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Uterine Fibroids

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Uterine Fibroids. Fibroids. Synonyms : Myoma, Leiomyoma, Fibromyoma Most common benign neoplasm in uterus and female pelvis Incidence : 20 to 40% of reproductive age women. Epidemiological risk factors. Increased risk. Decreased risk. ↑↑ parity E xercise ↑↑intake of green vegetables - PowerPoint PPT Presentation

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Uterine Fibroids

FibroidsSynonyms : Myoma, Leiomyoma, FibromyomaMost common benign neoplasm in uterus and female pelvisIncidence : 20 to 40% of reproductive age womenEpidemiological risk factorsIncreased risk Increased risk Age 35 to 45 years nulliparous or low parity Black women strong family historyObesity early Menarche Diabetes hypertensionDecreased risk parity Exercise intake of green vegetables Progesterone only contraceptives Cigarette smokingEtiology It arises from smooth muscle cells of myometriumExact etiology not known Monoclonal origin ( arising from single cell) confirmed by G6PD studies Genetic basis definiteVarious growth factors like TGF , EGF, IGF-1, IGF-2, BFGF are recently implicated in the development of fibroidsFibroid - Etiology Genetic basis: Responsible for 40 % cases of fibroids Translocation between Chromosome 12 & 14 Trisomy 12 Rearrangement of short arm of Chromo 6 Rearrangement of long arm of Ch. 10Deletion of Ch.3 or Ch.7q Fibroid - Etiology Estrogen although not proved for causing myoma, is definitely implicated in its growth Uncommon before puberty & regress after menopauseHigher incidence in nulliparous womenCommon in obese womenMay increase during pregnancyStudies show high concentrations of estrogen receptors in leiomyoma than myometriumCommon in fifth decade due to anovulatory cycles with high or unopposed estrogenTypes of FibroidsMore common in uterine corpus, less common in cervixAll fibroids are interstitial to begin with and then enlargeMay remain intramural, become subserosal or submucosalSubserosal may become pedunculated & occassionally parasitic receiving blood from other organs usually omentumSubmucous fibroid may become pedunculated and present in the vagina through the cervixLarge submucous fibroid may pull down the cervix resulting in chronic inversion

Classification of Fibroids

Fibroid Pathology Gross appearance- Multiple, discrete, spherical, pinkish white, firm capsulated masses protruding from surrounding myometrium. Pseudo capsule is made up of compressed myometrium giving it a distinct outlineMicroscopy- nonstriated muscle fibres are arranged in interlacing bundles of varying size & running in different directions (whorled appearance). Varying amount of connective tissue is intermixed with smooth muscle fibres Fibroid Pathological variantsMicroscopic variants Cellular myoma, mitotically active myoma, bizarre myoma, lipoleiomyoma, Intravenous leiomyomatosisLPD leiomyomatosis peritonealis dissemination Secondary changes- Hyaline, calcific, necrosis, red degeneration during pregnancy, fatty degenerationLeiomyosarcoma- 0.49-0.79%, more common in the 5th decade, diagnosed with presence of mitotic figuresClinical presentation- Asymptomatic- most common Abnormal uterine bleeding 30-50% of patients . It is due to surface area, vascularity, thinning and ulceration of overlying myometrium, endometrial hyperplasia, venous obstruction, interference with contractions. More common with submucosal but may occur with all typesAnemia due to excessive blood lossPelvic pain in 1/3rd patients, backache. Acute pain due to torsion, infection, expulsion, red degeneration, vascular complication Dysmenorrhoea Spasmodic as well as congestive

