Uterine fibroids

Uterine fibroids

• Most common tumors of the female genital tract

• Commonest cause of Hysterectomy

Uterine fibroids

• Most common benign tumor of the female genital tract

• Risk factors- ethnicity, nulliparity, genetics and hormonal factors, Obesity

• Heterogeneity in behavior of fibroids and the symptoms attributable to them

Regulation of the growth of uterine fibroids

• Estrogen and progesterone dependent• Increased estrogen receptor gene expression

in uterine fibroids• Role of apoptosis

Clinical presentation of fibroids

• Peaks in the peri menopausal years and declines after the menopause

• More than 50% of myomas are asymptomatic

Common symptoms

• Abnormal uterine bleeding

• Pelvic pressure symptoms & discomfort

ABNORMAL VAGINAL BLEEDING

• Most characteristic of myomas is menorrhagia• Increased endometrial surface area• Increased vascularity of the uterus Interference with normal uterine contractility• Endometrial ulceration over submucous

leiomyomas, which could also cause intermenstrual bleeding

• Compression of venous plexus within the myometrium

PELVIC PAIN

• Fibroids located posteriorly- lower back pain • Anterior tumours may cause bladder

discomfort and increased urinary frequency. • Leiomyomas that fill the pelvis may cause difficulty with urination, defaecation and dyspareunia Broad ligament may cause unilateral lower abdominal pain or sciatic nerve pain

Acute pain

• Torsion

• Red degeneration-localized tenderness over the fibroid, mild leukocytosis, pyrexia, and nausea and vomiting

• Pain however is not a common feature of fibroids

• Rule out other conditions like endometriosis, adenomyosis

PELVIC MASS SYMPTOMS

• May simply put on weight• Bladder capacity reduced- increased

frequency• Retention of urine

REPRODUCTIVE DYSFUNCTION

• Infertility• obstruct the tubal ostia• Submucosal fibroids and intramural fibroids

distorting the uterine cavity• Myomectomy, whether by the conventional

abdominal route or laparoscopically, appears to be associated with improved pregnancy rates

• Bulletti C, Ziegler D, Levi Setti P et al. Myomas, pregnancy outcome, and in vitro fertilization. Ann NY Acad Sci 2004; 1034: 84–92.

Fibroids and Infertility

• Despite the lack of evidence from randomized studies it does appear that surgical intervention for uterine fibroids does increase pregnancy rates

• 50% of women conceiving following myomectomy for fibroid-associated infertility.

• Palomba S, Zupi E, Russo T et al. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: short-term outcomes. Fertil Steril 2007; 88: 942–951

Abortion and Myoma

• Submucus or myomas distorting the cavity• Multiple myomas Miscarriage rates fall after myomectomy

FIBROIDS AND THEIR IMPACT ON ANTENATAL COMPLICATIONSOF PREGNANCY AND LABOUR

• Have been linked to a number of complications

• Positive association between the presence of fibroids and malpresentations such as breech presentation, operative delivery and caesarean section - demonstrated repeatedly

Fibroids and pregnancy

• Only few fibroids grow(20%) in pregnancy, growth limited to first trimester

• Submucus fibroid – abortion• Weak association with preterm labour• Placenta previa weak association• PPH weak association

POSTPARTUM SEQUELAE OF FIBROIDS

• Ischaemic degenerationanaerobic infection

• Fibroid tissue may be expelled

RARE ASSOCIATIONS

• Myomas may be parasitic

• secondary polycythaemia

• Ascites• Benign metastasizing myomas• Intravenous leiomyomatosis• Leiomyomatosis peritonealis disseminata

MALIGNANCY

• leiomyosarcomas arise de novo• 0.13 and 0.29%

Asymptomatic uterine fibroids

• Even with symptoms such as infertility, pelvic pain and abnormal bleeding, it is not always possible to be certain that a given myoma is not simply an innocent bystander

• 40% by 35 years of age and almost 70% by 50 years of age

• 50% of fibroids are asymptomatic

Asymptomatic fibroid

• Why some cause symptoms and others don’t?• Is there is any possibility of malignancy?• Whether they need a hysterectomy?• Whether the fibroid(s) will compromise fertility

and pregnancy outcomes? • Whether the fibroids are likely to grow, and if

there is any therapy to stop them Growing?• Does waiting and watching will cause any harm?

