MANAGEMENT OF UTERINE FIBROIDSMANAGEMENT OF UTERINE FIBROIDS

BYBYDr Bennett AriweriokumaDr Bennett AriweriokumaDepartment of O & GDepartment of O & G UPTHUPTH Port HarcourtPort Harcourt

INTRODUCTIONINTRODUCTION

CLINICAL PRESENTATIONCLINICAL PRESENTATION

DEFFRENTIALSDEFFRENTIALS

INVESTIGATIONSINVESTIGATIONS

TREATMENT MODALITIESTREATMENT MODALITIES

COMPLICATIONS COMPLICATIONS

SPECIAL CONDITIONSSPECIAL CONDITIONS

–INTRODUCTIONINTRODUCTIONUterine leiomyomas are benign neoplasia Uterine leiomyomas are benign neoplasia of the uterus commonly refered to as of the uterus commonly refered to as myomas, fibromyomas or fibroids because myomas, fibromyomas or fibroids because of their fibrous character and high of their fibrous character and high collagen content.collagen content.Uterine fibroids are the most common Uterine fibroids are the most common pathologic abnormalities of the female pathologic abnormalities of the female reproductive system. reproductive system.

Not seen before pubertyNot seen before puberty

20-25% of reproductive age group of 20-25% of reproductive age group of womenwomen

3-9x more in blacks than whites.3-9x more in blacks than whites.

In Nigeria 80% of women above 25yrs In Nigeria 80% of women above 25yrs have fibroidshave fibroids

The cause of fibroid remains unknown.The cause of fibroid remains unknown.It can arise from a single cell- monoclonalIt can arise from a single cell- monoclonalFibroids can be single or multipleFibroids can be single or multipleThe transformation from a normal cell to fibroid The transformation from a normal cell to fibroid may be genetic.may be genetic.Paternal genetic up-regulationPaternal genetic up-regulationSomatic genetic mutation, deletion or Somatic genetic mutation, deletion or translocation in chromosome 12q14 -15 and translocation in chromosome 12q14 -15 and 7q22. Such mutations predispose the 7q22. Such mutations predispose the leiomyocyte more sensitive to estrogens and leiomyocyte more sensitive to estrogens and insulin like growth hormones .insulin like growth hormones .

This means that there is familial This means that there is familial inheritanceinheritance

Common in nulliparity but reduces with Common in nulliparity but reduces with pregnancies.pregnancies.

Women weighing >70kg have x3 risk.Women weighing >70kg have x3 risk.

Smoking, COC and progestogens protect Smoking, COC and progestogens protect occurrence of the condition.occurrence of the condition.

The management of fibroid is very important The management of fibroid is very important because there is a growing social trend in because there is a growing social trend in delayed childbearing in developed and delayed childbearing in developed and developing countries.developing countries.

Many women in search of education may Many women in search of education may delay pregnancy until the age of 25 – 30yrs delay pregnancy until the age of 25 – 30yrs and that is the period when the incidence of and that is the period when the incidence of fibroid rises.fibroid rises.

Although women want gynaecological solutions Although women want gynaecological solutions to fibroids they dislike the traditional to fibroids they dislike the traditional myomectomy or hysterectomy.myomectomy or hysterectomy.They prefer minimal access surgery or medical They prefer minimal access surgery or medical treatment to cure the fibroid and also preserve treatment to cure the fibroid and also preserve their fertility.their fertility.It was against this barground that the 3It was against this barground that the 3 rdrd world world congress on controversies in obstetrics, congress on controversies in obstetrics, gynaecology and infertility meeting held in W-DCgynaecology and infertility meeting held in W-DCJune 2002 challenged the traditional surgery June 2002 challenged the traditional surgery and encourage minimal access surgery for the and encourage minimal access surgery for the future. future.

CLINICAL FEATURESCLINICAL FEATURES

Most are asymptomaticMost are asymptomaticSymptomatic present as:- Symptomatic present as:- abdominal massabdominal mass menstrual abnormalitiesmenstrual abnormalities infertility, recurrent abortionsinfertility, recurrent abortions lower abdominal painslower abdominal pains dysmenorrhoeadysmenorrhoeaPressure symptoms on urinary, GIT. Lower limb Pressure symptoms on urinary, GIT. Lower limb

vascular and lymphatic vessels.vascular and lymphatic vessels.

