uterine fibroids by oouth unit b medical students o&g
TRANSCRIPT
UTERINE FIBROIDSUNIT C PRESENTATION
• Mrs AA is a 42 year old woman who has a large abdominal mass but no symptoms of heavy period. The smear history is normal.She has two children but still wishes to retain her fertility as she is planning a third. She is married, a non smoker and otherwise fit and well. On examination, the abdomen is distended and there is a pelvic mass consistent with that of a 20 weeks size pregnancy. Vaginal examination confirms this and ultrasound scan shows two large fibroids that are intramyometrial but also subserous.
• INTRODUCTION•EPIDEMIOLOGY•AETIOLOGY\RISK FACTORS•PATHOLOGY•CLINICAL FEATURES•MANAGEMENT•CONCLUSION•REFERENCES
Introduction DEFINITION• Uterine fibroids are benign proliferation of smooth muscle cells of the
uterus • It is synonymous to fibromyomata, myomata, leiomyomata• It is the commonest benign tumour of the female genital tract
Epidemiology• Quite high in Nigerian women and the blacks over the age of 25yrs• Over 80% of the women over the age of 25yrs have fibroids if only of
the size of a seedling• 3-9 times more commoner in blacks than Caucasian
AetiologyAetiology is unknown but there are associated risk factors whichinclude • Nulliparity• Africa racial origin • Obesity• Positive family history• Smoking decreases chances of occurrence• The role of ovarian steroid hormone as etiological factors is now
recognized
Cont’d• Somatic mutation in myometrial cells resulting in progressive loss
of growth regulation Genetic predispositions • Clues : ethnic predisposition studies, twin studies and familial
aggregation studies. • cytogenetic aberrations on chromosome 12, 6, 3 and 7, a ring
chromosome 1.translocation on chromosomes 12 and 14 [t(12;14)] associated with large fibroids[del(7)q22q32)] with smaller fibroids
PathologyGROSS PATHOLOGY• Size• solitary or multiple • sessile or pedunculated • They are rounded in shape especially when confined to the myometrium • There is usually a line of cleavage between fibroid and the myometrium
which makes it possible to shell it out at operation• The cut surface presents white appearance with the characteristic
whorled pattern
PATHOLOGYMICROSCOPY• Microscopically, tumor cells resemble normal cells (elongated, spindle
shaped, with a cigar-shaped nucleus) and form bundles arranged in a concentric pattern with different directions (whorled).• Some fibrous connective tissue may be interspersed between the
muscle bundles.• These cells are uniform in size and shape, with scarce mitoses. • There are three benign variants: bizarre (atypical); cellular; and
mitotically active.
Sites• Subserous: when it is beneath the serous covering. Sometimes this may
possess a stalk and may be referred to as pedunculated fibroid• Interstitial or intramural: when it is within the substance of the
myometrial tissue• Submucous: when it is beneath the mucous or endometrial lining.
Sometimes this may also develop a stalk and become a fibroid polyp• Cervical: when it is situated in the cervix. The incidence of cervical
fibroid is quoted as 1-2% of all cases of fibroid• Broad ligament (intraligamentary): when a subserous fibroid burrows
into the Broad ligament
Degenerative changes• Hyaline degeneration ⅔ of fibriod: it occurs when the fibroid
gradually outgrows its blood supply, and may progress to central necrosis, leaving cystic spaces. • Cystic degeneration: this may follow hyaline degeneration. The
hyaline tissue liquefies and forms cystic areas thus making the whole tumour become soft and cystic.• Fatty degeneration: this may occur when fat is deposited in a fibroid
and the tumour then assumes a yellowish appearance
Degenerative changes• Red degeneration (Necrobiosis): it follows an acute disruption of the
blood supply to the fibroid during active growth, classically during the mid-second trimester of pregnancy• Calcification: fibroids may become calcified and this visible on an X-
ray. This degeneration may occur post-menopausally or secondary to necrosis• Sarcomatous change 0.2-0.5%• Atrophy
Clinical Features• Asymptomatic: most fibroids are usually asymptomatic especially if they
are small• Symptomatic: symptoms peak in the perimenopausal years and declines
after the menopause. These symptoms include:• Menorrhagia- this more common with the submucous type.
