UTERINE FIBROIDS (LEIOMYOMATAS)

• Smooth Muscle Tumor of the Uterus

• The most common uterine tumor

– Occurring in about 30% of women above the age of 30 years.

• Occurs up to 75% of hysterectomy specimens

• Symptomatic in 1/3 of cases

What are they?

Patient Characteristics• Age:

– 30-40 years.

– Rare before 30 or after 40 years

• Parity: – Common in nulliparas, patients with low parity.

– It is rare in multiparas.

• Race: – 3-9 times more common in negroids.

• Family history: – Usually positive.

• Hyper-estrenemia: – Estrogen receptors (ER) more than the surrounding myometrium but less

than those in the endometrium• Common in low parity.

• Atrophies and shrinks after menopause.

• Common association with other hyper-estrenic conditions as endometriosis, endometrial hyperplasia and endometrial carcinoma.

Fibroids

Uterine [99%] Extrauterine [1%]

Corporeal [95%] Cervical [4%]

Interstitial [60%]

Submucous [ 20%]

Subserous [15%]

Genital Extragenital

Parasitic Fibroid

Others

[15%]

[20%]

[60%]

Submucous leiomyomaPedunculatedsubmucousIntramural or interstitialSubserous or subperitonealPedunculatedabdominalParasiticIntraligmentaryCervical

Signs of fibroid

• General examination:

– signs of chronic anemia.

• Abdominal examination:

– large pelvi-abdominal swelling in huge fibroids.

• Pelvic examination:

– symmetrically or asymmetrically enlarged uterus.

• Speculum examination

– fibroid polyp.

Differential Diagnosis• Causes of symmetrically enlarged uterus:

– Pregnancy– Subinvolution of the uterus.– Submucous or interstitial fibroid.– Metropathia hemorrhagica.– Adenomyosis uteri.– Carcinoma or sarcoma of the uterus.– Pyo, hemato, or physometra.

• Causes of asymmetrically enlarged uterus:– Subserous fibroid.– Localized adenomyosis.– Ovarian, tubal, or broad ligamentary swelling.– Pregnancy in a rudimentary horn.

Management

• Conservative Management

– small asymptomatic fibroid,

– fibroid in pregnancy or puerperium.

• Just keep observation every 6 months.

• Beware of underlying and/or associated pathology

Medical Treatment:

• Pre-operative till the time of surgery.

• Patient near the menopause, or newly married with minimal symptoms.

• Red degeneration with pregnancy.

• Lines of treatment:– Symptomatic:

• Correction of anemia,

• haemostatics,

• analgesics, and anti-spasmodics (anti-PG).

– Anti-estrogens: • large dose of progesterone,

• Tamoxifen, Danazol,

• LH-RH analogues – useful in decreasing the size and vascularity of the tumor by 50%

which is beneficial before myomectomy

Surgical Management

Myomectomy vs. Hysterectomy

??!!

•Indications:•Symptomatic cases or uterus larger than 12 weeks size.•Suspected malignancy (rapidly enlarging or post-menopausal growth).•Multiple huge fibroids liable to complications.•Infertility.

Myomectomy

• Abdominal Myomectomy

• Vaginal Myomectomy

• Endoscopic Myomectomy

– Hysteroscopic

– Laparoscopic

• Embolization techniques ( Interventional Radiology)

Secondary Changes in Fibroids

• Degenerative

• Vascular

• Inflammatory

• Malignant Changes