VOL. 47, No. 1 Janzuary, 1955 45

The Uterine Fibroid

JULIAN WALDO Ross, M.D.Professor anzd Head, Department of Obstetrics and Gynecology,

Howard Unitersity, School of Medicine and Freedmen's Hospital, WVashinigton, D.C.

TEIOMYOMA, myoma uteri, uterine fibroidor so-called round tumor of the uterus, the

most common tumor affecting the female, is abenign organoid newgrowth consisting of the samehistologic elements as the uterine wall, viz., chieflymuscular fibers and connective tissue.

It begins as a local hyperplasia, the result inall probability of irritation, but the conditionsfavoring such or the specific factor giving rise tothe irritation are as little known today as a centuryand a half ago when the tumor was described first,by Bayle, in 1803.

That it may be an expression of persistent andexcessive bombardment of the uterus (myome-trium) by estrogenic stimulation, in the absenceof pregnancy, seems plausible in the light of theknown endometrial response (hyperplasia andpolyps) to such stimulation.

Although this tumor starts as a local hyperplasiaof the myometrium, its developmcnt does not fol-low the pattern of a generalized hypertrophy andhyperplasia of the uterine-wall elements character-istic of a pregnant uterus. Instead, the tumororigin and development are so focal and peculiarlyintensive that its pressure from growth causes com-pression and condensation of the surroundinguterine tissue with the formation of a capsule.This capsule, through which the tumor receivesits nourishment, separates the fibroid from thenormal uterine tissue and, from which, usually,the tumor may be easily enucleated, is a character-istic peculiar to most fibroids. Another character-istic of these tumors is their tendency to ceasegrowing at menopause.The blood supply to the fibroid is rather meager,

the arteries being very small and scant as com-pared to the veins and lymphatics which are largeand plentiful. Hence, the usual fibroid, in theabsence of certain degenerative changes, appearswhite, hard and dry. These latter characteristicsare dependent more largely, however, upon therelative proportion of the fibrous tissue to the con-stituent muscular elements.

Predominance of the fibrous tissue gives theso-called fibroma dura, easily shelled out of itscapsule; with predominance of the muscular ele-ments, the fibroid appears darker, more vascular,softer and juicy, the so-called fibroma molle notso easily, if at all, shelled out or separated fromthe surrounding muscle fibers.On section, the tumor bulges from the cut edges

showing a release of pressure; the tumor elementsexhibiting the characteristic silvery grey whorls ofa fibromyoma with, not infrequently, a concentricarrangement about the periphery of the tumor.Microscopically, the tumor is seen to be made upof interlacing bundles of unstriped muscle fibersand a network of connective tissue. These muscle(tumor) cells are longer, narrower and more close-ly compact than those of the normal uterine tissue;and their nuclei are long and, with their cytoplasm,stain deeper than those of the normal uterinemuscle. With Von Giesson's method, the musclefibers of the tumor stain yellow and the fibroustissue pink.

Etiology: While the cause of fibromyomata uteriis as yet unknown, a few pertinent observations aredeservcd of more than casual interest. Seldom, ifever, are these tumors encountered, for the firsttime, before puberty or after the menopause; thelargest age-group is between the thirtieth andfiftieth years, nearly 80 per cent; 43 per cent to46 per cent between the ages of thirty-five and forty-five; 20 per cent of all women over thirty-fiveyears have fibroids and 50 per cent over 50 yearsof age have them; the clinical incidence of fibroidsis about 5 per cent; non-parous women seem morelikely to have these tumors.

It is reported by American and English authorsthat fibroids are more common among Negroesand Mulattos than among the Whites and, thatovarian cysts and carcinoma of the uterus are rarein Negroes and Mulattos. Contrariwise, we haveencountered the latter conditions (ovarian cystsand uterine carcinoma) not infrequently in ourservice in Freedmen's Hospital, during the past

46 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JANUARY, 1955

forty-two years. It is interesting to note that, inthe full-blooded African, uterine fibroids are, prac-tically, a non-entity.Number and Size of Fibroids: As many as fifty

or more tumors have been seen in one uterus, andthe size ranges from pin-head to as much as 40kgms. in one reported case.