CLINICAL SIGNSCLINICAL SIGNS

Depends on the size, shape and number.Depends on the size, shape and number.

Palpable firm single or multiple fibroid Palpable firm single or multiple fibroid nodules.nodules.

Vaginal exam :-Cx fibroid polyp. Cx fibroidVaginal exam :-Cx fibroid polyp. Cx fibroid

Uterine fibroidsUterine fibroids

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Adenomyosis Adenomyosis PregnancyPregnancy AbortionAbortion Tubo ovarian massTubo ovarian mass Ovarian tumourOvarian tumour Pelvic kidneyPelvic kidney Genetic carcinomasGenetic carcinomas

INVESTIGATIONS:-INVESTIGATIONS:-

FBCFBCURINALYSISURINALYSISULTRASOUND SCANULTRASOUND SCANHSG for submucous fibroid and the state HSG for submucous fibroid and the state of the tubes.of the tubes.Hysteroscopy, laparoscopyHysteroscopy, laparoscopyEUA & Endometrial biopsyEUA & Endometrial biopsyCT SCAN, MRI rarely used.CT SCAN, MRI rarely used.

TREATMENTTREATMENTEXPECTANT EXPECTANT

NON SURGICALNON SURGICAL

- medical- medical

-radiological intervention-radiological intervention

-MINIMAL ACCESS SURGERY-MINIMAL ACCESS SURGERY

Laparoscopic-myolysis, myomectomy with Laparoscopic-myolysis, myomectomy with endoscopic knotting.endoscopic knotting.

hysterospic –myomectomy, endometrial hysterospic –myomectomy, endometrial resection or ablation resection or ablation

SURGERYSURGERY

Myomectomy-abdominalMyomectomy-abdominal

- vaginal- vaginal

Hysterectomy –abdominalHysterectomy –abdominal

- vaginal- vaginal

Low tech uterine artery ligationLow tech uterine artery ligation

- abdominal- abdominal

- vaginal- vaginal

-coagulation of uterine artery-coagulation of uterine artery

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

Age of the patientAge of the patient

Size of the fibroidSize of the fibroid

Severity of the symptomsSeverity of the symptoms

The reproductive desires of the patientThe reproductive desires of the patient

GENERAL TREATMENTGENERAL TREATMENT

Correct anaemia with – haematinics; tablets or Correct anaemia with – haematinics; tablets or parenterallyparenterallyContinuous COC therapyContinuous COC therapy

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENTIndications:-Indications:-Small fibroid 6-8cm in diameterSmall fibroid 6-8cm in diameterFibroid outside endometriumFibroid outside endometriumAsymtomatic fibroidAsymtomatic fibroidMyoma co existing with pregnancyMyoma co existing with pregnancyPost menopuasal womanPost menopuasal woman

FOLLOWUPFOLLOWUPReview patient quarterlyReview patient quarterlyPatient should complete her family Patient should complete her family Postmenopausal should be regularly seenPostmenopausal should be regularly seen

MEDICAL MANAGEMENTMEDICAL MANAGEMENTIndications:-Indications:-A young woman who has symptomatic fibroid but does A young woman who has symptomatic fibroid but does not want surgerynot want surgeryFor elderly women- diagnostic curettage and ablationFor elderly women- diagnostic curettage and ablationDrugs to shrink the fibroidDrugs to shrink the fibroid

DRUGS IN USEDRUGS IN USE

Danazol Danazol (danacrine )-400mg-800mg daily in (danacrine )-400mg-800mg daily in divided doses for 6-9 months.divided doses for 6-9 months.

Suppresses –FSH/LH secretion by the ovaries Suppresses –FSH/LH secretion by the ovaries leading to low estrogen and progesteroneleading to low estrogen and progesterone

Causes endometrial atrophy.Causes endometrial atrophy.

May reduce tumour size.May reduce tumour size.

