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Fibroids Dr. Haresh U. Doshi M.D., Diploma (USG), FICOG, PGDMLS Professor & Chief of Unit B.J. Med. College, New Civil Hosp. Ahmedabad.

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Presentation on theme: "Fibroids Dr. Haresh U. Doshi M.D., Diploma (USG), FICOG, PGDMLS Professor & Chief of Unit B.J. Med. College, New Civil Hosp. Ahmedabad."— Presentation transcript:

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2 Fibroids

3 Dr. Haresh U. Doshi M.D., Diploma (USG), FICOG, PGDMLS Professor & Chief of Unit B.J. Med. College, New Civil Hosp. Ahmedabad

4 Fibroid Synonyms : Myoma, Leiomyoma, Fibromyoma Synonyms : Myoma, Leiomyoma, Fibromyoma Most common benign neoplasm in the female. Most common benign neoplasm in the female. Incidence : 20 to 40% of reproductive age women. Incidence : 20 to 40% of reproductive age women.

5 Fibroid Etiology : It arises from smooth muscle cell of myometrium. Etiology : It arises from smooth muscle cell of myometrium. Exact etiology not known. Exact etiology not known. Monoclonal origin ( arising from single cell confirmed by G6PD studies. Monoclonal origin ( arising from single cell confirmed by G6PD studies. Genetic basis definite. Genetic basis definite. Various growth factors like TGFβ, EGF, IGF-1, IGF- 2, BFGF are recently implicated in the development of fibroids. Various growth factors like TGFβ, EGF, IGF-1, IGF- 2, BFGF are recently implicated in the development of fibroids.

6 Fibroid - Etiology Epidemiological risk factors :- Epidemiological risk factors :- Increased risk age 35 to 45 years, nulliparous or low parity, Black women, strong family history, obesity, early Menarche, Diabetes, hypertension. Increased risk age 35 to 45 years, nulliparous or low parity, Black women, strong family history, obesity, early Menarche, Diabetes, hypertension. Decreased risk parity, exercise, intake of green vegetables, Prog.only contraceptives, cigarette smoking Decreased risk parity, exercise, intake of green vegetables, Prog.only contraceptives, cigarette smoking

7 Fibroid - Etiology Genetic basis: Responsible for 40 % cases of fibroids Genetic basis: Responsible for 40 % cases of fibroids Translocation between Chromo. 12 & 14, Translocation between Chromo. 12 & 14, Trisomy 12, Trisomy 12, Rearrangement of short arm of Chromo 6 Rearrangement of short arm of Chromo 6 Rearrangement of long arm of Ch. 10, Rearrangement of long arm of Ch. 10, Deletion of Ch.3 or Ch.7. Deletion of Ch.3 or Ch.7.

8 Fibroid - Etiology Estrogen although not proved for causing myoma definitely implicated in its growth. Estrogen although not proved for causing myoma definitely implicated in its growth. Not detected before puberty & regresses after menopause. Not detected before puberty & regresses after menopause. May increase during pregnancy May increase during pregnancy Estrogen receptors are in higher concent.ns Estrogen receptors are in higher concent.ns Common fifth decade due to anovulatory cycles with high or unopposed estrogen. Common fifth decade due to anovulatory cycles with high or unopposed estrogen.

9 Fibroid Types : Uterine Subserous – Sessile pedunculated Intramural Intramural Submucous - Sessile pedunculated Submucous - Sessile pedunculated Cervical : Anterior, posterior lateral or central Cervical : Anterior, posterior lateral or central Intraligamentous Intraligamentous Parasitic Parasitic

10 Fibroid Submucous fibroids are classified by European society for gynec endoscopy ( ESGE ): for gynec endoscopy ( ESGE ): Type 0 – No intramural extension Type 0 – No intramural extension Type I – Intramural extension < 50 % Type I – Intramural extension < 50 % Type II – Intramural extension > 50 % Type II – Intramural extension > 50 %

11 Fibroid Pathology Multiple, discrete, spherical, pinkish white, firm capsulated masses. Pseudo capsule is made up of compressed myometrium & areolar tissue. Multiple, discrete, spherical, pinkish white, firm capsulated masses. Pseudo capsule is made up of compressed myometrium & areolar tissue. Microscopically nonstriated muscle fibres are arranged in interlacing bundles of varying size & running in different directions ( whorled appearance ) Varying amount of connective tissue is intermixed with smooth muscle fibres. Microscopically nonstriated muscle fibres are arranged in interlacing bundles of varying size & running in different directions ( whorled appearance ) Varying amount of connective tissue is intermixed with smooth muscle fibres.

