FIBROIDSDR. PREKSHA JAIN

DR. PRACHI DIXIT

Contents

• Introduction

• Incidence

• Etiology

• Risk factors

• Symptoms

• Natural history

• Secondary changes &

complications

• Diagnosis & Types

• Fibroids in Pregnancy

• Treatment (Medical & surgical)

• Recent advances

Introduction

• Definition

• Myoma, leiomyoma, fibromyoma

• Derived from smooth muscle cell rests from vessel wall

or uterine musculature

Incidence

• M/c benign tumors of myometrium

• 77% of hysterectomy specimen

• 60% in 35-49 yrs

• 80% in >50 yrs

• 40% in 35 yrs

• 70% in 50 yrs

Afro american

White women

Etiology

• Genetic (40%)

• Hormonal

• Growth factors

Genetics

• Cellular, atypical & large fibroids

• Translocations 12 & 14 chrm

• Deletion of 7 chrm

• Trisomy of 12 chrm

• Leiomyosarcoma have different origin

Hormones

• E & P increase in receptors no. & responsiveness.

• Hyperestrogenic states- Obesity, Ca endometrium,

early menarche, anovulatory infertility.

• Highest mitotic counts encountered in peak

progesterone production.

• Before puberty & after menopause – less incidence

Growth Factors

• TGF-β, bFGF, EGF, PDGF, IGF, VEGF, PRL

Risk Factors

INCREASE DECREASE NO EFFECT

Age Green veg OCP

Endogenous hormone Exercise IUCD

Family history (2.5 times) Parity STI, CMV, HSV, EBV

Afro American Smoking

Weight

Classification

UTERINE FIBROIDS

BODY CERVIX

INTERSTITIAL SUBSEROUS SUBMUCOUS

SUBSEROUSBROAD

LIGAMENTPARASITIC

• ANTERIOR

• POSTERIOR

• CENTRAL

• LATERAL

• SESSILE

• PEDUNCULATED

75%

15%

10%

OTHERS-

• Intravenous leiomyomatosis• Leiomyomatosis peritonalis disseminata• Bizzare leiomyoma

Symptoms

Asymptomatic 50% (<5cm size & uterus <12cm)

Abnormal uterine bleeding – 30%

Menorrhagia (intramural & submucous)

Metrorrhagia (submucous & endometrial cancer)

Polymenorrhea (cystic ovaries & PID)

Purulent discharge (infected fibroid polyp)

Symptoms

Pain-

• Congestive & spasmodic dysmenorrhea

• Acute pain - torsion, hemorrhage & red degeneration.

• Chronic Pelvic pain

• Rapidly growing sarcoma

Symptoms

Pressure symptoms –

• Retention of urine premenstrual

• Hydroureter & hydronephrosis

• Constipation

• Intestinal obstruction

Symptoms

Infertility – 30%

• >4cm

• Distortion of cavity

• PID, endometriosis, anovulation

• Fertility rate –

Submucous type

Subserosal type- No effect

Intramural type - slightly decrease

Symptoms

Abdominal lump –

• Rapid growth

• Pseudo Meig’s syndrome

Others –

• Secondary to anemia

• Vaginal discharge

Natural History

• Grow slowly 9% over 1 year

• Regress after menopause

• Rapid growth in Premenopausal- indicates pregnancy

not sarcoma

• Postmenopausal with pain & bleeding- Sarcoma

• Secondary or degenerative changes

Secondary changes & complications

• Hyaline 65%, cystic, fatty, calcareous 10% & red

degeneration, necrosis

• Atrophy

• Sarcomatous change

• Torsion, Inversion, Hemorrhage, Infection

• Association with endometrial cancer(3%), adenomyosis/

endometriosis 30%, salpingoophoritis 15%, Anovulation

CYSTIC DEGENERATION

HEMORRHAGE & CALCIFICATION

RED DEGENERATION

SARCOMATOUS – 0.1-0.5%

ENDOMETRIAL CANCER

Diagnosis

• History

• Pelvic Examination – enlarged irregularly, firm, non

tender, mobile, arising from uterus.

• FIGO classification

• Imaging

Imaging

IMAGING SENSITIVITY SPECIFICITY

MRI 100% 91%

TVS 83% 90%

SIS 90% 90%

Hysteroscopy 82% 87%

MRI

TAS

TVS

SIS

Differential diagnosis

• Pregnancy

• Hematometra

• Adenomyosis

• Bicornuate uterus

• Ovarian cysts & tumors

• Ectopic pregnancy

• Pelvic kidney

• Chronic inversion

Management Routine investigations

Others – IVP, Laparoscopy

Treatment-

• Conservative-

1. Observation

2. Medical

3. Non-invasive- MRgFUS

4. Minimally invasive- UAE, Myolysis

5. Invasive- Thermal Ablation

• Surgical –Polypectomy, Myomectomy, Hysteroscopicresection, Hysterectomy

• INDICATIONS for intervention:

1. Infertility

2. Recurrent pregnancy losses

3. Asymp >12wk/pedunculated

4. Pressure symptoms

5. Rapidly growing fibroid/ growth after menopause

6. Symptomatic- AUB

Medical Management

• Temporary palliation-

1. Menorrhagia

2. Before surgery-

Correction of anemia,

decrease size &

vascularity

3. Postpone surgery

• Alternative to surgery

1. Perimenopausal

2. Desiring fertility

3. Unfit for surgery

Drug Dose Advantage Disadvantage

ANTIFIBRINOLYTICS Tranexamic Acid

1-4gm/d

blood loss

Correct anemia

Size remain same

GnRH AGONIST Goserelin (Zoladex)