This can be due to • increase endometrial surface area • Endometrial hyperplasia• Congestion and dilatation of the venous plexus• Imbalance in the prostaglandin productions as fibroids have been
shown to release a prostacyclin• Disturbance in the uterine contractility
Clinica features• Abdominal mass- the woman may complain of a swelling in abdomen
or increased abdominal girth if the tumour is a big one• Irregular bleeding- the menstrual pattern may become irregular and
the bleeding heavy in the presence of fibroid polyp or when a submucous fibroid becomes ulcerated• Abdominal pain- causes include red degeneration, torsion, malignant
change, infection of fibroid, compression of pelvic nerves
Clinical features• Pressure symptoms- a large fibroid may compress the surrounding organs
and present corresponding symptoms:• Bladder- when the bladder is compressed there may be frequency of
micturition or retention of urine• Rectum- compression of the organs may result in constipation or dyspepsia• Lymphatics- oedema of the legs is the result of compression of the
lymphatics by fibroid• Veins- varicosity of the veins in the legs is the result of compression of veins
like the iliac veins• Nerves- occasionally, pressure on the sacral plexus may cause pain
MANAGEMENT• History taking• Examination : General examination • Pallor• Oedema and varicose veins on the leg• Abdominal examination• Findings include:Firm in consistency and surface is irregular in case of multiple fibroids• Tenderness may be elicited only if the tumour is undergoing red or sarcomatous
degenerative changes• Bimanual examination will confirm that that the mass is uterine.
Investigations• Investigations include the following:Full blood countAbdominal ultrasoundDiagnostic curettageHysterosalpingographyHysteroscopy
INVESTIGATION (Cont’d)Intravenous urography (IVU)- it is mandatory in a case of large uterine
fibroid for the following reasons:Presence of hydronephrosis and hydroureterIVU will show the course of the ureters which is a great advantage to
the surgeon.Plain X-ray of abdomen: a soft tissue mass may indicate a fibroid
tumour. This may be more diagnostic if areas of calcification are shown within the tissue mass
TREATMENT• Treatment options depends on:• Size of the fibroid• Presenting symptoms • Reproductive wishes of the woman• Surgical fitness• Desire to retain the uterus
• Treatment is not required if a fibroid is asymptomatic.• However fibroids that enlarge the uterus to about 12 weeks
pregnancy size, whether symptomless or not, should preferably be removed.
• Treatment can be• Medical management• Surgical management
Medical management INDICATIONS FOR MEDICAL MANAGEMENT• To control menorrhagia• For patient that are not ready for surgery• Unfit for surgery• To reduce tumour size before surgery• Perimenopausal patient
DRUGSGonadotropin releasing hormone analogues: Goserelin, buserelin, zaferelin, naferelin and leuprolide• Danazol• Antiprogestrogen: Mifepristone, To treat menorrhagia• Antifibrinolytic: Tranexemic acid• NSAIDS: mefenamic acid
ADVANTAGES• Shrinks the fibroid before surgery• Reduce compression symptoms• Reduce blood loss during surgery• Allow use of pfannenstiel incision DISADVANTAGES• Cost of drugs• Rebound recurrence• Loss of cleavage plane• Prolong use is associated with post menopausal PG
SURGICAL MANAGEMENT• Hysterectomy • Myomectomy• Laparoscopic myolysis• Uterine artery embolisation
SURGICAL MANAGEMENT• Myomectomy• This is the treatment of choice when patient is desirous of pregnancy. Indications for myomectomy• In child bearing age to preserve the uterus.• Pain• Pressure effect• Abnormal bleeding.• Infertility after other cause have been ruled out – in patients with
unexplained infertility and uterine fibroids, about 20-40% are known to have conceived after myomectomy.• Uterine size greater than or equal to 20 weeks.