Fibroid – C section

• Fibroids should be left well alone at the time of caesarean section

TheManagement of Uterine FibroidsWorking Party

of the New Zealand Guidelines Group• Size less than 16 weeks observe after

excluding other pathology• Concern about possible complications related

to fibroids in pregnancy is not an indication for myomectomy, except in women who have experienced a previous pregnancy with complications related to these fibroids

• Trial of conception for 6 months

TheManagement of Uterine FibroidsWorking Party of the New

Zealand Guidelines Group

• Myomas that disturb the cavity may be removed before IVF

Imaging

• Aim • Determination of the number, size and

position ofmyomata, as well as the dimensions of the uterus

• To rule out other pathology

USG

• Preferred method• Well demarcated mass with in myometrium• May be hypo/hyper • Adenomyosis.-minimal or no mass effect

elliptical shape of uterus maintained• Colour doppler diffuse vascularity in

adneomyosis

USG

• Both TAS and TVS• TVS endometrium small fibroids• Sonohysterography submucus myomas

MRI

• Submucus myomas• Cervical myomas

Rule out

• Leiomyosarcoma no sharp margins• Sample endometrium if ET > 15 mm in

premenopausal woman• Adnexal masses may be confused with

subserosal pedunculated leiomyomata – CT MRI Laparoscopy

Medical management of fibroids

• Fibroid growth is hormone dependent

• Medical treatments mainly involve hormonal manipulations

Indications for medical therapy

• Treatment for temporary relief of symptoms for short period

• Pre-operative adjunct to reduce the size of fibroids, to control bleeding and to improve haemoglobin levels

GnRH analogues

• Symptoms of estrogen deficiency limit the standard use of GnRHa to 6 months

• Fibroids returning to their original size or even enlarging more rapidly upon cessation of therapy

• Add back -tibolone, raloxifene, progestogens alone, oestrogens alone, and combined oestrogens and progestogens

Preoperative use of GnRHa

• GnRHa render surgical planes less distinct, making enucleation difficult

• large and multiple fibroids (level of the umbilicus and beyond) responds poorly

• GnRHa increases the risk of recurrence since smaller fibroids regress and missed

• Not cost effective (Vassopressin cheaper)

GnRH analogues

• Only indication of GnRH analogues is to reduce the size of submucus myoma before hysteroscopic myomectomy

GNRH ANTAGONISTS

• Not studied well

SELECTIVE OESTROGEN RECEPTOR MODULATORS

• Insufficient evidence to conclude that SERMs reduce the size of fibroids or improve clinical outcomes in premenopausal women

AROMATASE INHIBITORS

• Anastrozole• Confined to case reports• Not very effective in premenopausal women• long-term use and risk of bone loss and

fracture risk

LEVONORGESTEROL INTRA-UTERINE DEVICE

• Reduction in menstural blood loss& symptoms

• Not suitable fro sunmucus and large myomas

ANTIPROGESTERONES

No change in bone mineral density

5 or 10 mg/day for 1 year

Myomectomy

• Sole purpose of myomectomy is to improve fertility

• In 2/3 of women who have had myomectomy menstrual symptoms does not subside

Conventional myomectomy

• Contrary to popular belief, this is an operation which demands considerable skill if it is to yield optimal outcomes

Pre-operative assessment

• USG , MRI for cervical fibroids • Submucus fibroids hysteroscopy

Preoperative assessment

• Small risk of needing to progress to hysterectomy

• Pre-existing anaemia should be corrected

Intra-operative measures and surgical technique

• Transverse incision• Pull sow with myoma screw

Uterus is “bloody” organ

Physical occlusion of blood flow

• Boneys clamp

• Single tourniquet around uterine A the cervix to achieve haemostasis

• Occlude the ovarian arteries, and one to occlude the uterine arteries

• Preoperative Uterine A Embolisation?