12 Fibroid Pathological variants Microscopic variants Cellular myoma, mitotically active myoma, bizarre myoma, lipoleiomyoma, Microscopic variants Cellular myoma, mitotically active myoma, bizarre myoma, lipoleiomyoma, Intravenous leiomyomatosis Intravenous leiomyomatosis LPD – leiomyomatosis peritonealis dissemination LPD – leiomyomatosis peritonealis dissemination Leiomyosarcoma Leiomyosarcoma

13 Fibroid Symptoms Asymptomatic Asymptomatic - Abnormal uterine bleeding – 30-50% of patients. It is due to surface area, vascularity, endometrial hyperplasia, venous obstruction, interference with contractions. - Anemia due to excessive blood loss - Dysmenorrhoea – Spasmodic as well as congestive

14 Fibroid Symptoms -pelvic pain in 1/3rd patients, backache. -Acute pain due to torsion, infection, expulsion, red degeneration, vascular complication - Pressure symptoms : - Lump in abdomen -Infertility – 2 to 10 % cases * Rare symptoms : Ascites, polycythemia,

15 Effects of fibroid on pregnancy : Pregnancy : Abortion Pregnancy : Abortion Pressure symptoms Pressure symptoms Malpresentation Malpresentation Retrodisplacement of uterus Retrodisplacement of uterus Labour : Preterm labour Malpresentation Labour : Preterm labour Malpresentation Uterine inertia PPH Uterine inertia PPH Dystocia MRP Dystocia MRP Puerperium : Subinvolution Puerperium : Subinvolution Sec. PPH Sec. PPH Puerperal sepsis Puerperal sepsis Inversion Inversion

16 Effects of fibroid on pregnancy : Increase in size & softening occurs. Increase occurs mainly in the 1st trimester & in 22 to 32 % cases. Increase in size & softening occurs. Increase occurs mainly in the 1st trimester & in 22 to 32 % cases. Red degeneration in 2nd trimester – due to rapid growth there is congestion with interstitial hemorrhage & venous thrombosis Red degeneration in 2nd trimester – due to rapid growth there is congestion with interstitial hemorrhage & venous thrombosis Impaction in pelvis Impaction in pelvis Torsion Torsion Infection Infection Expulsion Expulsion Injury- Pressure necrosis during delivery Injury- Pressure necrosis during delivery Rupture of subserous vein Internal hemorrhage Rupture of subserous vein Internal hemorrhage

17 Fibroid Signs G/E – Anemia due to prolonged heavy bleeding. G/E – Anemia due to prolonged heavy bleeding. P/A – If > 12 weeks size, firm, nodular, arising from P/A – If > 12 weeks size, firm, nodular, arising from pelvis, lower limit cant be reached, relatively well pelvis, lower limit cant be reached, relatively well defined, mobile from side to side, nontender, dull defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen on percussion, no free fluid in abdomen P/S – Cervix pulled higher up P/S – Cervix pulled higher up P/V – Uterus enlarged, nodular. P/V – Uterus enlarged, nodular. D/D from ovarian tumour Uterus not separately D/D from ovarian tumour Uterus not separately felt, transmitted movement present, notch not felt. felt, transmitted movement present, notch not felt. P/R – May help in difficult cases. P/R – May help in difficult cases.

18 Fibroid Diagnosis Clinical : From symptoms & signs Clinical : From symptoms & signs USG : Well defined hypoechoic USG : Well defined hypoechoic lesions. Peripheral calcification lesions. Peripheral calcification with distal shadowing in old fibroids with distal shadowing in old fibroids Adenomyosis is differentiated by diffuse lesion, less echodense, disordered echogenicity & more prominent at or just after menstruation Adenomyosis is differentiated by diffuse lesion, less echodense, disordered echogenicity & more prominent at or just after menstruation Hysteroscopy : Submucous fibroids Hysteroscopy : Submucous fibroids

19 Fibroid USG

20 Fibroid Diagnosis MRI : Most accurate imaging modality for diagnosis of fibroid. It does precise fibroid mapping & characterization Detects all fibroids accurately D/D from adenomyosis D/D from adenomyosis D/D from adnexal pathology D/D from adnexal pathology Ovaries are easily seen Ovaries are easily seen Detects small myomas(0.5 cm) Detects small myomas(0.5 cm) H S G : Not done for diagnosis, Done for infertility evaluation filling defects may be seen.

