MEANING:

Fibroids are the tumours composed

of smooth muscle and fibrous
connective tissue of uterus. These
are commonly benign tumours.
- D C. Dutta
ALTERNATIVE NAMES :
• Myoma
• Leiomyoma
• Fibromyoma
• Uterine tumour
• Myomata
• Fibromyomata
TUMOURS OF THE BODY OF UTERUS
I. BENIGN : II. MALIGNANT :
1. Adenoma 1. Carcinoma
2. Myoma 2. Sarcoma
3. Chorio-carcinoma
4. Mesodermal
mixed tumour
5. Secondaries
INCIDENCE:
 20% of women at 30 years of age
(asymptomatic)
 3% of women in OPD (symptomatic)
 10% more prevalence in England
 Higher rate in black race
 More common in nulliparous or in
women having infertility after 1 child
 Highest prevalence between 35-45years
SITES OF FIBROIDS:
HISTOGENESIS :
Risk factors for fibroids:
Increased risk Reduced risk

 Nulliparity  Multiparity
 Obesity  Smoking
 Hyperestrogenic
state
 Black women
 Age between 35-45
F/h/o tumour
ETIOLOGY :

1. Unknown
2. Immature muscle cells present in
myometrium
3. Excessive Oestrogens
- myomas grow during child
bearing age only.
- after menopause the growth of
tumour stops or regression in size
Causes of Neoplastic transformation :
ORIGIN:
1. Chromosomal abnormality:
- About 30% the chromosome abnormality
is seen in 6th or 7th
chromosome( rearrangement or deletion)
2. Role of polypeptide growth factors:
- Epidermal growth factors (EGF), Insulin
like growth factor-1( IGF-1), Transforming
growth factor (TGF), stimulate the growth
of leiomyoma directly or via estrogen
GROWTH:
• Predominantly estrogen-dependent
tumuor.Oestrogen dependency evidenced by:
 Growth potentiality is limited to during child
bearing period
 Increased growth during pregnancy
 They don’t occur before menarche
 Following menopause, decrease in size of
tumour or cessation of growth.
 Frequent association of anovulation
 More of oestrogen receptors than adjacent
myometrium
Contd…
• Growth rate is slow & takes about 3-5
years to be felt per abdomen
• Grows rapidly during pregnancy or pill
users
• Rapid growth can be due to
degeneration or malignant change
FEATURES OF TUMOURS:
 Arise from muscles not from fibres
 Single or multiple ( upto 200)
 Size variable from millimeters to the size of
foot ball (filling whole abdomen)
 Spherical in shape & firm consistency
 Surrounded by pseudo-capsule
 Cut surface of the tumour becomes convex
& has white whorled appearance
 Nuclei rod shaped, uniform in size & shape
TYPES OF FIBROIDS:
I. Body (Corporeal)
II. Cervical

1. Interstitial or Intramural
2. Sub-peritoneal or subserous
3. Submucous
4. Pseudo-cervical fibroids
TYPES OF FIBROIDS :
TYPES OF FIBROIDS :
INTERSTITIAL or INTRAMURAL:
- In this case the myomas grow &
stay in the wall of the uterus
- Surrounded by myometrial tissue
- Initially fibroids are intramural
subsequently pushed outward or
inward
- 70% persist in position.
SUBSEROUS:
- Fibroid are partitially or completely
covered by peritoneum
- When completely covered it attains a
pedicle called as ‘Pedunculated
subserous fibroid’
- If the pedicle is torn then it gets
nourishment from omental or
mesenteric adhesions called as
‘Wandering’ or ‘Parasitic fibroid’.
Contd…
- If the fibroid is pushed out in between
the layers of broad ligament, called as
‘ Broad ligament fibroid’ ( false or
pseudo)
SUBMUCOUS:
- Fibroids grow towards the uterine cavity or
cervical canal, may form a polyp in the
cavity & covered by the endometrium.
- They come out through the cervix, may be
infected or ulcerated causing metrorrhagia.
FATE –
 Surface necrosis
 Polypoid change
 Infection
 Degerations
SUBMUCOUS FIBROID:
CERVICAL
o Rare about 1-2%
o Seen in supravaginal part of cervix, may
be any one above type
o May be anterior, posterior, lateral or
central depending on position
o Disturb the pelvic anatomy, specially
ureter
PSEUDOCERVICAL:
• Fibroid polyp
arising from the
uterine body
when occupies &
distends the
cervical canal, it
is called as
Pseudocervical
fibroid.
CORPOREAL FIBROIDS
PATHOLOGY OF FIBROIDS:
Secondary changes in fibroids:

