1. Fibroid

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

3. Fibroid Etiology : It arises from smooth muscle cell of myometrium.
* Exact etiology not known.
* Monoclonal origin ( arising from single cell)
* Genetic basis definite.
* Various growth factors like TGFβ , EGF, IGF-1, IGF-2, BFGF

4. 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

5. 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

6. 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.

7. Site of origin
Corporeal fibroid
(97% )
Cervical
fibroid
(3%)

8. Fibroids are often described according to their location in the uterus

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 %

11. Pathology Well circumscribed white firm mass with a whorled appearance
- surrounded by false capsule formed by compressed by uterine muscle

12. Pathology Microscopically
Smooth muscle Connective tissues

13. Asymptomatic: (50%). Symptomatic (50%)
Symptoms
Asymptomatic: (50%).
Symptomatic
(50%)

14. Abnormal uterine Bleeding
Pelvic pressure & pain
Reproductive Dysfunction

15. Abnormal uterine bleeding
It is the most common symptom.
Menorrhagia
Intermenstrual bleeding
postmenopausal bleeding
are not characteristic of myomas
except if

16. Secondary pathological degenerative changes and complications of fibroids

17. Atrophy.
Necrosis.
Degeneration.
Malignancy.
Infection.
Torsion.
Incarceration.
Inversion of the uteruss.

18. Risk of Malignancy 0.1% in reproductive age group
1.7% after age of 60 years

19. Fibroid Signs G/E – Pallor
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.

20. Fibroid Diagnosis Clinical : From symptoms & signs
USG : Well defined hypoechoic
lesions. Peripheral calcification
with distal shadowing in old fibroids

21. TAS&TVS
size, site and number of fibroids
differentiates the tumour from other swellings as ovarian tumour

22. Fibroid USG

23. 2-Saline infusion sonography

24. (3) Hysteroscopy
To visualize a sub mucous fibroid or a small fibroid polyp.

25. (4) Intra venous pyelogram (IVP)
In cervical and broad ligament fibroid
Course of ureter.
Hydroureter & hydroneprosis
- Kidney function.

26. Fibroid Diagnosis
5. 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)
6. H S G : Not done for diagnosis , Done for infertility
evaluation filling defects may be seen.

27. Fibroid MRI

28. Fibroid MRI

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

30. 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

31. Treatment Medical Surgical Embolization of both uterine arteries
Myomectomy
Hysterectomy
Embolization of both uterine arteries
MRI-guided Focused Ultrasound (MRI-FUS)

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

33. GnRH analogues 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
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

34. 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

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

36. 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

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

38. Hysteroscopic myomectomy
For submucous myoma causing infertility, Recurrent pregnancy loss, AUB or pain
Criteria :- < 5 cm in size
< 50 % intramural component
< 12 cm2 uterine size

39. Laparoscopic myomectomy
In 3 phases  excision of myoma, repair of myometrium & extraction
Suitable for subserous & intramural fibroids upto 10 cm size
Complications are those of operative laparoscopy + myomectomy

40. Abdominal myomectomy Other factors for infertility should be ruled out
Consent for hysterectomy
Blood cross 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 .

41. 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 prevention should be taken.

42. Open myomectomy

43. 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.

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

45. 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

46. Uterine artery embolization

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

48. Uterine artery embolization

49. Fibroid Newer Management
Mirena :
Third generation IUCD
Contains Progesterone LNG 60 mg releasing 20 ug /day
Fibroids decreases in size 6 – 12 months of use.
Future research in fibroid Rx :
MRI guided focused ultrasound therapy
SPRM –Selective progesterone Receptor
modulator  Asoprisnil
Somatostatin analogues  Lanreotide
Aromatase inhibitors

50. MRI-guided Focused Ultrasound (MRI-FUS)

51. MCQs in Fibroid Intramural. Subserosal. Submucosal. Broad ligament.
 Most common type of uterine leiomyoma .
Intramural.
Subserosal.
Submucosal.
Broad ligament.
Which of the following is for symptomatic treatment of fibroid. 
OCPs
Testosterone.
GnRH agonist.
GnRH antagonist.

52. MCQs Most common symptom of fibroid Abnormal uterine bleeding.
Pelvic pain.
Mass in abdomen.
Abdominal discomfort
Most common pelvic tumor of reproductive age group is
Uterine fibroid
Dermoid cyst .
Ovarian cysts.
Ovarian tumor.

53. Thank You