3.6mg every 28days

3-6mth s/c

30% size

35% ut vol

in 6mth

• Hypoestrogenic effect

• Rebound size

• Loss of plane

• Seedling fibroids missed

• Expensive

GnRH ANTAGONIST Cetorelix, Ganirelix 30% size in

3weeks

Under evaluation

ANTIANDROGEN Danazol 200-400mg

6-12mth

Gestrinone

Volume

No regrowth

Androgenic effect

PROGESTERONE

ANTAGONIST

Mifepristone

25-30mg 3-6mth

25-75% size

50% ut vol

Amenorrhea

Endometrial hyperplasia

Hot flushes, deranged LFT

• Antiestrogen- Faslox, Raloxifene, fadrozole (aromatase

inhibitor)

• MIRENA

• Others- chinese herbal medicine

SPRM

• Selective progesterone receptor modulator

ULIPRISTAL -

• Partial agonist & antagonist of Pg receptors

ASOPRISNIL –

• 10-25mg per day 3mth

• Inhibits growth

• Decreases uterine artery blood flow & menorrhagia

• No effect on endometrial proliferation

Magnetic Resonance guided Focused

Ultrasound• FDA approved Oct 2004

• Selection criteria-

1. 4-10cm fibroids

2. Family completed

3. Perimenopausal

4. Subcut tissue to fibroid <12cm

5. Clearly visible on MRI

• Thermal ablation

• 31% reduction ut vol in 6mth

• US is focused either

1. Geometrically via Lens, Curved Transducer

2. Electronically via Phased Array

• Adv-

1. No scar

2. Short stay, early resuming of activities

3. Least chances of infection, complications

4. Repetition of procedure with low risk

Uterine Artery Embolization

• Procedure

• Indication-Symptomatic fibroid, surgery not feasible

• Contraindications-

1. Immunocompromised

2. Genital tract infection or malignancy

3. Vascular disease

4. Contrast allergy/ impaired renal function

5. Infertility

• Adv-

1. 80% decrease in menorrhagia, 33% reduction of fibroid

in 3mth. Success rate 85-95%.

2. Short stay

3. No bleeding, adhesions

• Disadv-

1. Postembolization syndrome

2. Early ovarian failure & early menopause

3. Effect on fertility & pregnancy

4. May require hysterectomy

5. Death, sepsis, loss of organs

Myolysis

• Lap procedure

• Destroys by laser, cryotherapy, electrosurgical energy

• Indications-

1. Perimenopausal 3-10cm

2. Ut size < 14wk

Surgical Management

• I/c-

1. Severe anemia

2. Torsion

3. Pain, urinary symptoms compromising QOL

• Preoperative-

1. Correction of anemia

2. Control menorrhagia

3. Control medical problems

ACOG criteria for Hysterectomy

• Confirmation of indication:

1. Asymptomatic 12wk concern to patient

2. Excessive bleeding- Profuse bleeding >8days or

anemia

3. Pelvic discomfort- Acute & severe or chronic pain,

Pressure symptoms

Myomectomy

I/c : Unexplained infertility with cavity distortion

Unexplained RPL

Fertility conservation

Subserous pedunculated

• Prerequisities-

1. Correct Hb, oral iron, GnRH-a, Autotransfusion

2. Other causes of infertility should be ruled out

3. Consent for hysterectomy

4. Perform in preovulatory menstrual cycle

5. Endometrial cancer rule out by D&C

Myomectomy

• Types-

1. Vaginal

2. Hysteroscopic resection of submucous myomata

3. Laparoscopic

4. Abdominal

Abdominal Myomectomy1. Examination rectovaginal abdominal bimannual examination under

anesthesia

2. Cervical dilatation

3. Maylard incision & retraction

4. Prevent adhesions

5. Prevent blood loss- Hypotensive anesthesia, temporary uterine artery

occlusion or vasoconstrictive agents, CO2 laser

6. Planning Uterine incision

7. Dissection & Enucleation

8. Repairing defects - Bonneys hood method, Complete obliteration of cavity

9. Serosal closure - Baseball sutures.

10. Confirm hemostasis.

Results of Myomectomy

• Complications-

1. Intraperitoneal bleeding

2. Infections

• 80% menorrhagia controlled

• 40-60% pregnancy rate

• 5% take home baby rate

• 30-50% recurrence

• 20-25% relaparotomy

VAGINAL

MYOMECTOMY

BONNEY’S HOOD

PROCEDURE

Radiofrequency Ablation

• Halt’s method

• Under Phase 3 clinical trials awaits approval

• 3 small incisions-

1. Laparoscopic camera

2. Intraabdominal ultrasound probe

3. Halt Device

Gene Therapy

• Recent evidence suggests that, fibroids develop as an

over expression of p14Arf Gene.

• This drives a negative feedback loop between, p53 &

MDM2 genes, which governs the fate of each individual

fibroid.

• NUTLIN -3, a known MDM2 antagonist, was thus used

to oppose the proliferative activity in cell cultures from

fibroids.

• It also stimulates Senescence Gene- p21 & Apoptosis

Gene- BAX, in vitro.

Fibroids in Pregnancy • Incidence – 18%, 1 in 1000

• Effect of pregnancy –

1. Increase in vascularity & size

2. Torsion of subserous

3. Puerperal infection

4. Red degeneration – 5%

Presentation

Appearance

Cause

• Effect of fibroid on pregnancy –RPL, Ante, intra, postpartum

• Indication of removal during CS-

1. Pedunculated subserosal

2. Interfering with delivery or closure

3. Intractable pain

4. Incarcerated fibroid

5. Rapid growth with pressure symptoms