1. Degeneration
2. Atrophy
3. Necrosis
4. Infection
5. Vascular changes
6. Sarcomatous change
1.DEGENERATION:
a. Hyaline degeneration- common type, firm
feel of tumour becomes soft elastic.
b. Cystic degeneration- after the
menopause, in interstitial fibroids.
Liquefaction of areas with hyaline
changes, if becomes big may be confused
with ovarian cyst or pregnancy
c. Fatty degeneration- at or after
menopause, fat globules get deposited in
muscle cells
d. Red (carneous) degeneration- occur in
2nd half of pregnancy or puerperium.
Cut section revealing raw beef
appearance, cystic space & fishy odor
e. Calcareous degeneration- common in
subserous type followed by fatty
degeneration. There is precipitation of
calcium carbonate or phosphate then
whole tumour is converted into
calcified mass called ‘Womb stone’
2. ATROPHY
• Following menopause due to loss of
oestrogen support
• Reduction in size of tumour ( as similar
to that occurs after pregnancy)
3.NECROSIS :
• Inadequacy of circulation leads to
central necrosis of tumour ( in
submucous polyp or subserous)
4. INFECTION:
• Gains way to tumour through the thinned
& sloughed surface epithelium of
submucous fibroid, following abortion or
delivery
5. VASCULAR CHANGES:
• Dilatation of the vessels (telangiectasis)
• Dilatation of lymphatic channels occur.
6. SARCOMATOUS CHANGES:
• Occur in less than 0.1%
• Usual type is lieomyosarcoma.
CHANGES IN THE PELVIC ORGANS:
> Uterus- Shape distorted, asymmetrical
-Endometrium with features of anovulation
with hyperplasia, as result becomes thick,
congested & edematous
> Uterine tubes- Frequent infection
> Ovaries- Enlarged, congested & filled
with multiple cysts.
> Ureter- Compressed leading to
hydroureter or hydronephrosis
CLINICAL FEATURES:

PATIENT PROFILE:
 Usually nalliparous
 Chronic secondary infertility
 Early marriage
 Frequent child birth
 Age between 35-45 years
 Delayed menopause
Contd…

SYMPTOMS:
 Asymptomatic (75%)
 Symptoms depend on anatomic type &
size
 Symptoms depend on the site than the
size
 Small submucous fibroid may produce
more symptoms than big subserous
fibroid
I. Menstrual abnormalities:
1. Menorrhagia (30%)
CAUSES:
• Increased surface area of endometrium
• Interference with normal contractility
• Congestion & dilatation venous plexuses
• Endometrial hyperplasia due to
hyperoestrinism
• Pelvic congestion
• Role of prostanoids
Contd…

2. Metrorrhagia:
CAUSES:
• Ulceration of submucous fibroid or
fibroid polyp
• Torn vessels from the sloughing base
of polyp
• Associated endometrial carcinoma
Contd…

