Uterine Fibroid

UTERINE FIBROID
LEIOMYOMA
By: Ms. Faizah, Mr. Ng De Lone, Mr. Zulhilmi
OBJECTIVES
To understand the pathogenesis and features of
uterine fibroid
Clinical presentation of uterine fibroid and its
impact on womens health, pregnancy and
reproductive function.
Diagnosis of uterine fibroid by history & physical
examination
Laboratory investigations and imaging modalities.
Management (surgical and non-surgical) according
to age, symptomatology, site and size of fibroid
and wishes for reproductive function.
INTRODUCTION
Definition:
Benign tumors that arise from the

overgrowth of smooth muscle and connective
tissue in the uterus
Commonest benign tumor in women
> 25% of women in reproductive age group
have uterine fibroid.
> 50% of all women will develop at least one
fibroid during their lives
Primary indication for hysterectomies carried
out in US
Factors Associated with development of

Uterine Fibroid
RISK
Reproductive age
Race: Ethnicity ( AfricanAmerican)
Nulliparity
Family history
Obesity
PCOS
DM, HTN
RISK
Smoking
OCP
Injectable progesterone
PATHOGENESIS
Benign smooth muscle tumor of myometrium
Initiating factors are not known; seems to arise from
a single myometrial cell

Growth is dependent on ovarian sex steroid
hormones
Rare before menarche and regress after menopause
Macroscopic features of Fibroid

Spherical, well circumscribed tumour,
Pale-whitish mass, with sheets of whorled
appearance on cut section

Pseudocapsulated
Consistency: firm to hard
Receive blood supply at peripheries and
very few vessels transverse the pseudocapsule to reach the core
As fibroid increase in size, it often outgrows
the
blood
supply
and
undergoes
degenerative changes.
Microscopic Features :
Tumour consists of bundles of plain muscle cells,
separated by varying amount of fibrous strands
DEGENERATIVE CHANGES
1. Hyaline degeneration
Commonest
Smooth muscles are replaced by hyaline tissue
Soft , on cut section whorled pattern lost & become

cystic
Degenerative changes
2. Cystic degeneration
Hyaline substance breakdown
3. Calcification
Common in post-menopausal
Fatty degeneration
Rare
5 Red degeneration : Occurs during
pregnancy
Haemorrhage into tumor

Painful
SITES
Commonly start from myometrium and can
attain impressive dimension

Intramural
Sub mucosal
Subserosal
Cervical fibroid
Broad ligament fibroid
Pedunculated fibroid with long stalk or pedicle
mobile
Sub mucosal fibroid which may protrude from

cervical canal
Subserosal fibroid latching on blood supply of
omentum and mesentery losing its uterine
attachment parasitic fibroid
Parasitic fibroid can invade great vein and
migrate up to level of atrium of heart (rare)
Intravenous leiomyomatosis
CLINICAL PRESENTATION
Symptoms:
Mostly
asymptomatic
Depends on:
Site and size
Pressure on other pelvic structure
Pregnancy status
Clinical features
Heavy, painful, prolonged vaginal bleeding
(Menorrhagia)
Intramural, subserosal, cervical fibroid

Untreated excessive & prolonged bleeding anaemia
( weakness/ dyspnea/ CCF)
Intermenstrual bleeding (Metrorrhagia)

sub mucosal fibroid ulcerating from endometrium or
protruding from cervical canal
Non-specific symptoms:
Pelvic congestion, lower abdominal bloating, heaviness
Dyspareunia (some)
CLINICAL PRESENTATION
Pain : Uncommon
May occur:
If fibroid is impacted
Undergoes acute torsion
Red degeneration during pregnancy
Pressure effect on surrounding structure
Uncommon
Difficulty in micturition/ defecation
Rapid growth in size especially after
postmenopausal period
Leiomyosarcoma
Symptoms related to pregnancy

Sub fertility
Difficulty in conception/ early pregnancy wastages
Exact mechanism cant be explained
Fibroid distorts endometrial cavity or impedes implantation
Location of fibroid has been shown to affect both fertility &
early pregnancy loss.
Subserosal:
Does not affect fertility outcome.

Abnormal lie/prolonged labour/ delivery of placenta/ PPH/
subinvolution of uterus in puerperium
Intramural & Sub mucosal : fertility &

miscarriage rate
Improvement following myomectomy
SIGNS
Central pelvic mass
; palpable on bimanual
examination as firm, irregularly enlarged uterus with

smooth or bosselated surface.
Those with long stalks ; maybe palpated
abdominally as separated masses from uterus.

A pedunculated submucous fibroid can prolaspe through
cervical canal presenting with heavy menstrual bleeding,
ulcerations on surface, and infection.
Anemia is common in these situations.
IMAGING MODALITIES
Ultrasonography (transvaginal or transabdominal probe)
- Useful in imaging and locating fibrioids.

- Delineates the site and size and demonstrates any distortions of
endometrial lining.
Doppler assesment
- Blood flow at the peripheries of a fibroid is a characteristic finding.
MRI
- Employed if fibroid dimension and site needs to be assessed
accurately.
Hysteroscopy
- Essential imaging tool in submucosal fibroid.
- Hysteroscopic myomectomy through a resectoscope maybe
warranted in symptomatic small submucous fibroids.
Transvaginal sonohysterography
- Endometrial cavity distended with saline infusion and imaged with
a transvaginal ultrasonography.
- This delineates the submucosal fibroid well.
Transvaginal sonohysterography
- Endometrial cavity distended with saline infusion and imaged with
a transvaginal ultrasonography.
- This delineates the submucosal fibroid well.
Diagnostic Laparoscopy
Hysteroscopy
- Recognizes a sub mucous myoma
- Also allows its excision under direct vision
Treatment
Management options
Medical
Surgical
Interventional
radiology
Medical
Management of uterine fibroids depends largely on
the site of fibroids, age of patient, symptoms and

how it affects the quality of life and need for
continued reproductive function.
For e.g., iron deficiency anemia resulting from
menorrhagia is optimized with hematinics and

sometimes with blood transfusions
Anti-fibrinolytic
Menorrhagia can be managed medically.
- Recommended 1st line therapy is tranexamic acid

