fibroids – Flashcard

-Myoma Fibromyoma Leiomyoma

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- Commonest genital tract tumor - One of the most common tumors of the body - Affect almost one in every 4 women Age . Limited to fertile period Race . More common in black race Parity . More common in nulliparous women Family history . More with +ve family history BMI . More in obese

unknown , possible relation to Estrogen: . Appears only during the period of ovarian activity . Shrinks in size after menopause . Increases in size during pregnancy & returns to original size after delivery . Commonly associated with estrogen dependent disease . Drugs that lower serum estrogen may cause shrinkage in the size of fibroids

All fibroids originate in the myometrium, then: I- In the body of the uterus . may remain within the myometrium " interstitial fibroid " 70% . Or protrude outwards to lie under the peritoneum " subserous fibroid " 20% . Or protrude inwards to lie under the endometrium " submucous fibroid " 10% 2- In the cervix ( < 5% of all fibroids ) . May remain within the cervix " true cervical fibroid " . Or protrude outwards to lie inbetween the 2 layers of the broad ligament " pseudo cervical fibroid " . Or protrude inwards in the cervical canal " cervical fibroid polyp "

- Number : usually multiple ( 90 % ) - Size : variable ( lentil size to watermelon size ) - Shape : usually spherical , may be ovoid - Consistency : usually firm ( if not complicated ) - Cut section : whorled appearance - Capsule : false capsule (compressed myomet ) - Rate of growth : variable

- Fibroid is paler, harder & more fibrous than the surrounding uterine wall - Fibroid is surrounded by a thin plane of loose cellular tissue containing blood vessels - Fibroids receive their blood supply from the vessels in the surrounding capsule - Within the fibroid itself, there are very few blood vessels

1- Subserous fibroids may adhere to a nearby abdominal structure ( omentum), obtain a new blood supply from it , become detached completely from uterus " parasitic fibroid" 2- Submucous fibroids may grow inwards & become totally situated in the uterine cavity with a thin pedicle joining it to the uterine wall "submucous fibroid polyp". Uterine contractions may expel this polyp through the cervix into the vagina ( infection, sloughing, ulceration) 3- Degenerative changes Poor blood supply may lead to degenerative changes, there are many forms: . Hyaline degeneration . Cystic degeneration . Fatty degeneration . Calcareous degeneration Apart from causing a change in the consistency of the fibroid, they have no clinical significance 4- Red degeneration (necrobiosis) . Occurs mostly during ***pregnancy & puerperium . Cause is unknown . Fibroid becomes dark red in color ( name) . Usually leads to ***severe abdominal pain & tenderness . May be associated with vomiting & low grade fever . Self limited (about one week ) 5- Malignant transformation . Very rare ( 0.1%) , more in large tumors . Sarcoma . Usually there is rapid increase in size & pain

1- Asymptomatic fibroids discovered accidentally during routine examination 2- Symptomatic fibroids causing abnormal genital bleeding, pain or pressure symptoms 3- fibroids associated with infertility

. Common presentation (about 50%) . Usually discovered on routine clinical examination or pelvic ultrasound . No relation between number or size of fibroids & the presence of symptoms . No treatment is needed, just assurance & follow-up

Any form of abnormal uterine bleeding can arise . Menorrhagia & menostaxis in interstitial and submucous fibroids . Metrorrhagia in ulcerated submucous fibroids (if no submucous fibroid, exclude associated endometrial lesion) . Polymenorrhea & delayed menopause if there is associated ovarian dysfunction

. Severe uterine contractions to expel submucous fibroid or a large blood clot . Red degeneration . Pelvic heaviness in big fibroids . Congestive dysmenorrhea

. Bladder frequency & retention of urine . Ureter hydroureter & hydronephrosis . Rectum constipation . Pelvic veins piles . Sacral plexus sciatica

Abdominal mass big subserous fibroids Leucorrhea infected submucous fibroid polyps General weakness fibroids causing severe bleeding

. Which is the cause & which is the effect ? . Fibroids can contribute to infertility by : - mechanical compression or distortion of Fallopian tubes or cervical canal - submucous fibroids may interfere with implantation or cause repeated abortions - infected submucous fibroid polyps may produce vaginal discharge which is hostile to sperms - associated anovulation or endometriosis

. If fibroids cause severe bleeding , general signs of anemia ( pallor, tachycardia) may be elicited. . Otherwise, no abnormal general signs are foun

- Small fibroids cannot be felt on abdominal examination - Big fibroids are usually felt as a central pelviabdominal mass which is usually: . Firm . Not tender . Smooth or irregular surface . Free side to side mobility . Dull on percussion

Uterus is usually enlarged . Symmetrical in submucous & interstitial fibroids . Asymmetrical in subserous fibroid - Uterus may be displaced - Cervix moves with moving abdominal mass - Vaginal mass protruding from the cervix with possible ulceration & foul bloody discharge (submucous fibroid polyp )

***From other causes of uterine enlargement: . Pregnancy . Adenomyosis . Subinvolution . Cancer body From other pelviabdominal masses: . Ovarian tumors . Hydrosalpinx & pyosalpinx . Chocolate cysts . Pelvic kidney

1- Ultrasonography 2- MRI ( fibroid mapping in selected cases ) most accurate but expensive 3- Hysterography & hysteroscopy ( for the diagnosis of submucous fibroids ) 4- Calcified fibroids show on plain x-ray abdomen

. No treatment is required . Only regular follow up

I- Medical treatment : . Small tumors in women near menopause . Small tumors causing moderate bleeding and/or pain . Red degeneration . Prior to surgery to reduce tumor size It entails : . Correction of anaemia . Hemostatic drugs if there is bleeding . Analgesics if there is pain . Drugs which produce hypoestrogenic state that leads to reduction in fibroid size prior to surgery ( GnRH agonists & antagonists)

II- surgical treatment : . Pressure symptoms . Severe bleeding and/or pain . Submucous fibroids . Big fibroids causing abdominal masses . Suspicion of malignancy it entails : . Myomectomy if there is desire for future fertility . Hysterectomy if there is no desire for future fertility

- vaginal myomectomy pedunculated submucous fibroid prolapsed in vagina - hysteroscopic myomectomy small submucous fibroids in the uterine cavity - Abdominal myomectomy big or multiple interstitial or subserous fibroids - Laparoscopic myomectomy small subserous fibroids

- Vaginal hysterectomy only for small uterus (< 10 weeks) - Abdominal hysterectomy either total or subtotal, preserve the ovaries - Laparoscopic hysterectomy

- Myomectomy preserves fertility but it is a bloody operation & there is possible recurrence of fibroids. If pregnancy occurs, delivery must be by elective CS - Hysterectomy is less bloody & leads to permanent cure but it ends fertility

- Immediate Myomectomy . Submucous fibroid . Fibroids causing tubal obstruction . Fibroids causing distortion of cervical canal . Big fibroids . Before starting ART procedures - Observation for 1-2 years before trying myomectomy . Subserous fibroid . Small interstitial fibroids . + all other causes of infertility are excluded

Possible effect of pregnancy on fibroid : - Increase in size (reversible) - Red degeneration Possible effect of fibroid on pregnancy : - possible abortion & premature labor - abnormal uterine action - PROM - IUGR - abnormal presentations - obstructed labour - post partum haemorrhage

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