Leiomyomas (Fibroids)

Desabandu Dr. G.H.K.K. GunawardanaM.B.B.S.,M.S.(Obs & Gyn), F.R.C.O.G.,F.C.O.C.(S.L )Consultant Obstetrician and GynaecologistTeaching Hospital,Peradeniya.

Contents

IntroductionEpidemiologyPathologyClassificationClinical featuresDifferential DiagnosesComplicationsDiagnosisTreatmentsPrevention

Leiomyomas (fibroids)Benign smooth muscle tumors of the uterusCommonly called “fibroids”Estrogen dependentRarely occur before menarche or after

menopauseGrow larger during pregnancyRarely malignantMost common indication for pelvic surgery in

women

Epidemiology of LeiomyomasDevelop from smooth muscle cells by means

of hyperplasiaOccurs in 20% of women of reproductive ageMost often occurs among

Nulliparous womenWomen older than 35NonsmokersOral contraceptive or IUD usersObesePositive family historyAfrican American women

Classification of Leiomyomas

Submucous - Protrude into the uterine cavity Sessile submucous Pedunculated submucousIntramural - Within the myometrial wallSubserous - Growing toward the serous surface of the uterus Sessile Subserous Pedunculated SubserousIntraligamentous - Located in the cervix or in between the folds of the broad ligamentParasitic fibroid – No connection with uterus

PathologyMacroscopy Firm Composed of fibrous tissue and myometrial

tissue If myometrial tissue high - Myoma If fibrous tissue high - Fibromyoma

Growing fibroid Myometrium compressed and

atrophied False capsule

Leiomyomas:SymptomsUsually asymptomaticSymptoms increase as tumors growCommon symptoms

Menstrual disturbance Pressure symptoms Menorrhagia Feeling of “heaviness” Dysmenorrhea Bloating Spotting between periods Pelvic congestion, Varicose

veins Urinary retention, frequency, dysurea

DyspareuniaBack painA lump or swelling in the lower abdomenSubfertility

Leiomyomas Physical Examination

Abdomino pelvic lump Firm Non tender Irregular Mobile in transverse direction Mobility restricted in longitudinal direction except in pedunculated fibroidsAbsence of ascitesNormal bowel soundsMay be mistaken for adnexal mass if situated laterallyIf mass moves with the uterus, likely to be a

leiomyoma

Leiomyomas: Differential Diagnoses

Ovarian neoplasmTubo-ovarian inflammatory massDiverticular inflammatory massPregnancyEctopic pregnancyAdenomyosisPelvic kidneyMalignancy

Complications

Anaemia - Excessive menstrual blood loss can cause anaemia Urinary tract obstruction

Infertility Red degeneration - Very painful and tender Infection

Malignant change ( < 1% )

Complication in pregnancy

Antenatal Intra-Natal Post-Natal

EctopicMiscarriage premature delivery Placenta praeviaPlacental abruptionIUGRRed degenerationAnaemiaUnstable lie

MalpresentationObstructed labourPrimary PPHDifficult LSCS

Secondary PPHNecrosis and infectionPoor uterine involution

Fibroid in pregnancy

Diagnosis

USSCharacteristically appears hypoechogenic and well defined lesions

Hysteroscopy Pedunculated and submucous myomas can be

identified

Laparoscopy

Operative diagnosis

Hysteroscopy

USS

Uterus with big Myoma laparoscopic view

Laparoscopy

Management

Depends on Symptoms The location of fibroids Size and number of the fibroid Fertility wishes Patient’s wishes Facilities of the unit and the experience of

the operator

Management cont…1. Monitoring If the fibroids are causing no symptoms

and are not large, ‘wait and see’ approach Re-evaluate every 3-6 months Pelvic ultrasound as needed Monitor Hb frequently

Management cont…2.Medical treatment Drugs Oral contraceptive pills, either combination pills or progestin-only, in an effort to manage symptoms

Hormones, used in combination to shrink the fibroids prior to surgery Long term progesterone GnRH - analogues Danazole Gestrinone

Mifepristone Letrazole

Management cont…

3.Arterial embolisation Under local anaesthesia, a fine tube is passed

via an artery in the arm or leg into the main artery supplying the fibroid with blood

The whole process is monitored by x-ray

Fine particles (like sand) are injected into the artery to block the blood supply to the fibroid

The fibroid slowly dies and symptoms should settle over a few months

Arterial Embolisation

Management cont…

4.Ablation Therapy

HIFU (High intensity focused ultrasound), (Magnetic Resonance guided Focused Ultrasound)

Non-invasive intervention Uses high intensity focused ultrasound

waves to ablate (destroy) tissue in combination

with Magnetic Resonance Imaging (MRI)

Laser ablation

Management cont…

5.Surgical management Myomectomy

HysterectomyOnly the fibroid is removed 1. Hysteroscopic myomectomy

2. Laparoscopic myomectomy

3. Open myomectomy

Entire uterus is removed 1. Abdominal hysterectomy 2.Vaginal hysterectomy

Management cont…

Myomectomy is indicated when,

Solitary pedunculated myoma

Nature or location of the myoma appears to be interfering with fertility – sub

serous myoma or myomatous polyps

Myoma is causing pregnancy loss

Preservation of fertility is required

MyomectomyHysteroscopic myomectomy Fibroids are removed via the cervix, using a

hysteroscope Recommended for submucosal fibroids

Laparoscopic myomectomy Myomectomy through laparoscopy

Open myomectomy (Laparotomy & myomectomy) Larger fibroids removed via an abdominal incision. This weakens the uterine wall and makes Caesarean sections for subsequent pregnancies more likely

Management cont…

VaginalMyomectomy

Laparoscopic myomectomy

Open myomectomy

Management cont…

HysterectomyHysterectomy will indicated in,

Rapid enlargement of the uterus may mean possible malignancy

Abnormal uterine bleeding not responding to other methods of treatment and that may lead to anaemia

Pelvic painSecondary dysmenorrheaUrinary symptomsUterine growth after menopausePatient has completed childbearing

Management cont…

Hysterectomy

Abdominal Vaginal hysterectomy

hysterectomy

Type of hysterectomy depend on The size of the lump Previous abdominal surgeries

Fibroids — prevention

As the cause of fibroids is still unknown, there are no clear guidelines for preventing them

There are some things you could do that may help to reduce the risk

Keep your weight in check. This will minimize oestrogen levels in body

Eat green vegetables and fruit, and avoid red meat

Some studies suggest the combined pill may protect against fibroids by keeping hormone levels from peaking and falling

Thank You