(anti-fibrinolytic) which reduces blood loss by 50%.
It should be used in preference to NSAIDs
Danazol and Gestrinone

Reduces fibroid size and amount of blood loss
Prolonged use of danazol is limited by significant
androgenic side-effects.
This is contrary to gestrinone where the side effects
are less and fibroid re-growth after cessation of

therapy is gradual.
Mifepristone
Effective in reducing blood loss and uterine size at
various doses with minimal side effects
50% reduction in size is observed when 25 mg
Mifepristone is administered over three months
GnRH Analogues
It suppress the ovaries and induce a milieu of hypoestrogenism.
It controls the symptoms, but causes amenorrhea, vasomotor side-
effects.
Prolonged used; bone dimineralization resulting in osteoporosis
Use prior to surgery (myomectomy or hysterectomy) with concomitant
administration of hematinic effectively optimizes perioperative IDA.

Fibroid size is reduced significantly, making it possible for a transverse
scar on the abdomen or even a vaginal approach during surgery

Leuprolide: 3.75 mg once a month for 3 months
Myomectomy
Surgical removal of fibroid alone, by laparotomy or laparoscopy
Performed if fibroid is the cause of sub fertility or
Preservation of fertility is desired.
Heavy blood loss may occur during surgery
To control bleeding, techniques like:
- Intra myometrial vasopressin injection

- Occlusive clamps
- Tourniquets
Recurrence rate after surgery is 27%
Abdominal myomectomy
Cervical fibroid in a nulliparous woman
Myomas removed in piecemeal
Laparoscopic myomectomy
Feasible in :
- Pedunculated fibroid
- Sub serous fibroid not exceeding 10 cm, not more than four in number
Patient must be counselled for hysterectomy too

if the need arises
Indications of Myomectomy
1.
Persistent uterine bleeding despite medical therapy
2. Excessive pain or pressure symptoms

3. Size >12 weeks, woman desirous to have a baby
4. Unexplained infertility with distortion of the uterine
cavity
5. Rapidly growing leiomyoma during follow up
6. Sub serous pedunculated fibroid
Hysterectomy
Surgical procedure
Definitive treatment and is performed when medical
therapy fails, especially in presence of significant

symptoms affecting quality of life.
3 approaches of hysterectomy
Total
Abdominal hysterectomy
Vaginal
hysterectomy
Laparoscopic
Total Hysterectomy or LAVH
Hysterectomy
Open laparotomy: large fibroids or when the locations, access and
surgery itself poses great difficulties.

Vaginal approach is reserved for smaller one.
Supracervical hysterectomy adv:
1.
Shorter operating time
2. Less risk of injury

3. Better sexual function (since the vaginal length and cervix are
preserved)
4. Lesser risk of vault prolapse. The risk of malignant change in cervical
stump is negligible (<1%)
Uterine Artery Embolization

Injecting polyvinyl alcohol particles into uterine artery (via
femoral artery catheterization) to embolize uterine vascular bed.

Severe Cx are uncommon.
Effective in reducing blood loss and the fibroid size gradually.
Severe post-procedural ischemic pain is often encountered.
UAE can reduce the size of fibroids by up to 50%, with relief of
abnormal bleeding and pressure symptoms. Women report being

very satisfied by the treatment. Although longer term information
is more limited, many women will have a sustained improvement.

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UTERINE FIBROID

By: Ms. Faizah, Mr. Ng De Lone, Mr. Zulhilmi

Benign tumors that arise from the

Factors Associated with development of

a single myometrial cell

Macroscopic features of Fibroid

appearance on cut section

Smooth muscles are replaced by hyaline tissue

Soft , on cut section whorled pattern lost & become

Hyaline substance breakdown

Haemorrhage into tumor

attain impressive dimension

Pedunculated fibroid with long stalk or pedicle

Sub mucosal fibroid which may protrude from

Intramural, subserosal, cervical fibroid

Intermenstrual bleeding (Metrorrhagia)

Pelvic congestion, lower abdominal bloating, heaviness

Symptoms related to pregnancy

Does not affect fertility outcome.

Intramural & Sub mucosal : fertility &

Improvement following myomectomy

examination as firm, irregularly enlarged uterus with

abdominally as separated masses from uterus.

- Useful in imaging and locating fibrioids.

the site of fibroids, age of patient, symptoms and

menorrhagia is optimized with hematinics and

- Recommended 1st line therapy is tranexamic acid

It should be used in preference to NSAIDs

Danazol and Gestrinone

are less and fibroid re-growth after cessation of

various doses with minimal side effects

50% reduction in size is observed when 25 mg

Mifepristone is administered over three months

administration of hematinic effectively optimizes perioperative IDA.

scar on the abdomen or even a vaginal approach during surgery

- Intra myometrial vasopressin injection

Cervical fibroid in a nulliparous woman

Myomas removed in piecemeal

Patient must be counselled for hysterectomy too

Persistent uterine bleeding despite medical therapy

2. Excessive pain or pressure symptoms

therapy fails, especially in presence of significant

Total Hysterectomy or LAVH

surgery itself poses great difficulties.

Shorter operating time

2. Less risk of injury

stump is negligible (<1%)

Uterine Artery Embolization

femoral artery catheterization) to embolize uterine vascular bed.

abnormal bleeding and pressure symptoms. Women report being

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