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Fibroids.

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Presentation on theme: "Fibroids."— Presentation transcript:

1 Fibroids

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

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

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

5 Fibroid - Etiology Epidemiological risk factors :-
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

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

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

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

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

10 Fibroid Pathology 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.

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

12 Fibroid Symptoms 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

13 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,

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

15 Effects of fibroid on pregnancy :
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 Impaction in pelvis Torsion Infection Expulsion Injury- Pressure necrosis during delivery Rupture of subserous vein  Internal hemorrhage

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

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

18 Fibroid USG

19 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 adnexal pathology  Ovaries are easily seen  Detects small myomas(0.5 cm) H S G : Not done for diagnosis , Done for infertility evaluation filling defects may be seen.

20 Fibroid MRI

21 Fibroid MRI

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

23 Fibroid Pathology Secondary changes :-
Benign : Atrophy, hyaline, necrosis, cystic, calcification,red degeneration, myxomatous ( fatty) , infection Malignant : Leiomyosarcoma < 1 % in < 50 years < 2 % in > 50 years age

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

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

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

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

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

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

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

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

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

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

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

35 Hysteroscopic myomectomy
For submucous myoma causing infertility, RPL, AUB or pain Criteria :- < 5 cm in size < 50 % intramural component < 12 cm2 uterine size Gn RH analogue may be given preoperatively Suspicion of malignancy, infection & excessive mural component contraindicates surgery Advantages are short procedure , rapid recovery & all disadvantages of laprotomy avoided.

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

37 Abdominal myomectomy - Other factors for infertility should be ruled out - Consent for hysterectomy - Blood ‘X’ matched & ready - Pap’s smear & endometrial sampling to rule out malignancy - Medical or mechanical means to control blood loss  Bonney’s 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 .

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

39 Abdominal myomectomy Morcellation – Deeply embedded
tumours are best removed by cutting them into bits. Bonney’s 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.

40 Vaginal myomectomy Submucous pedunculated or small sessile cervical fibroids are removed vaginally. Ligation of pedicle if accessible 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.

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

42 Uterine artery embolization
By interventional radiologist 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. 60 – 65 % reduction in size of fibroid 80 – 90 % have improvements in menorrhagia & pressure symptoms

43 Uterine artery embolization

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

45 Uterine artery embolization

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

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

48 Newer Management- MRGFUS
Fasting overnight Shaving of lower abdomen Foley’s catheter Sonications of 20 to 40 seconds interval with 80 – 90 seconds cooling

49 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 Pirfenidone an antifibrotic agent is under trial

50 Thank You


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