Classification as to Location: 95 per cent ofuterine fibroids have their origin in the body ofthe uterus and 5 per cent in its cervix. The majori-ty of the body tumors starts in the posterior wallof the uterus near the fundus, next the anteriorwall, next the fundus, then the sides. The majorityof cervical fibroids arises from the anterior lip.

All fibroids begin as interstitial or intramuraland 60 per cent to 70 per cent develop and remainas such; while 20 per cent to 30 per cent developor grow centrifugally and are known as subserousfibroids (sessile or pedunculated) and 10 per centto 15 per cent develop or grow centripetally tobecome submucous (sessile or pedunculated). Fi-broids are also encountered infrequently as intra-ligamentous and parasitic or "wandering fibroids."

Rarely, very large interstitial fibroids are sovascular as to form large blood-filled sinuses re-sembling those at the site of placental attachment,in advanced pregnancy; to such a tumor Virchowgave the designation "myoma telangiectodes, suecavernosum." Such tumors lend weight to thetheory that, at least some fibroids may develop fromthe walls of blood vessels in the uterus.

Rate of Growth: As a general proposition, thegrowth of fibroids is slow. A clinico-histologicrule is: the rate of growth is inversely propor-tional to the ratio of the amounts of its fibroustissue to its muscular element; that is, the greaterthe predominance of fibrous tissue, slower is thegrowth and visa versa. Growth of the tumor isincreased by pregnancy and menstruation; also,fibroids encountered near puberty are prone to amore rapid growth. A sudden rapid growth of afibroid in the very young or in a woman past themenopause should be strongly suspected as sarco-matous degeneration of the fibroid.Symptoms: Uterine fibroids may be asymptomat-

ic; however, the symptomatology of fibromyomatadepends upon the location, size, number and con-dition of the tumor. Chief to be considered areuterine hemorrhage, leucorrhea, pressure symptoms,pain and symptoms of certain degenerations of

the tumor; also, infertility following the produc-tion of a pathologic flexion of the uterus, or abilateral compression of the tubes, by the tumors;and, rarely, pyometra may result from pluggingthe cervical canal by a submucous fibroid.

Only the interstitial and submucous varieties offibroids cause abnormal uterine bleeding. A largeinterstitial tumor, by increasing the responsive area(the endometrium), or many small interstitialfibroids producing atony of the uterine muscula-ture, would produce menorrhagia (too much ortoo long menstrual flow), respectively.The submucous fibroid, on the other hand, by

superficial necrosis of the endometrium wouldproduce metrostaxis, characteristically, and menor-rhagia, dysmenorrhea from irregular uterine con-tractions, leucorrhea from congestion and edemaand gland secretion from irritation.

Pressure symptoms depend on the extent towhich an organ or structure may be encroachedupon. For example, the rectum resulting in con-stipation and rarely fistula formation; the urinarybladder or constriction of the urethra giving symp-toms of cystitis; the lumbo-sacral plexus of nervescausing backache; the ureters giving hydronephro-sis and what may follow; the pelvic veins givingedema or hemorrhoids and, finally, pressure onthe upper abdominal organs giving circulatoryand/or respiratory embarrassment.

Pain, in addition to the dysmenorrhea, men-tioned above, may be caused by peritoneal irrita-tion by the subserous pedunculated fibroid or bynecrobiosis of the tumor; rarely twisting of pedicleof the subserous fibroid may give the signs of anacute abdomen.

Degeneration: The degeneration of the fibroidis dependent predominantly upon interference withthe blood supply through the capsule. Pressure onor interference with the arterial supply would re-sult in hyaline degeneration, necrobiosis (reddegeneration) and necrosis, depending directlyupon the amount of nutritional deprivation. Pres-sure on or interference with the venous or lymphreturn would result in edema, liquefaction necrosisand cystic formations, depending directly uponthe amount of interference.