21 Fibroid MRI

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23 Fibroid D/D Pregnancy Pregnancy Adenomyosis Adenomyosis Ovarian tumour Ovarian tumour Ectopic pregnancy Ectopic pregnancy Endometriosis Endometriosis T O mass T O mass

24 Fibroid Pathology Secondary changes :- Benign : Atrophy, hyaline, necrosis, cystic, Benign : Atrophy, hyaline, necrosis, cystic, calcification,red degeneration, calcification,red degeneration, myxomatous ( fatty), infection myxomatous ( fatty), infection Malignant : Leiomyosarcoma Malignant : Leiomyosarcoma < 1 % in < 50 years < 1 % in < 50 years 50 years age 50 years age

25 Fibroid Management Expectant : asymptomatic, Size < 12 weeks, Size < 12 weeks, near menopause. near menopause. Regular follow up every 6 months Regular follow up every 6 months Recent guidelines suggest upto 16 wks size Recent guidelines suggest upto 16 wks size however difficult to practice however difficult to practice

26 Medical Management Not a definitive Rx Not a definitive Rx For symptomatic relief For symptomatic relief Preoperatively to decrease the size Preoperatively to decrease the size Progestogens, antiprogestogens ( Miefpristone ) androgens ( Danazol, Gestrinone ) & GnRH analogues are used Progestogens, antiprogestogens ( Miefpristone ) androgens ( Danazol, Gestrinone ) & GnRH analogues are used

27 GnRH analogues Agonists are commonly used drugs :- Agonists are commonly used drugs :- Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 months Triptorelin ( Decapeptyl) 3.75 mg or leuprolide depot 3.75 mg I/M or Goseraline ( Zoladex) 3.6 mg SC for 3 months Advantages : Decrease in size of myoma by 20 to 50 % Advantages : Decrease in size of myoma by 20 to 50 % Decrease in bleeding increases Hb level Decrease in bleeding increases Hb level Decreases blood loss during surgery Decreases blood loss during surgery Converts hysterectomy into myomectomy Converts hysterectomy into myomectomy Converts Abd. hyst into vag. hysterectomy Converts Abd. hyst into vag. hysterectomy Makes hysterectomic resection possible Makes hysterectomic resection possible

28 GnRH analogues Disadvantages : High cost Disadvantages : High cost Hypoestrogenic side effects Hypoestrogenic side effects Effect is reversible Effect is reversible Rarely bleeding due to degeneration Rarely bleeding due to degeneration Occasionally difficulty in enucleation Occasionally difficulty in enucleation Antagonist Antagonist Cetrorelix is used Cetrorelix is used 60 mg I/M repeated after 3-4 months if necessary 60 mg I/M repeated after 3-4 months if necessary Initial flare up does not occur Initial flare up does not occur

29 Medical - Newer Therapy SERM – Raloxifen 60 mg /day is tried for 6 to 12 mths. 60 mg /day is tried for 6 to 12 mths. Higher doses ( 180 mg) are required for Higher doses ( 180 mg) are required for effective decrease in size. effective decrease in size. Better if combined with GnRH analogs Better if combined with GnRH analogs

30 Medical - Newer Therapy SPRM - Asoprisnil 5 to 25 mg/day is used 5 to 25 mg/day is used Mechanism of inhibitory action is not known Mechanism of inhibitory action is not known Possible risk of endometrial hyperplasia is not studied Possible risk of endometrial hyperplasia is not studied

31 Medical - Newer Therap y Mifepristone 5 – 10 mg is tried 5 – 10 mg is tried No loss of bone density No loss of bone density Promising results Promising results Steinaure et al reviewed 6 trials Decrease in myoma volume by %. Decrease in myoma volume by %. No effect on bone density No effect on bone density Endometrial hyperplasia may limit its longterm use. Endometrial hyperplasia may limit its longterm use.

