2 Dr. Haresh U. Doshi M.D., Diploma (USG), FICOG, PGDMLS Professor & Chief of UnitB.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 - EtiologyGenetic basis: Responsible for 40 % cases of fibroidsTranslocation between Chromo. 12 & 14,Trisomy 12,Rearrangement of short arm of Chromo 6Rearrangement of long arm of Ch. 10,Deletion of Ch.3 or Ch.7 .
7 Fibroid - EtiologyEstrogen although not proved for causing myoma definitely implicated in its growth.Not detected before puberty & regresses after menopause.May increase during pregnancyEstrogen receptors are in higher concent.nsCommon fifth decade due to anovulatory cycles with high or unopposed estrogen.
9 Fibroid Submucous fibroids are classified by European society for gynec endoscopy ( ESGE ):Type 0 – No intramural extensionType I – Intramural extension < 50 %Type II – Intramural extension > 50 %
10 Fibroid PathologyMultiple, 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.
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 abdomenInfertility – 2 to 10 % cases* Rare symptoms : Ascites, polycythemia,
14 Effects of fibroid on pregnancy : Pregnancy : AbortionPressure symptomsMalpresentationRetrodisplacement of uterusLabour : Preterm labour MalpresentationUterine inertia PPHDystocia MRPPuerperium : SubinvolutionSec. PPHPuerperal sepsisInversion
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 thrombosisImpaction in pelvisTorsionInfectionExpulsionInjury- Pressure necrosis during deliveryRupture 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 frompelvis, lower limit can’t be reached, relatively welldefined, mobile from side to side, nontender, dullon percussion, no free fluid in abdomenP/S – Cervix pulled higher upP/V – Uterus enlarged, nodular.D/D from ovarian tumour Uterus not separatelyfelt , transmitted movement present, notch not felt.P/R – May help in difficult cases .
17 Fibroid Diagnosis Clinical : From symptoms & signs USG : Well defined hypoechoiclesions. Peripheral calcificationwith distal shadowing in old fibroidsAdenomyosis is differentiated by diffuse lesion, less echodense , disordered echogenicity & more prominent at or just after menstruationHysteroscopy : Submucous fibroids
19 Fibroid DiagnosisMRI : 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.
22 Fibroid D/D Pregnancy Adenomyosis Ovarian tumour Ectopic pregnancy EndometriosisT O mass
23 Fibroid Pathology Secondary changes :- Benign : Atrophy, hyaline, necrosis, cystic,calcification,red degeneration,myxomatous ( fatty) , infectionMalignant : 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 monthsRecent guidelines suggest upto 16 wks sizehowever difficult to practice
25 Medical Management Not a definitive Rx For symptomatic relief Preoperatively to decrease the sizeProgestogens, 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 monthsAdvantages : Decrease in size of myoma by 20 to 50 %Decrease in bleeding increases Hb levelDecreases blood loss during surgeryConverts hysterectomy into myomectomyConverts Abd. hyst into vag. hysterectomyMakes hysterectomic resection possible
27 GnRH analogues Disadvantages : High cost Hypoestrogenic side effects Effect is reversibleRarely ↑↑ bleeding due to degenerationOccasionally difficulty in enucleationAntagonistCetrorelix is used60 mg I/M repeated after 3-4 months if necessaryInitial flare up does not occur
28 Medical - Newer Therapy SERM – Raloxifen60 mg /day is tried for 6 to 12 mths.Higher doses ( 180 mg) are required foreffective decrease in size.Better if combined with GnRH analogs
29 Medical - Newer Therapy SPRM - Asoprisnil5 to 25 mg/day is usedMechanism of inhibitory action is not knownPossible risk of endometrial hyperplasia is not studied
30 Medical - Newer Therapy Mifepristone5 – 10 mg is triedNo loss of bone densityPromising resultsSteinaure et al reviewed 6 trialsDecrease in myoma volume by %.No effect on bone densityEndometrial hyperplasia may limit its longterm use.
31 Medical - Newer Therapy Aromatase inhibitorsDirectly inhibit estrogen synthesis & rapidly produce hypoestrogenic state.Fadrozole is tried in couple of studies71 % reduction occurred in 8 weeksAppears to be promising therapy.
33 Surgical Management Vaginal hysterectomy is favoured in following if Uterus < 16 wks, preferably < 14 wksNo associated pathology like endometriosis , PID, adhesionsUterus mobile & adequatelateral space in pelvisExperienced vaginal surgeon
34 Surgical Management Myomectomy is done in following :- Infertility Recurrent pregnancy loss & no other causeYoung patientsPatients who wish to preserve their uterus
35 Hysteroscopic myomectomy For submucous myoma causing infertility, RPL, AUB or painCriteria :- < 5 cm in size< 50 % intramural component< 12 cm2 uterine sizeGn RH analogue may be given preoperativelySuspicion of malignancy, infection & excessive mural component contraindicates surgeryAdvantages are short procedure , rapid recovery & all disadvantages of laprotomy avoided.
36 Laproscopic myomectomy In 3 phases excision of myoma, repair of myometrium & extractionSuitable for subserous & intramural fibroids upto cm sizeComplications are those of operative laproscopy + myomectomyFibroid 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 myomectomyMinimum 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 haemostasisMultiple 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 bycutting 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 myomectomySubmucous pedunculated or small sessile cervical fibroids are removed vaginally.Ligation of pedicle if accessibleTwisting off the fibroids if pedicle not accessible in case of small & medium size fibroidsTo 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 radiologistCatheter 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 fibroid80 – 90 % have improvements in menorrhagia & pressure symptoms
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 UAIThe risk of ovarian failure must be counselledPost embolization syndrome ( fever ,vomiting, pain) can occur
46 Fibroid Newer Management Mirena :Third generation IUCDContains Progesteron LNG 60 mg releasing 20 ug /dayFibroids decreases in size 6 – 12 mths of use.May have variable effects on uterine myomas depending upon balance of growth factorsCouple of studies have shown beneficial resultsSuitable for those who also desire contraception
47 Newer Management- MRGFUS Permitted by FDA since 2004MRI guidance is used to direct ultrasound to tissues to elicit coagulative necrosis via thermal ablation.
48 Newer Management- MRGFUS Fasting overnightShaving of lower abdomenFoley’s catheterSonications of 20 to 40seconds interval with80 – 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 areinvolved in angiogenesis or fibrosisPirfenidone an antifibrotic agent is under trial