Hyaline is the most common and generalizedof all uterine fibroid degenerations and, at thesame time, is of the least clinical significance. How-ever, red degeneration and necrosis are of such

VOL. 47, No. 1 The Uterine Fibroid 47

clinical importance, in that they produce disturbingclinical manifestations, such as pain and tender-ness over the tumor where pain was not before,rapid pulse, rapid sedimentation rate, fever, leu-cocytosis and, rarely, sepsis, that surgical removalof the fibroid becomes imperative. Lately, in suchcases, we have successfully combatted the sympto-matology by bed-rest, ice-bag over the tumor andcoal-tar derivatives with or without codeine for thetenderness and pain; at the same time, the use ofsulfa and antibiotic therapy has effectively immun-ized the circulation and confined the necrotic effectwithin the tumor. Such management, in obstetrics,has enabled us both to postpone the immediate re-sort to surgery, until after delivery, and to carrythe pregnancy safely to term.

Calcareous degeneration giving the so-called"womb stones" by the old gynecologist shouldrather be designated an infiltration.

Sarcomatous degeneration of fibroids, estimatedas high as 4 per cent is much too high; in ourexperience, it is less than one-half of one per cent.While such a degeneration is possible through meta-plasia, it is a question, in my mind, whether or notsarcoma was present from the beginning. Carcino-matous degeneration of fibroids discussed in someof the older textbooks on gynecology does not existhisto-pathologically. It is difficult to conceive of amuscle cell metaplasing into an epithelial cell. But,what does happen, rarely, is that a fibroid is thehabitat of adenomyosis which, by virtue of itsepithelial element, may undergo carcinomatous de-velopment.

Diagnosis: The diagnosis of fibromyoma uteriis made on the history, abdomino-pelvic examina-tion, uterine curettage or hysterography. Calcifiedfibroids may be detected by use of the x-ray.

Large fibroids must be differentiated from uter-ine pregnancy (uterine fibroids never produceamenorrhea), hydatid mole, large ovarian cyst, ex-tensive adenomyosis interna, ascites, tympanites, ab-dominal fat, omental tumor and, rarely, old chronicsalpingitis.

Prognosis: Being benign, uterine fibroids, perse, do not cause death; however, severe anemiafrom blood loss, marked pressure symptoms, signsof an acute abdomen, certain tumor degenerationsor pyometra may render the prognosis unfavorable.

Treatment: Asymptomatic fibroids should beleft surgically alone, unless they be removed for

cosmetic purposes; and, only such symptoms orcomplications as hemorrhage, pressure, pain, signsof tumor degeneration or rapid tumor growth, anacute abdomen, interference with the pregnantstates or marital purposes should warrant coelio-tomy. A brief sketch of the evolution of the treat-ment of uterine fibromyomata might not be amiss,here.

Prior to 1843, women having uterine fibroids thatneeded surgical removal had to forego the fulfill-ment of that requirement; for then the surgeonhad neither acquired the technique of a safe coelio-tomy nor achieved acquaintanceship with surgicalasepsis and antisepsis. As consequence, the treat-ment was medicinal (ergot by mouth and the useof intrauterine styptics). Prolonged use of theergot produced obliterative endarteritis and hyper-tension with resulting cerebral or cardio-renal vas-cular disease or accidents.

Submucous polyp visible through the externalos was removed by twisting its pedicle (vaginalpolypectomy) with good results; but when attemptswere made to remove other submucous and evensome interstitial tumors, through anterior vaginalhysterotomy, so many cases succumbed from sepsisand sapremia that this method was soon aban-doned.

Since it had been observed that fibroids ceasedgrowing at the menopause, Hegar advocated bi-lateral oophorectomy to bring about an early meno-pause; obvious was the fate of such a treatment onthe child-bearing period. Apostoli, a physician dur-ing the Crimean War, employed electrolysis forthe treatment of fibroids, but, with very few ex-ceptions, this method was disappointing.To Heath and Charles Clay of Manchester, Eng-

land, credit is given for performing the first coelio-tomies for fibroid tumors, one in 1843 and onein 1844, with a mortality of 100 per cent. AnAmerican, by name, Burnham, performed the firstsuccessful coeliotomy operation for fibroids in1853. Thomas Keith, Koeberle, Pean followed byWinter, Price and others, fortified by the epoch-making innovations by Lister (surgical antisepsis)and Pasteur (germ theory of disease) placed coeli-otomy on a basis firm and enduring.

