( also called uterine Leiomyoma, Myoma, Myomata uteri, fibromyoma).

objective objective

* There is many benign lesion of the uterus the most important is fibriod

*In spit that fibriod is benign tumor it cause many structural and functional disturbance in reproductive life of women's.

*50% asymptomatic and the other group has one or more of important symptoms. *Secondary changes in fibroids makes the tumor more difficult in diagnosis and management . *There is different ways in treatment the most curative is myomectomy which is bloody surgery needs preparation

and a written consent for hysterectomy.

. Definition: Circumscribed , benign tumor composed of muscle with

fibrous connective tissue elements.. most common masses of uterine origin.. may occur singly but usually multiple ( as many as 100

or more have been found in a single uterus).. in 20 - 40% of women of reproductive age.. more often found in nulliparous women or in women who

have not been pregnant for sometime.. 3 - 9 times more common in blacks..may be found in organs outside uterus such as fallopian

tube, vagina, round ligament, uterosacral lig.,vulva, and GIT

A etiology: localized proliferation of smooth ms.Cells and there is gradual addition of fibrous material . . fibroids arise from immature ms. Cells & cell nests. Contraction of uterine muscles points

of stress within the myometrium act as growth stimuli to immature muscle cells fibroids. . dependent on estrogen for growth :increase in pregnancy.Rarely found before puberty, and stop growing after

menopause.New myomas rarely appear after menopause

Types of myomasTypes of myomas::

1.Intramural myoma ( interstitial ) : most common, pseudo encapsulated , isolated nodules of varying sizes, occurring within the wall of the uterus.

::

2.Sub mucous myoma : beneath the endometrium, grow into the uterine cavity, maintaining attachment to the uterus by a pedicle, may associated with disturbed bleeding pattern

3.Sub serous myoma : beneath the serosa, usually asymptomatic , grow out toward the peritoneal cavity, may reach a large size , and also may develop a pedicle ( pedunculated ), it may be mobile and may attach to the surrounding structures.

Symptoms:Symptoms:1.Abnormal menstrual bleeding : most common symptoms,

it's typically Menorrhagia.2.Pain : acute pain associated with either torsion of a

pedunculated myoma or infarction of myoma.3.Pressure : as myomas enlarge , they may cause a feeling of

pelvic heaviness or produce pressure symptoms on the surrounding structures:

a. Urinary frequency : a common symptoms. b.Urinary retention : when myoma creates a fixed

retroverted uterus.c.May cause unilateral urethral obstruction and

hydronephrosis.d.Constipation and difficult defecation : by large posterior

myoma.4.Reproductive disorders :a. infertility.b.Increase incidence of abortion and premature labour.

•Signs :Signs :1.Abdominal examination: may be palpated as

irregular, nodular tumours protruding against the ant. Abdo. Wall, usually firm upon palpation. Softness and tenderness suggest the presence of edema, sarcoma, pregnancy, or degenerative changes.

2.Pelvic examination: the most common finding is uterine enlargement. The shape of the uterus is usually irregular in outline.

Secondary changes in FibroidsSecondary changes in Fibroids

1.Atrophy.2.Necrosis.3.Degeneration (Hyaline degeneration,

Cystic degeneration, Fatty degeneration, Calcification, Red degeneration or necrobiosis).

4.Infection.5.Vascular changes.6.Malignancy (Sarcoma).

Differential diagnosis:Differential diagnosis:

1.Dysfunctional uterine bleeding: irregular bleeding with slight enlargement of the uterus.

2.Adenomyoma: heavy menstrual bleeding accompanied by pain.

3.Ovarian tumours: rate of growth is rapid, u.s.4.Inflammatory swellings: 2ry dysmenorrhea,

tenderness, uterus not enlarged.5.Abdominal & pelvic carcinomas: laparatomy is

often justified.6.Cervical & endometrial carcinomas: cytological

exam. And biopsy.7.Pregnancy : amenorrhea, soft elastic uterus

enlargement. U.S., immunological tests for preg

Malignancy :Malignancy :

Rare , about 1 - 3 / 1000, may be increased if:Age >40 yrs, solitary fundal myoma , rapidincrease of size.