11Clinical presentation- Pressure symptoms Lump in abdomen Urinary symptoms- urgency, frequency, incontinence, rarely urethral obstruction Bowel symptoms- constipation, intermittent intestinal obstruction- Abdominal distention- with large fibroidsRapid growth- with pregnancy and malignancyInfertility 2 to 10 % cases- Anovulatory, irregular cavity interfering with sperm transport, endometrial changes* Rare symptoms : Ascites, polycythemia Effects of fibroid on pregnancy :Pregnancy : Abortion Pressure symptoms Malpresentation Retrodisplacement of uterusLabour : Preterm labour Malpresentation Uterine inertia PPH Dystocia MRPPuerperium : Subinvolution Sec. PPH Puerperal sepsis Inversion Effects of pregnancy on fibroid :Increase in size & softening occurs . Increase occurs mainly in the 1st trimester & in 22 to 32 % cases.Red degeneration in 2nd trimester due to rapid growth there is congestion with interstitial hemorrhage & venous thrombosis Impaction in pelvisTorsionInfectionExpulsionInjury- Pressure necrosis during deliveryRupture of subserous vein Internal hemorrhageFibroid - SignsGeneral examination Anemia due to prolonged heavy bleeding . P/A If > 12 weeks size , firm, nodular, arising from pelvis, lower limit cant be reached, relatively well defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen P/S Cervix pulled higher up P/V Uterus enlarged, nodular. D/D from ovarian tumour Uterus not separately felt , transmitted movement present, notch not felt. P/R May help in difficult cases .Fibroid - Diagnosis InvestigationsUSG : Well defined hypoechoic lesions. Peripheral calcification with distal shadowing in old fibroids Adenomyosis is differentiated by diffuse lesion, less echodense , disordered echogenicity & more prominent at or just after menstruation Hysteroscopy : Submucous fibroidsSaline infusion sonography- help differentiate submucous from intramural fibroids

16Fibroid USG

Fibroid Diagnosis MRI : Most accurate imaging modality for diagnosis of fibroid. It does precise fibroid mapping & characterization Detects all fibroids accurately D/D from adenomyosis D/D from adnexal pathology Ovaries are easily seen Detects small myomas(0.5 cm) H S G : Not done for diagnosis. Done for infertility evaluation filling defects may be seen.Fibroid MRI

Fibroid MRI

Fibroid D/DPregnancyAdenomyosisOvarian tumourEctopic pregnancyEndometriosisT O massFibroid- ManagementExpectant : asymptomatic incidental fibroids Size < 12 weeks, nearing menopause Regular follow up every 6 monthsRoutine pelvic examinationBaseline imaging to compare regression

Medical ManagementNot a definitive treatmentFor symptomatic relief from pain- NSAIDsAlso decrease menstrual blood lossPreoperatively to decrease the sizeDrugs used:Progestogens, antiprogestogens(Mifepristone), androgens ( Danazol, Gestrinone) & GnRH analogues are usedGnRH analogues GnRH Agonists are commonly used drugs :-Triptorelin (Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline (Zoladex) 3.6 mg SC for 3 monthsAdvantages : Decrease in size of myoma by 20 to 50 % Decrease in bleeding increases Hb level Decreases blood loss during surgery Converts hysterectomy into myomectomy Converts Abd. hyst into vag. hysterectomy Makes hysterectomic resection possible GnRH analoguesDisadvantages : High cost Hypoestrogenic side effects- medical menopause Effect is reversible Rarely bleeding due to degeneration Occasionally difficulty in enucleationAntagonist Cetrorelix is used 60 mg I/M repeated after 3-4 months if necessary Initial flare up does not occur Decrease volume of fibroid Medical - Newer Therapy SERM Raloxifen60 mg /day is tried for 6 to 12 mths.Higher doses ( 180 mg) are required for effective decrease in size.Better if combined with GnRH analogsMedical - Newer Therapy SPRM Asoprisnil (Selective Progesterone Receptor Modulator)5 to 25 mg/day is usedMechanism of inhibitory action is not knownPossible risk of endometrial hyperplasia is not studiedMedical - Newer Therapy Mifepristone 5 10 mg is tried No loss of bone densityPromising results Decrease in myoma volume by 26-74 %.No effect on bone densityEndometrial hyperplasia may limit its longterm use. Medical - Newer Therapy Aromatase inhibitorsDirectly inhibit estrogen synthesis & rapidly produce hypoestrogenic state Fadrozole/ Letrozole is tried in couple of studies71 % reduction occurred in 8 weeksAppears to be promising therapyMedical - Newer TherapyProgesterone releasing IUD- LNG-IUDFibroids with uterus

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