32 Medical - Newer Therapy Aromatase inhibitors Aromatase inhibitors Directly inhibit estrogen synthesis & rapidly produce hypoestrogenic state. Directly inhibit estrogen synthesis & rapidly produce hypoestrogenic state. Fadrozole is tried in couple of studies Fadrozole is tried in couple of studies 71 % reduction occurred in 8 weeks 71 % reduction occurred in 8 weeks Appears to be promising therapy. Appears to be promising therapy.

33 Surgical Management * Hysterectomy Abdominal Vaginal Vaginal LAVH, TLH LAVH, TLH * Myomectomy Abdominal Vaginal Vaginal Hysteroscopic Hysteroscopic Laproscopic Laproscopic

34 Surgical Management Vaginal hysterectomy is favoured in following if Vaginal hysterectomy is favoured in following if Uterus < 16 wks, preferably < 14 wks Uterus < 16 wks, preferably < 14 wks No associated pathology like endometriosis, PID, adhesions No associated pathology like endometriosis, PID, adhesions Uterus mobile & adequate Uterus mobile & adequate lateral space in pelvis lateral space in pelvis Experienced vaginal surgeon Experienced vaginal surgeon

35 Surgical Management Myomectomy is done in following :- Infertility Infertility Recurrent pregnancy loss & no other cause Recurrent pregnancy loss & no other cause Young patients Young patients Patients who wish to preserve their uterus Patients who wish to preserve their uterus

36 Hysteroscopic myomectomy For submucous myoma causing infertility, RPL, AUB or pain For submucous myoma causing infertility, RPL, AUB or pain Criteria :- < 5 cm in size Criteria :- < 5 cm in size < 50 % intramural component < 50 % intramural component < 12 cm 2 uterine size < 12 cm 2 uterine size Gn RH analogue may be given preoperatively Gn RH analogue may be given preoperatively Suspicion of malignancy, infection & excessive mural component contraindicates surgery Suspicion of malignancy, infection & excessive mural component contraindicates surgery Advantages are short procedure, rapid recovery & all disadvantages of laprotomy avoided. Advantages are short procedure, rapid recovery & all disadvantages of laprotomy avoided.

37 Laproscopic myomectomy In 3 phases excision of myoma, repair of myometrium & extraction In 3 phases excision of myoma, repair of myometrium & extraction Suitable for subserous & intramural fibroids upto 10 cm size Suitable for subserous & intramural fibroids upto 10 cm size Complications are those of operative laproscopy + myomectomy Complications are those of operative laproscopy + myomectomy Fibroid excised are remoyed by electronic morcellators or through posterior colpotomy incision vaginally. Fibroid excised are remoyed by electronic morcellators or through posterior colpotomy incision vaginally.

38 Abdominal myomectomy - Other factors for infertility should be ruled out - Consent for hysterectomy - Blood X matched & ready - Paps smear & endometrial sampling to rule out malignancy - Medical or mechanical means to control blood loss Bonneys Myomectomy clamp, rubber tourniquet, manual ( finger compression) pressure at isthmic region or use of vasopressin 10 – 20 units diluted in 100ml saline infiltrated before putting the incision.

39 Abdominal myomectomy Minimum incisions are kept – preferably single midline vertical, lower, anterior wall. Minimum incisions are kept – preferably single midline vertical, lower, anterior wall. Removal of as many fibroids as possible through one incision & secondary tunnelling incisions. Removal of as many fibroids as possible through one incision & secondary tunnelling incisions. Meticulous closure of all dead space. Meticulous closure of all dead space. Proper haemostasis Proper haemostasis Multiple small fibroids can be removed enbloc by wedge resection. Multiple small fibroids can be removed enbloc by wedge resection. Measures for adhesion prvention should be taken. Measures for adhesion prvention should be taken.