3. Dysmenorrhoea:
 Congestive variety- may be associated
with pelvic congestion or
endometriosis
 Spasmodic type- may be associated
with extrusion of polyp & its expulsion
from the uterine cavity
Contd… II. INFERTILITY:
CAUSES:
1. Uterine –
> Distortion & or elongation of uterine cavity
difficult sperm ascent
 Prevent rhythmic uterine contraction
during intercourse impaired sperm
transport
 Congestion & dilatation of endometrial
venous plexuses defctive nidation
 Atrophy & ulceration of endometrium
Contd…
2. Tubal –
 Conual block due position of fibroid
 Marked elongation of tubes over big
fibroid
 Association salpingitis with tubal block
3. Ovarian – Anovulation
4. Peritoneal – Endometriosis
5. Unknown
III. Pregnancy related problems:
• Abortion
• Preterm labour
• IUGR
• PPH
Causes:
- Defective implantation of placenta
- Poorly developed endometrium
- Reduced space for the growing fetus
IV. Pain lower abdomen
• Usually painless
CAUSES:
- Due to tumour degeneration
- Torsion subserous pedunculated fibroid
- Extrusion of polyp
- Associated pathology like PID,
endometriosis
V. Abdominal swelling
- Heaviness in lower abdomen
VI. Pressure symptoms:
- Constipation
- Dysuria
- Retention of urine
- Hydroureter
- Hydronephrosis
- Infection
- Pyelitis
SIGNS:
1. Pallor
2. Enlargement of abdomen
3. Firm feel on palpation
4. Restricted mobility
5. Dullness on percussion
6. bimanul findings
- Irregular uterus
- Cervix moves with movement of tumour
INVESTIGATIONS:
1. History
2. Pelvic examination
3. USG & Colour doppler (TVS)
- Uterine contour enlarged & distorted
- Echogenecity vary
- Vascularisation at periphery
- Central vascularisation indicate
degeneration
Contd…
4. MRI
5. Laparoscopy
6. Hysteroscopy or HSG
7. Uterine currettage
8. Straight x-ray
9. IVF
10. Blood tests
11. Urine analysis
DIFFERENTIAL DIAGNOSIS
• Pregnancy
• Full bladder
• Adenomyosis
• Myohyperplasia
• Ovarian tumour
• TO mass
COMPLICATIONS:
• Persistent menorrhagia, metrorrhagia or
vaginal bleeding leading to severe
anaemia
• Severe intraperitoneal haemorrhage
• Severe infection leading to peritonitis or
septicaemia
• Sarcoma
 MANAGEMENT PROTOCOL:

Cervix
Body

Symptomatic Asymptomatic

Regular supervision Surgery

Medical Surgery

Endoscopic Hysterectomy Supravaginal vaginal

resection Size increases Size stationary

Myomectomy
Myomectomy Hysterectomy
Surgery Follow up

Myomectomy Polypectomy
MEDICAL MANAGEMENT:

Objectives:
 To improve menorrhagia & correct
anemia
 To minimise size & vascularity of tumour
 To facilitate endoscopic surgery
(infertility)
 An alternative to surgery
 When surgery is postponed temporarily
DRUGS TO MINIMISE BLOOD LOSS:
• Progestogens
• Antifibrinolytics
• Antiprogesterones
• Prostanglandin synthetase inhibitors
• Danazol
• GnRH analogues
- Agonists
- Antagonists
Benefits of GnRH analogue therapy:
• Improvement of menorrhagia & may
produce amenorrhoea
• Improvement of anaemia
• Relief of pressure symptoms
• Reduction in size(50%), used for 6months
• Reduction in vascularity of tumour
• Reduction blood loss during myomectomy
• May facilitate laparoscopic or
hysteroscopic surgery
SURGICAL MANAGEMENT:
1. Myomectomy:
Indications:
 Patient in reproductive age group
desirous of having a child
 Age below 35 -40
 Recurrent pregnancy wastage
 Patient consent to save uterus
 Nulliparous women
Contd…
Prerequisites for myomectomy:
• Examination of husband from fertility
point of view
• Hysteroscopy or HSG to detect fibroid
encroaching uterine cavity or polyp or
tubal block
• Diagnostic DC in irregular cycles to
detect polyp or endometrial carcinoma
Contd…
Contraindications:
1. Infertility- if tubes blocked
- If azoospermia or oligospermia
2. Associated carcinoma
3. Associated bilateral infective TO mass
4. Infected fibroids
5. Big broad ligament fibroid
6. Too many fibroids
7. Sarcomatous change
8. Associated regnancy
MYOMECTOMY:
2. ENDOSCOPIC SURGERY:
a. Hysteroscopy:
- Fibroid 3-4cm diameter or polyp resection
- Pedicle or base of fibroid coagulated
- complications-
perforation, fluid overload, haemorrhage,
pulmonary oedema, cerebral edema,
hyponatraemia, gas embolism, injury to
other abdominal organs, Neurological
symptoms
 Contd…
b. Laproscopy:
- Subserous & intramural can be removed
- Electrocautery, laser, & extra corporeal
sutures used for haemostasis
Contraindication: fibroid too large, deep
intramural, multiple or technically
inaccessible.
Complications: Extraperitoneal insufflation,
omental emphysema, cardiac arrhythmia,
injury to blood vessels, injury to other
organs, thermal injury, gas embolism etc.
3. HYSTERECTOMY:
-Indications: Sudden distoration of GC
: Associated endometriosis
- Removal of ovary
Advantages of hysterectomy
 No chance of recurrence
 Adnexal pathology & unhealthy cervix
- Vaginal hysterectomy- If size of 10-12
weeks of pregnancy with uterine prolapse
- Embolisation of uterine arteries to cause
avascular necrosis & shrinkage of fibroid
HYSTERECTOMY:
ASYMPTOMATIC FIBROID:
1. Observation:
 Perform diagnostic tests
 Begin expectant therapy
 Size < 12 wks of pregnancy
 Diagnosis certain
 Follow up
 Periodic examination at 6mth interval
 Observe the symptoms of fibroids
Contd…
2. Surgery:
Indications:
- Size >12 wks of pregnancy
- Diagnosis not certain
- Fibroid grows during follow up
- Subserous pedunculated fibroid
- Unexplained infertility with distortion of
uterine cavity
- Unexpalined recurrent abortion
- Present in lower pole of uterus likely to
complicate delivery
CERVICAL FIBROIDS
SYMPTOMS:
1. Anterior cervical:
- Frequency or retention of urine
2. Posterior cervical:
- Rectal symptoms (constipation)
3. Lateral cervical:
- Vascular obstruction
- Haemorrhoids
- Pedal oedema
- Ureters pushed laterally & below tumour
Contd…

4. Central cervical:
- Produce bladder symptoms
- Cervix expanded on all sides
- Asymptomatic during pregnancy
- Obstruction during labour.
- If pedunculated, sensation of something
coming out, if infected a foul smelling
discharge per vagina
TREATMENT:
1. Supravaginal fibroids:
 Myomectomy – Its not only technically
difficult but the anatomic & functional
restoration of cervix cannot be adequate
to achieve the future reproduction
 Hysterectomy
2. Vaginal part fibroids:
 Myomectomy
 If, pedunculated polypectomy
PREGNANCY AND MYOMAS

EFFECTS OF MYOMAS ON PREGNANCY:

1. During pregnancy
 Abortion: distortion pf uterine cavity,
defective implantation, interference
with accomodation & increase in size,
impaction of myoma in pelvis
 Premature onset of labour
 Malpresentation
contd…
2. During labour:
 Abnormal uterine action
 Cervical dystcia
 Obstructed labour
 Retainned placenta
 Post partum haemorrhage
3. During puerperium:
 Puerperal sepsis
 Delayed involution of uterus
Contd…
EFFECTS OF PREGNANCY ON MYOMAS:
 Increase in size
 Change in consistency
 Red degeneration
 Torsion & infection
REMEMBER:
Regular physical check ups
Do not neglect growing mass
Do not neglect irregular cycles
Do not postpone the treatment
Appropriate age for marriage
Follow proper spacing