Side effects:-Increase LDL, decrease HDL, Side effects:-Increase LDL, decrease HDL, weight gain, oedema, reduced breast size, oily weight gain, oedema, reduced breast size, oily skin and hirsutismskin and hirsutism

GnRH AgonistsGnRH Agonists – peptides synthesized by substituting the – peptides synthesized by substituting the 66thth and 10 and 10thth amino acid in the native GnRH molecule to amino acid in the native GnRH molecule to achieve longer action and better binding to receptor site.achieve longer action and better binding to receptor site.It causes flare effect and after the 2It causes flare effect and after the 2ndnd week it down week it down regulates the pituitary leading to low FSH, LH and regulates the pituitary leading to low FSH, LH and oestrogen.oestrogen.When used for 6months tumuor size reduces by 57% When used for 6months tumuor size reduces by 57% with the hope to do surgerywith the hope to do surgerySide effects:- tumour size returns after use.Side effects:- tumour size returns after use.Pseudomenopause, osteoporosis and fracture.Pseudomenopause, osteoporosis and fracture.

MifepristoneMifepristone:-competively interferes with progesterone and oetrogen :-competively interferes with progesterone and oetrogen sites in the nucleus thereby reducing their effect.sites in the nucleus thereby reducing their effect.Given 25mg daily for 3 months.Given 25mg daily for 3 months.It may reduce the fibroid size.It may reduce the fibroid size.

PROGESTOGENS:-PROGESTOGENS:-Gestrinone, depomedroxy progesterone acetate all cause atrophy of Gestrinone, depomedroxy progesterone acetate all cause atrophy of the endometrium and reduce uterine bleeding.the endometrium and reduce uterine bleeding.

LNG-IUCDLNG-IUCD atrophies the endometrium and inhibits the insulin like atrophies the endometrium and inhibits the insulin like growth hormones thereby reduces the fibroid.growth hormones thereby reduces the fibroid.

FadrosoleFadrosole which is an an aromatase inhibitor blocks the conversion of which is an an aromatase inhibitor blocks the conversion of testosterone to oestrogen.testosterone to oestrogen.

GENE GENE therapy:- Still exprimental.therapy:- Still exprimental.

RADIOLOGICAL INTERVENTION THERAPYRADIOLOGICAL INTERVENTION THERAPY(uterine artery embolizattion)(uterine artery embolizattion)

It uses poly vinyl particles via a catheter through It uses poly vinyl particles via a catheter through the femoral artrery to selectively occlude the the femoral artrery to selectively occlude the uterine artery in order to cause ischaemic uterine artery in order to cause ischaemic necrosis of the fibroid.necrosis of the fibroid.Can be used for fibroid size <24wks and those Can be used for fibroid size <24wks and those who reject hysterectomy.who reject hysterectomy.Not used for pedunculated or infected fibroid.Not used for pedunculated or infected fibroid.Menorrhagia is rapidly reduced.Menorrhagia is rapidly reduced.

ComplicationsComplications

Allergy to contrast mediumAllergy to contrast medium

Haematoma and trauma to femoral arteryHaematoma and trauma to femoral artery

Ischaemia and ovarian failureIschaemia and ovarian failure

InfectionInfection

Damage to endometrial vasculature & Damage to endometrial vasculature & synaechiasynaechia

Maybe larger and more spherical particles Maybe larger and more spherical particles may reduce the complications.may reduce the complications.

IMPACT ON FERTILITY OF NON IMPACT ON FERTILITY OF NON SURGICAL PROCEDURESSURGICAL PROCEDURES

Literature review from Dec 2002 -2004 on current Literature review from Dec 2002 -2004 on current opinion in obstetrics and gynaecology states that:-opinion in obstetrics and gynaecology states that:- A large randomised trial showed that pre operative A large randomised trial showed that pre operative treatment with GnRH agonist did not improve surgicaltreatment with GnRH agonist did not improve surgical

result or blood loss.result or blood loss. In general non surgical therapy do not enhance In general non surgical therapy do not enhance fertility as they cause anovulatory cycles.fertility as they cause anovulatory cycles. Few data exist as regards the course of pregnancy Few data exist as regards the course of pregnancy and outcome following embolizationand outcome following embolization Therefore non surgical therapy is experimental for Therefore non surgical therapy is experimental for those who need pregnancy but beneficial to those who those who need pregnancy but beneficial to those who do not desire pregnancy do not desire pregnancy

TYPES OF SURGERYTYPES OF SURGERY

Myomectomy:- this involves the Myomectomy:- this involves the enucleation of myomas from the uterus .enucleation of myomas from the uterus .