Preop GnRH

• Small fibroids may be missed• Planes unclear Not generally recommended Huge fibroids respond poorly Not cost effective Planes destroyed, increase the risk of recurrenceOnly indication may be sub mucus fibroid, where it may facilitate an hysteroscopic removal

• 1 g tranexamic acid by slow intravenous infusion at the time of induction of anaesthesia

• Dilute 20 units vasopressin in 100 mL normal saline

• Avoid injection directly into blood vessels

• Intravaginal misoprostol 400 microgram

Vasopressin vs. physical occlusion

• o difference in operative blood loss, operative time, postoperative febrile morbidity, preoperative, and postoperative hematocrits or transfusion rates.

• Ginsburg ES, Benson CB, Garfield JM, Gleason RE & FreidmanAJ (1993). The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. FertilSteril 60:956-62

Uterine incision

• Single, anterior, midline vertical incision

• multiple incisions are minimum.

The incision should extend through the serosa, myometrium and into the capsule of the leiomyoma

• “Stay with in the pseudocapsule and myoma”

• Every effort should be made to remove all visible and/or palpable myomas

• If the endometrial cavity is breached, the repair it with fine interrupted extramural sutures using 2/0 vicryl

Closure

• 1/0 vicryl sutures• Interrupted figure of eight

sutures

Bonney's hood

Myomas in special locations

• Broad ligament myoma • Incise round ligament• Work with in the capsule

Cervical myomas

• Real challenge• Accurate location of myoma by MRI• Preoperative GnRH • Central divide UV fold and bisect the Uterus• Posterior myoma-low posterior incision at the back of the uterus

RISKS AND COMPLICATIONS OF CONVENTIONAL MYOMECTOMY

• Bleeding• Exceptionally rare to have to resort to

hysterectomy• Infectious morbidity is infrequent• Adhesions-meticulous haemostasis• Use of minimally reactive absorbable sutures;

copious irrigation at the time of myomectomy; paying attention to suturing techniques and, possibly, use of intraperitoneal drains

Risk of recurrence after myomectomy

• 40% and 50%• Risk decreased with• Single myoma• Pregnancy

Endoscopic management of uterine fibroids

• Less adhesions, rates of conception, miscarriage, preterm birth and caesarean

section were similarSeracchioli R, Rossi S, Govoni F et al. Fertility and obstetric outcome after laparoscopic myomectomy of large fibroid: a randomized comparison with abdominal myomectomy. Hum Reprod 2000; 15: 2663–2668.

Lap myomectomy

• Less than 15 cm(6-10cm)• 3 fiborids less than 5 cm• Surgeon loses the ability to palpate uterine

tissue to detect smaller myomas• Incidence of rupture uterus in pregnancy

similar with open myomectomy

Lap myomectomy

Lap myomectomy

• Not adhesion free

• But incidence of adhesion is less compared to laparotomy

• Conversion rate to open myomectomy 5%

• Fibroid myolysis

LAPAROSCOPIC THERMOMYOLYSIS

• Rupture

• Adhesion

Radiological treatment of symptomaticuterine fibroids

• Uterine artery embolisation• Menorrhagia is controlled in 85–95% of

patients, and bulk-related symptoms are controlled in 70–90% of patients

• Sub mucus forbids are better treated with hysteroscopic resection

UAE and Fertility

• Premature menopause induced by UAE has been estimated at up to 25% in women above the age of 45 years and 1% in younger women

• Procedure should not be offered routinely to women who wish to preserve their reproductive potential

• Ahmad A, Qadan L, Hassan N et al. Uterine artery embolization treatment of uterine fibroids: effect on ovarian function in younger women. J Vasc Interv Radiol 2002; 13: 1017–1020

UAE and fertility

• Concerns of preterm labour,abnormal placentation

• Carpenter TT & Walker WJ. Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies. Br J Obstet Gynaecol 2005; 112: 321–325

