FIBROMYOMAS

Defn: Benign, uterine neoplasms, arises from the myometrium, primarily

composed of smooth muscle

These are also called leiomyomas , fibroids or myomas.

Generally benign and found in upto 20% of women in the reproductive age group.

etiology

1.25-50% has genetic abnormality,

2.hormone-dependent tumors- estrogen dependent Evidence ： Occurs in reproductive age. Fibroids growing faster during pregnancy. After the onset of menopause, uterine fibroids stop

growing and even atrophy. the estrogen receptors and progesterone receptors

in Uterine fibroid tissue are higher than normal.

3. derived from smooth muscle cells.

4.rarely found before puberty. 5.progesterone inhibits the growth .

Anatomy-1.A typical myoma is a well circumscribed tumour with

a pseudocapsule.2.Firm in consistency . 3.Cut surface – is pinkish white and has a whorled

appearance . 4.Blood vessels – lies in the capsule.

(Central portion of the tumour receives least blood supply leading to early degeneration in this part of the tumour).

5.Calcification – begins at the periphery . 6.Microscopically – consists of bundles of plain

muscle cells , seperated by fibrous strands .

Types-

1.Intramural or interstitial – 75% , tumour grow symmetrically , within the myometrial wall . 2.Subserous – 10% , tumour grows out wards, towards the peritoneal surface . – Subserous

– Pedunculated subserous (abdominal)

– parasitic

– Intraligamentous

3.submucous- 15% , myoma lying towards cavity of uterus , covered by thin endometrium .

-either submucosal, pedunculated submucosal or pedunculated vaginal

Unusual form of myomas – Intra-venous myomatosis , with polypoid projections

into the veins of the parametrium and broad ligaments .

These appear worm-like cords , when pulled out of the veins .

Fragments of tumour emboli can cause sudden death ( due to obstruction of blood flow from the atrium).

Majority of myomas arise in the uterus . But may also arise from round ligament ,

uterovarian and uterosacral ligaments , the vagina and the vulva .

The intramural and subserous myomas may be single or multiple , varying in size .

The submucous , cervical and broad ligament myomas are usually single.

SECONDARY CHANGES –Degenerations –1.Atrophy –a. shrinkage in size of the tumour

after menopause , due to diminished vascularity .

b. Becomes firmer . 2.Calcareous degeneration –Starts in the periphery along the course of vessels .

( phosphates and carbonates of lime are deposited ).Best example of calcareous myomas are – in old

patients with long standing myomas (found as womb – stones by radiography).

3. Red degeneration –a. This complication of uterine myomas

develops during pregnancy . b. Causes severe abdominal pain – myoma

becomes tense and tender . c. Tumour becomes purple red colour

Cystic degeneration

Red degeneration

e. Develops fishy odour f. Patient is febrile . Needs to be differentiated from – appendicitis ,

twisted ovarian cyst , pyelitis and accidental haemorrhage .

Diagnosed by- ultrasound.

Ovarian tumour

4.Sarcomatous change –a. Extremely rare . ( 0.5 % of all myomas)b. Intramural and submucous tumours have higher

potential for sarcomatous change than subserous tumour.

c. Rare under the age of 40 d. Mostly found in post menopausal women suddenly ,

causing pain and post menopausal bleeding .

sarcoma

e. It is yellowish grey in colour . f. Consistency is soft and friable , not firm like a

simple myoma . g. Non-encapsulation of tumour . h. Sarcoma is highly malignant and spreads via

blood stream .

Other complications of myomas –1.Torsion – subserous pedunculated myoma may

undergo torsion . - severe abdominal pain because of torsion . 2. Inversion – uterus is turned inside out . caused by submucous fundal myoma. women complains of lower abdominal pain

and irregular bleeding.