40 Abdominal myomectomy Morcellation – Deeply embedded Morcellation – Deeply embedded tumours are best removed by tumours are best removed by cutting them into bits. cutting them into bits. Bonneys hood – for posterior fundal large fibroid transverse fundal incision posterior to tubal insertion is made & uterine wall after enucleation is sutured anteriorly covering the fundus as a hood. Bonneys hood – for posterior fundal large fibroid transverse fundal incision posterior to tubal insertion is made & uterine wall after enucleation is sutured anteriorly covering the fundus as a hood. Complications of myomectomy like hemorrhage & infection are less in modern times. Complications of myomectomy like hemorrhage & infection are less in modern times.

41 Vaginal myomectomy Submucous pedunculated or small sessile cervical fibroids are removed vaginally. Submucous pedunculated or small sessile cervical fibroids are removed vaginally. Ligation of pedicle if accessible Ligation of pedicle if accessible Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids Twisting off the fibroids if pedicle not accessible in case of small & medium size fibroids To gain access to pedicle of higher & big fibroid incision on the cervix can be made. To gain access to pedicle of higher & big fibroid incision on the cervix can be made.

42 Surgical Management Laproscopic myolysis :- Laproscopic myolysis :- By ND-YAG laser or long bipolar needle electrode thro. Laproscope blood supply of myoma is coagulated. By ND-YAG laser or long bipolar needle electrode thro. Laproscope blood supply of myoma is coagulated. Without blood supply myoma atrophies. Without blood supply myoma atrophies. Applicable to cm size & myomas < 4 in number Applicable to cm size & myomas < 4 in number * Cryomyolysis is under investigation

43 Uterine artery embolization By interventional radiologist By interventional radiologist Catheter is passed retrograde thro. Right femoral artery to bifurcation of aorta & then negotiated down to opposite uterine artery first. Catheter is passed retrograde thro. Right femoral artery to bifurcation of aorta & then negotiated down to opposite uterine artery first. Polyvinyl alcohol ( PVA ) particles ( um) or gelfoam are used for embolization. Polyvinyl alcohol ( PVA ) particles ( um) or gelfoam are used for embolization. 60 – 65 % reduction in size of fibroid 60 – 65 % reduction in size of fibroid 80 – 90 % have improvements in menorrhagia & pressure symptoms 80 – 90 % have improvements in menorrhagia & pressure symptoms

44 Uterine artery embolization

45 High vascularity & solitary fibroid are associated with greater chance of longterm success. High vascularity & solitary fibroid are associated with greater chance of longterm success. Pregnancy, active infection & suspicion of malignancy are absolute C I. Pregnancy, active infection & suspicion of malignancy are absolute C I. Desire for fertility is also a contraindication to UAI Desire for fertility is also a contraindication to UAI The risk of ovarian failure must be counselled The risk of ovarian failure must be counselled Post embolization syndrome ( fever,vomiting, pain) can occur Post embolization syndrome ( fever,vomiting, pain) can occur

46 Uterine artery embolization

47 Fibroid Newer Management Mirena : Third generation IUCD Third generation IUCD Contains Progesteron LNG 60 mg releasing 20 ug /day Contains Progesteron LNG 60 mg releasing 20 ug /day Fibroids decreases in size 6 – 12 mths of use. Fibroids decreases in size 6 – 12 mths of use. May have variable effects on uterine myomas depending upon balance of growth factors May have variable effects on uterine myomas depending upon balance of growth factors Couple of studies have shown beneficial results Couple of studies have shown beneficial results Suitable for those who also desire contraception Suitable for those who also desire contraception

48 Newer Management- MRGFUS Permitted by FDA since 2004 Permitted by FDA since 2004 MRI guidance is used to direct ultrasound to tissues to elicit coagulative necrosis via thermal ablation. MRI guidance is used to direct ultrasound to tissues to elicit coagulative necrosis via thermal ablation.

49 Newer Management- MRGFUS Fasting overnight Fasting overnight Shaving of lower abdomen Shaving of lower abdomen Foleys catheter Foleys catheter Sonications of 20 to 40 Sonications of 20 to 40 seconds interval with seconds interval with 80 – 90 seconds cooling 80 – 90 seconds cooling

50 Research Lanreotide a long acting somatostatin analog reduces GH secretion 30 mg depot reduced fibroid size by 41.6 % Targetting growth factors that are involved in angiogenesis or fibrosis involved in angiogenesis or fibrosis Pirfenidone an antifibrotic agent is under trial

51 Thank You


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