• Because hemorrhage is the most serious complication of myomectomy,it is important that conscious effort is made to minimize blood loss and its effect on the patient.• Preoperatively• Patient should not be anaemic- pcv not less than 30%.this enhances the
patient”s ability to tolerate any blood loss.• The timing of the surgery where possible should be in the proliferation
phase of the menstrual cycle when the uterus is less vascular.• For huge fibroids, gnrh agonists to shrink the fibroid.• Hemodilution with 2 litres of normal saline
• Intraoperatively• Use of torniquette.• Minimizing adhesions• Use of single anteror incision,use of synthetic absorbable sutures
during uterine repair,antibiotic prophylaxis,gentle handling of tissues,post operative peritoneal lavage.
Surgical management (cont’d)• Hysterectomy .This is the definitive treatment of uterine fibroids.• Abdominal hysterectomy with bilateral salpingo-oophorectomy is
offered to women with fibroids if they are:Over 40 yearsHave completed childbearingPerimenopausal• The procedure is not readily acceptable by our women of childbearing
age for reasons earlier stated
Surgical management (cont’d)•Vaginal hysterectomy• This operation can be carried out if fibroid is
associated with utero-vaginal prolapse provided the fibroid is not bigger than 10-12 weeks pregnant size
Surgical Management (cont’d)PolypectomyThis is an operation for the removal of fibroid polyp per vaginamThe stalk or pedicle is ligated as far as up as possible and then excised
distal to the ligatureIn some cases, it may be necessary to first carry out dilatation of the
cervical canal.
MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND• Is a non invasive outpatient, procedure that uses high intensity
focused ultrasound waves to ablate the fibroid tissue.
COMPLICATIONS OF FIBROIDS• Degenerative changes
• Hyaline changes• Red degeneration changes• Cystic change• Calcification• Fatty• Atrophic• Sarcomatous
• Infection• Pain• Haemorrhage• Infertility• Torsion
Differential Diagnosis• Ovarian tumour: this can be differentiated from fibroid • Pregnancy• Pelvic inflammatory disease • Chronic ectopic pregnancy
FIBROID AND PREGNANCY• During pregnancy, fibroids may reduce in size ,grow bigger or flatten out.• It returns to pre-pregnancy size after the puerperium• Red degeneration is a common complication in pregnancy especially during
the fifth to seventh months of pregnancy• The woman usually presents with severe abdominal pain and low grade
pyrexia• Management consists of bed rest and analgesics
FIBROID AND PREGNANCY (CONT’D)• Other complications are:• First trimester Recurrent miscarriages.• Third trimester
Placenta praeviaPremature labourMiscarriageAbnormal lieObstructed labourMalpresentationMalpositioning• Postpartum hemorrhage
Prognosis• The recurrence rate of fibroid, if treated by myomectomy, may be as
high as 10 percent especially as a few fibroid seedlings may escape removal and these may grow to a big size over the next few years• Some of our women have been known to come back with recurrence
within two or three years• It is however interesting to note that the rate of fibroid growth cannot
be determined with certainty• In some women, it grows rapidly while in others, it may be dormant
for years
CONCLUSION• The important factor here is that Mrs AA is asymptomatic and
therefore there is no need for any specific treatment. The other important feature is that she wishes to retain her fertility and therefore hysterectomy is contraindicated. Myomectomy is not necessary unless she has problems conceiving.She should be counselled that there is a risk of bleeding and that hysterectomy is a possibilty.
REFERENCES• Gynaecology by Ten Teachers 19th edition.Edited by Ash Monga and
Stephen Dobbs.• Textbook of Obstetrics and Gynaecology for Medical students. Second
edition.• Uterine Fibroids by DR M.A LAMINA.• Uterine fibroids by DR E.O JAGUN.• Foundations of clincal gynaecology in the tropics. First edition by
PETER N. EBEIGBE.
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