It is worthwhile to remember that the merepresence of an uterine fibroid(s) is not neces-sarily responsible for the abnormal bleeding.Hence, an endometrial diagnostic curettage should

48 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JANUARY, 1955

precede every decision for abdominal surgical in-tervention, in order to rule out other possible cau-sative or contributing factors, such as endometrialhyperplasia, polyps, tuberculosis or malignancywhich, if found, would modify the therapeuticprocedure.

Moreover, if an organic lesion or other circum-stance would constitute an unpredictable hazard tosurgery, wisdom or necessity should suggest theuse of organo-or irradiation therapy, instead, tocheck the bleeding and the tumor growth as well.It is to be remembered, however, that by election,age under forty years, the tumor larger than afour-month pregnant uterus, signs of adnexitis,certain tumor degenerations, severe anemia orrapid growth contraindicates x-ray or radium ther-apy for fibroids.

Surgical intervention then having been decidedupon because of the abnormal bleeding or otherindications, there are two methods of approach:myomectomy and hysterectomy. It should be bornein mind, a priori, that the uterine fibroid(s) is abenign condition; and the coordinated functionsof the uterus and ovaries are just as essential forreproduction as are the brain or bowel for humanpreservation. One would dare not extricate thebrain or bowel because it happened to be the sightof a benign tumor. Why remove the uterus thusaffected ?The rational procedure, therefore, should be

myomectomy, even multiple, which can be and isdone in our service, regardless of the size, numberor location of the fibroid, especially during thechild-bearing period, with increasingly gratifyingresults.Time is not too remote when myomectomy for

the submucous fibroid was tantamount to signinga death warrant for the patient, because of theresulting sepsis and sapremia, and hysterectomy be-

came the inevitable procedure of choice.Fortunately, hysterectomy, a devastating operation

with its unpredictable consequences, for the re-moval of submucous fibroids, is passe in our serviceand has been superseded by myomectomy, a physi-ology-preserving procedure.

This has been brought about, largely, throughthe routine preoperative, operative and postopera-tive preparation, technique and care of the patient,respectively.' To which should be added: main-tenance of the proper electrolyte and fluid balance,plasma proteins to at least 6 per cent (4 per centof which being the albumen fraction), indicatedblood transfusions, better anesthesiology and theindicated use of the Wangensteen suction apparatusor the Miller-Abbott tube.

These have placed myomectomy on a sound, safeand satisfactory basis to which one hundred andfive known healthy babies, following myomectomyin our service during the past five years, are aliving testimonial.

Deviation from the beaten path of hysterectomytaxed our ingenuity, but it did enhance the ultimatesuccess of our undertaking. Broad anatomic knowl-edge and experience enabled us to avoid many pit-falls. The cervix uteri is carefully evaluated, inthe parous woman, before decision for myomec-tomy.And what is of no less importance, to many

other such women, is the fact that, after myomec-tomy, reproductive possibility is preserved, andthey remain unimpaired biologically, sociologicallyand psychologically, to which every woman isinnately entitled.

LITERATURE CITED

1. Ross, J. W. Surgery in the Uterine Fibroid, A Pleafor Myomectomy. Am. J. Obst. and Gynec. v. 53,266-270, 1947.

PREVENTION OF MENTAL DEFICIENCY BY STERILIZATION

Sterilization laws have been operative in thirty states. In three, Alabama, New York and Washington, theyhave been found unconstitutional because of technical defects in wording. Gamble made comprehensive studies ofthe mentally deficient sterilized in New Hampshire and estimated that each 100 sterilizations of females and each200 of males will prevent the birth of ninety feebleminded children. Since the passage of sterilization laws,25,903 mentally deficient persons have been protected from parenthood in 29 states. Gamble estimated that thesesterilizations would prevent the birth of 19,000 mentally deficient children. At least 98 per cent of the eugenicsterilizations reported in 1949 were with the consent of the patient or his family.

See, Clarence J. Gamble, The Prevention of Mentally Deficiency by Sterilization, 1949. Am. J. of MentalDef., v. 56, pp. 192-197, 1951.