Ultrasound confirms inversion . 3. Capsular haemorrhage –Due to rupture of large veins on the surface of a

subserous myoma 4. Infection –Common in submucous and myomatous polypi

if they project into cervical canal/vagina , causing purulent ,

blood-stained discharge.5.Associated endometrial carcinoma –Found with myoma in women over 40 years age

in 3% cases .SYMPTOMS-1.menorrhagia , polymenorrhoea, metrorrhagia

– in intra-mural and submucous myoma

2.Infertility , recurrent abortions – due to associated PID , endometriosis ,

Submucous myoma is responsible for recurrent pregnancy loss .

3.pain- heaviness in lower abdomen , acute pain in torsion , haemorrhage and red degeneration .

In elderly women – may be sarcoma .

4. Abdominal lump- Large myoma may be observed as an abdominal

tumour growing for a long time.Rapid growth occurs only during pregnancy , on

OCP , malignancy .

5.Pressure symptoms – frequency and retention of urine more often premenstrually .

Constipation is rare . 6.Vaginal discharge.50% women are asymptomatic. Myomas are

detected during ultrasonography.

Signs-1.Anaemia 2.Abdominal lump – arising from pelvis , well

defined margins , firm in consistency and having smooth surface.

tumour is mobile from side to side .

Differential diagnosis-1.Pregnancy2.Haematometra 3.Adenomyosis4.Bicornuate uterus5.Endometriosis , chocolate cyst6.Ectopic pregnancy7.Chronic PID8.Benign/malignant ovarian tumour

9.Endometrial cancer 10.Myomatous polyp 11.Chronic inversion of uterus 12.Pelvic kidney

INVESTIGATIONS-1.Hb, blood group 2.USG- a well defined rounded tumour ,

hypoechoic with cystic space if degeneration has occurred .

3.Hysterosalpingography – confirms submucous myoma and checks the patency of fallopian tubes in infertility.

4.Hysteroscopy – recognizes submucous polyp , excision is made under direct vision .

5.D/C - is required to rule out endometrial cancer .

6.Laparoscopy – in inversion of uterus while excising a myomatous polyp .

TREATMENT-Small and asymptomatic myomas need no treatment , observe

every 6 months .Indications for treatment –1.Infertility 2.Symptomatic myomas 3.Rapid growth of myomas in menopausal women 4.When nature of tumour cannot be ascertained clinically .

Medical treatment-1.Iron therapy – for anaemia 2.Drugs to control menorrhagia – Danazol 400-

800 mg daily for 3-6 months. Ru 486 (mifepristone ).50mg daily for 3 months . Treatment is costly and only advocated in young

women .

Surgery-1.Myomectomy – in infertile/desirous of child

bearing . Myomectomy should be performed in pre

ovulatory menstrual cycle to reduce blood loss during surgery .

Complications of myomectomy-1.Haemorrhage – primary / reactionary /

secondary .2.trauma- to the bladder , ureter and bowel

during surgery 3.Infection 4.Adhesions/intestinal obstruction 5.Recurrence of myomas .

Hysterectomy – is indicated in women over 40 , multiparous women or associated with malignancy.

Complications of hysterectomy- 1.Haemorrhage – primary , reactionary and

secondary.2.Trauma- to bladder and bowel . 3.Sepsis.

4.Anaesthetic complications . 5.Paralytic ileus , intestinal obstruction due to

adhesion . 6.Thrombosis- pulmonary embolism

Family planning –Avoid OCP , IUCD Choose barrier method.

Treatment of sarcoma uterus – 1.Total hysterectomy with bilateral salpingo-

oophorectomy , followed by a full course of radiation therapy .

2.Radical hysterectomy with bilateral lymph node excision , followed by radiation therapy – if the growth is in the region of isthmus or cervix .

5 year cure rate is under 30% Presence of distant metastases is contraindication to

surgery .Radiotherapy is ineffective in distant metastases .Chemotherapy is the only choice – combination of

cyclophosphamide , vincristine , doxorubicin and actinomycin .