Uterine artery embolization as a surgical adjuvant

• Not recommended before myomectomy chances of rupture

• May help to convert midline incision to transverse incision in hysterectomy

Complications

• Chronic vaginal discharge 4-7% of patients • Fibroid extrusion through the vagina• Premature ovarian failure or severe pelvic

sepsis• Postembolization syndrome

Edwards RD et al UAE vs Surgery for symptomatic fibroid N E J M 2007:356(4):360-370

• 13% had intervention after 1 year in the UAE group

• Need for re-intervention for persistent symptoms at around 10% at 1 year

• Complication rates similar

REST trial (Randomized controlled trial of Embolization vs SurgicalTreatment for fibroids

UAE

• Recommended by the National Institute for Clincial Excellence (NICE) in the UK as an alternative therapy to hysterectomy

Long term outcome of UAE

• On 5-7 year follow 12-20% needs intervention• Spies JB, Bruno J, Czeyda-Pommersheim F et al. Long-term

outcome of uterine artery embolizationof leiomyomata. Obstet Gynecol 2005; 106: 933–939.

• Katsumori T, Kasahara T & Akazawa K. Long-term outcomes of uterine artery embolization using gelatin sponge particles alone for symptomatic fibroids. AJR Am J Roentgenol 2006; 186: 848–854

• Walker WJ & Barton-Smith P. Long-term follow up of uterine artery embolisation – an effective alternative in the treatment of fibroids. Br J Obstet Gynaecol 2006; 113: 464–468

Magnetic-resonance-guided focused ultrasound surgery

• Causes heat within the tissues and causes coagulative necrosis of tissue

• Symptomatic uterine fibroids and who have no desire for future pregnancy

• Volume reduction is less than UAE Mean time in return to normal activity 1 day

Laparoscopic uterine artery occlusion

• 50% reduction in menorhaghia

• Uterine volume was reduced by 35-40%

Hysterectomy

• The need to treat symptoms—abnormal uterine bleeding, pelvic pain, or pelvic pressure

• “Rapid” uterine enlargement , ureteral compression, or uterine growth after menopause

• ?Based on size > 12 weeks

Hysterectomy-Choice of Approach: Abdominal, Vaginal, or Laparoscopic

• Fibroids up to 12 weeks VAGINAL

• 12-16 weeks VH,LAVH>TLH

• > 16 weeks Abdominal Hystercetomy

• Lateral enlargement of uterus -TLH difficult

Hysterectomy for cervical fibroids

• Anterior• Posterior• Central-‘the lantern on the top of St Paul’s’• Pseudocervical fibroid • Lateral • Hysterectomy cant be done until myoma is

removed by myomectomy

Cervical fiborid

• ??GnRH analogues• Destroy planes and elimines one of the very

few ‘godsends’

Hysterectomy for an anteriorcervical myoma

Central cervical myoma Hemisection

Posterior myoma

CONTRACEPTIVE OPTIONS IN THE PRESENCE OF FIBROIDS

• OCP,POP,DMPA ARE OPTIONS• LNG-IUS-effective in controlling bleeding,may

reduce the size of fibroids• Contraceptive efficacy of LNG IUS in women

with fibroids, with or without menorrhagia, appears to remain intact

References

1) Uterine fibroids- Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 22, No. 4,20082) Malcolm G. Munro Uterine Leiomyomas,Current Concepts:Pathogenesis, Impact onReproductive Health and Medical, Procedural, and Surgical Management Obstet Gynecol Clin N Am 38 (2011) 703–731

3) Uterine myoma Obstetrics Gynaecology clinics of north America Volume 33, Issue 1 (March 2006)4) Te Lindes operative Gynaecology Rock, John A.; Jones, Howard W 10th edition Lippincott Williams & Wilkins5) Bonney’s gynaecological surgery.—10th ed. John M. Monaghan,Tito Lopes, Raj Naik. Blackwell Science Ltd

• 6) Togas Tulandi Uterine fibroids Embolisation and other treatment 2003 Cambridge univeristy press