Indications:-Indications:-

Fibroid polypFibroid polyp

Symptomatic fibroid in a patient who Symptomatic fibroid in a patient who desires to conserve her reproductive and desires to conserve her reproductive and menstrual functionmenstrual function

A Fibroid polyp that prolapses throughA Fibroid polyp that prolapses through

the cervix with a thin pedicle can be twisted the cervix with a thin pedicle can be twisted and avulsed in theatre.and avulsed in theatre.

Vaginal myomectomyVaginal myomectomy

A Fibroid polyp with a wide base: the A Fibroid polyp with a wide base: the cervico vaginal mucosa can be reflected cervico vaginal mucosa can be reflected for the myomectomy to be done. The for the myomectomy to be done. The wound is closed in two layers.wound is closed in two layers.

ABDOMINAL MYOMECTOMYABDOMINAL MYOMECTOMY

This is full laparatomyThis is full laparatomyDouble consent should be obtained from the patientDouble consent should be obtained from the patient

Techniques to reduce blood lossTechniques to reduce blood lossPre operationPre operation:-:-Surgery done in the proliferative phase of menstruation Surgery done in the proliferative phase of menstruation period.period.Haemodilution with normal saline, autologous blood Haemodilution with normal saline, autologous blood transfusion, use of 200ug misoprostol intravaginally 1 transfusion, use of 200ug misoprostol intravaginally 1 hour before surgeryhour before surgeryIntraoperativelyIntraoperatively:-:-Hypotensive anaesthesiaHypotensive anaesthesia

Application of rubber tourniquet at the anterior posterior Application of rubber tourniquet at the anterior posterior lower uterine isthmus occluding the uterine vessels for lower uterine isthmus occluding the uterine vessels for 40 – 45mins40 – 45minsSmaller rubber tourniquet is applied lateral to each Smaller rubber tourniquet is applied lateral to each ovary to occlude the vessels. Bonneys clamp can be ovary to occlude the vessels. Bonneys clamp can be usedusedDiluted vasopressin into the superficial myometrium and Diluted vasopressin into the superficial myometrium and the overlying serosathe overlying serosaUse of laser for the incisionUse of laser for the incisionFast surgeryFast surgeryFew incisions preferably at the anterior midlineFew incisions preferably at the anterior midlineUse one incision to remove as many fibroid nodules as Use one incision to remove as many fibroid nodules as possiblepossible

PREVENTION OF ADHESIONSPREVENTION OF ADHESIONS

Application of bonney’s hoodApplication of bonney’s hood

Reduce number incisionsReduce number incisions

Cover uterine surface with cellulose materialCover uterine surface with cellulose material

Wash off all blood clotsWash off all blood clots

instill into peritoneal cavity some normal saline instill into peritoneal cavity some normal saline or dextran 70or dextran 70

Insert a drainInsert a drain

POST OPERATIVE TREATMENTPOST OPERATIVE TREATMENTNil orally , I.V. fliuds until bowel sounds are Nil orally , I.V. fliuds until bowel sounds are establishedestablished

AnalgesicsAnalgesics

AntibioticsAntibiotics

Urethral catheter for 24 hours Urethral catheter for 24 hours

Blood transfusion where necessaryBlood transfusion where necessary

Stitches out on the 7Stitches out on the 7thth or 8 or 8thth post op day’ post op day’

Follow up in two weeks Follow up in two weeks

ComplicationsComplications

HaemorrhageHaemorrhage

Trauma to bladder, GIT, UretersTrauma to bladder, GIT, Ureters

InfectionsInfections

AdhesionsAdhesions

InfertilityInfertility

RecurrenceRecurrence

Rupture scar during labour if the uterine Rupture scar during labour if the uterine cavity was bridged during the myomectomycavity was bridged during the myomectomy