TreatmentTreatment::

. if the tumour is not excessively large, and there

are no symptoms, treatment may not be necessary

1.Observation: in absence of pain , abnormal bleeding, pressure symptoms, or large myomas, periodic examinations are sufficient management especially if the patient is nearing menopause ( the myoma will atrophy as estrogen level falls ).

a. Bimanual examination every 3-6 months.b.Palpation of uterosacral lig. for evidence

of endometriosis ( often coexists with fibroids ).

c.Regular blood counts, and oral iron may be required.

d.Pelvic u.s.

◦ 2.Gonadotropin - releasing hormone ( GnRH ) agonists:

Long acting GnRH agonists suppress gonadotropin secretion pseudomenopause, 55% reduction in the size of the myomas, the myomas usually regrow after the GnRh therapy is discontinued. Gnrh therapy may cause osteoporosis in prolonged therapy.

3.Surgery3.Surgery::

* Indications:I. bleeding , usually with sub mucous or

intramural myomas.II.Pain.III.When the size of the uterus exceeds that

of a 12 week gestation.IV.Sign & symptoms of pressure on the

bladder , bowel, or GIT.

* Surgical procedures* Surgical procedures::a.Myomectomy: removal of single or multiple

myomas while preserving the uterus. usually reserved for women who desire pregnancy. 30% recurrence rate within 10 years, higher in blacks. the incidence of becoming pregnant is 40% after myomectomy.preoperative GnRH agonist can reduce size of myoma up to 55%. Pelvic pain , menorrhagia, infection, and adhesion formation may occur after myomectomy.

b.Hysterectomy : if the indications for surgery are present & if the patient's childbearing is complete , total removal of the uterus is the procedure of the choice.

With hysterectomy both leiomyoma and any Associated disease are removed permanentlyAnd there is no risk of recurrence..Ovaries should be retained in women less

than 40-50 years of age

Example: 25 years old woman with 4 children and symptomatic fibroid Hysterectomy.

*glandular proliferation with or without cytological atypia.

*The aetiology may be attributed to the unopposed secretion of estrogen by progesterone.

*Unopposed estrogen is characteristic of chronic anovulatory states such as polycystic ovary disease; and estrogen-secreting tumours such as granulosa-theca cell tumour.

*The risk of progression to endometrial carcinoma is 1 - 14% in untreated cases, it is greatest in postmenopausal women and in women with atypical adenomatous hyperplasia.

Types:Types:1.Adenomatous hyperplasia:The glands are hyperchromatic and

separated by strands of stroma, there is no invasion or cytologic atypia.

2.Atypical adenomatous hyperplasia:It is concedered carcinoma-in-situ of the

endometrium.The glands are with intense

hyperchromatism and nuclear atypia, there is little intervening stroma but no invasion

Treatment:Treatment:

I. Teenagers:. cyclic estrogen with progestin for 6 months,

and endometrial sampling should be done regularly.

. if the patient continues to be anovulatory after medical treatment, oral estrogen and progestin or cyclic medroxyprogesterone acetate ( 10mg for 10 days every other month) should be continued to induce stabilization of the endometrium and to control withdrawal bleeding

ii.Women of childbearing:. 3 courses of cyclic estrogen with progestin

followed by a repeat of endometrial sampling.

. if the pregnancy is desired , ovulation can be induced with clomiphene citrate.

. If the pregnancy is not desired, cyclic estrogen with progestin or cyclic medroxy-

progesterone acetate.

iii.Perimenopausal and postmenopausal women:3-6 months of cyclic medroxyprogesterone

acetate ( 10-20mg for 10-12 days every month) or a depot of medroxyprogesterone acetate ( 200mg I.M. every 2 months for three courses), repeat sampling at 3-6 months is mandatory.

Hysterectomy: especially in persistent hyperplasia following treatment with progestational agents or in women with severe atypical adenomatous hyperplasia

Dr. Essam Abushwereb.Dr. Essam Abushwereb.Consultant Gynae&obst.Consultant Gynae&obst.

Thank you