralateral internal iliac
artery & corresponding uterine
artery. Polyvinyl alcohol is injected
for embolization under digital
fluoroscopy.

EMBOLIZATION.

Cont....

Daycase procedure or require overnight stay

Opiate analgesia for 24hours

Return to normal activities within 2 weeks

Advantages.

Decrease menstrual blood loss

pts satisfaction rates comparable to hysterectomy

Shorter hospital stay

Short recovery period

Improvement in health related QoL

Preservation of fertility

Cont
Complications.
Groin

injury-haematomainfection
Contrast allergy
Radiation exposure to ovaries
Misembolization
Fibroid expulsion
Persistent vaginal discharge

Cont....
Amenorrhea
Ovarian

failure
Post-embolization
syndrome(10%)
Sepsis(<1%)
Death (rare)
Rx failure- failed cannulation
or regrowth of fibroid

Other Radiological
Techniques:
Laser

ablation of fibroids

Hysteroscopic
Laproscopic
MRI

guided

USG

guided

Take home message;

B/C fibroid is common benign

gynaecological disease which can have
a significant impact on QoL, so new
modalities are being sought for uterine
fibroids & further development of new
treatment options is going on.

EXERCISE

CARE OF ANEMIA