ABDOMINAL HYSTERECTOMYABDOMINAL HYSTERECTOMY

IndicationsIndications:-:-

Huge uterine fibroid > 24wksHuge uterine fibroid > 24wks

Patient who has completed her family with Patient who has completed her family with symptomatic fibroidsymptomatic fibroid

Recurrent symptomatic fibroidsRecurrent symptomatic fibroids

Rapidly growing fibroid in the menopausal Rapidly growing fibroid in the menopausal periodperiod

Fibroids with recurrent PIDFibroids with recurrent PID

PRE OPERATIVE PREPARATIONPRE OPERATIVE PREPARATION

Counsel patient and obtain consentCounsel patient and obtain consent

FBCFBC

URINALYSISURINALYSIS

E/UE/U

PAP SMEARPAP SMEAR

ECG FOR THOSE > 50yrsECG FOR THOSE > 50yrs

ENDOMETRIAL BIOPSYENDOMETRIAL BIOPSY

OBESE PATIENT TO REDUCE WEIGHTOBESE PATIENT TO REDUCE WEIGHT

ANAESTHESIA :- Could be spinal or generalANAESTHESIA :- Could be spinal or generalClean vagina and cervix with antiseptic solution, then paint Clean vagina and cervix with antiseptic solution, then paint with methylene blue with methylene blue Pass self retaining urethral catheterPass self retaining urethral catheterClean anterior abdominal wall with antisepticClean anterior abdominal wall with antisepticSurgerySurgeryPOST OP RXPOST OP RXAdequate fluidsAdequate fluidsAnalgesicAnalgesicUrethral catheter out >24 hoursUrethral catheter out >24 hoursOral sips when bowel sounds returnOral sips when bowel sounds returnOpen wound 5Open wound 5thth day, stitches out on 7 day, stitches out on 7thth -9 -9thth day post op day post op

COMPLICATIONSCOMPLICATIONS

Anaesthetic complicationsAnaesthetic complicationsHaemorrhage intra-operatively, post – operatively, Haemorrhage intra-operatively, post – operatively, reactionary and secondaryreactionary and secondaryCuff haematomaCuff haematoma

INJURIESINJURIESBladder- VVFBladder- VVFUreters –transection ,ligation, crushing and kinking. Ureters –transection ,ligation, crushing and kinking. Uretero-vaginal fistulaUretero-vaginal fistulaInfectionInfectionWound dehiscenceWound dehiscencePelvic adhesion and intestinal obstructionPelvic adhesion and intestinal obstructionDeep vein thrombosisDeep vein thrombosis

VAGINAL HYSTERCTOMYVAGINAL HYSTERCTOMY

Indications:Indications:same as for abdominal hysterectomy but the same as for abdominal hysterectomy but the size of the fibroid should be < 12wkssize of the fibroid should be < 12wks

CAESAREAN MYOMECTOMYCAESAREAN MYOMECTOMYShould be avoided as much as possibleShould be avoided as much as possibleHowever may be done if leiomyoma is along the However may be done if leiomyoma is along the line of incisionline of incisionBleeding is more but not statistically significantBleeding is more but not statistically significantThere should be some pints of blood availableThere should be some pints of blood available

MYOMECTOMY AND IVFMYOMECTOMY AND IVF

For submucuos fibroid, myomectomy should For submucuos fibroid, myomectomy should be done first.be done first.

For others, IVF first.For others, IVF first.

CONCLUSIONCONCLUSIONThe treatment of uterine fibroid has been The treatment of uterine fibroid has been very dynamic in recent times in order to very dynamic in recent times in order to cope with the trend of social needs of cope with the trend of social needs of women in the reproductive age group.women in the reproductive age group.The non surgical procedures are The non surgical procedures are experimental in women that have not experimental in women that have not completed their families but may be useful completed their families but may be useful for those that have completed their for those that have completed their families and are scared of any major families and are scared of any major surgery. surgery.