1. Fibroid Uterus

2. Fibroids are benign neoplasms of uterus arising from smooth muscle rests of vessel walls or uterine musculature
Contain smooth muscle cells and varying amounts of connective tissue.
Incidence %
Age reprodutive age
more in forties

3. Etiology Myomas are oestrogen dependent -Rarely found before puberty
-Increase in size during pregnancy
-And during OC pill usage
-Regress after menopause
Monoclonal in origin
Chromosomal abnormalities 1,6,7,12,14,
del q 21-22
Seen more in black women

4. Classification Based on uterine layer interstitial 75% (intramural)
submucous %
subserous %
Various other cassifications based on hysteroscopy and location of submucous fibroid

5. Classification Based on location - corporeal - cervical - isthmic
Based on origin
-uterine
-Extrauterine –Ex: broad ligament
fibroid

6. Types of Fibroids

7. Anatomy and histology Well circumscribed Pseudoencapsulated
Firm in consistency
C/S - pinkish white,whorled in appearance
Microscopically –bundles of plain muscle cells,separated by varying amonts of fibrous strands

8. Cut section of fibroid

9. Secondary changes Atrophic degeneration - seen after menopause
Hyaline degeneration
Cystic degeneration
Calcareous degeneration
Red degeneration - aseptic degeneration
seen in second trimester of
pregnancy
Sarcomatous degeneration

10. Clinical features Depend on size,site,reproductive status
Asymptomatic %
Menstrual symptoms %
Pelvic pain %
Subfertility
Pressure symptoms
Abdominal lump
Pregnancy related complications

11. Menstrual symptoms
Most common-menorrhagia
Inter menstrual bleeding in submucous myoma
Pelvic pain
Dysmenorrhoea
Dyspareunia
Pelvic pressure
Torsion of subserous pedunculated fibroid
Red degeneration

12. Pressure symptoms Urinary symptoms acute retention of urine Frequency
urgency
dysuria
Rectal symptoms-
constipation
rectal pain
difficult defaecation
Hydro ureteronephrosis
due to pressure on ureter

13. Causes of menstrual symptoms
Increase in total surface area
Mechanical distortion of uterine cavity
Interference with contractility
Dilatation and congestion of endometrial venous plexuses
Endometrial hyperplaia due to high estrogen
Pelvic congestion
Ulceration of endometrium over submucous fibroids leading to intermenstrual bleeding

14. Causes of subfertility
Distortion and elongation of endometral cavity leading to difficult sperm ascent
Impaired contractility of uterus
Congestion of endometrial venous plexuses
Defective implantation
Cornual blockdue to fibroid
Elongation and streching of tube over a large fibroid
Associated anovulation

15. Pregnancy related symptoms
Effects on pregnancy
Recurrent abortions
Preterm labour
Fetal malpresentations
Obstructed labour
Post partum haemorrhage
Subinvolution
Puerperal sepsis
Effects on fibroid
Increase in size
Red degeneration

16. Physical signs
Woman may be anaemic
P/A -Suprapubic mass with well defined
margins
P/S –fibroid polyp may be seen
P/V –enlarged uterus-regular or irregular
cervical movements transmitted to the
mass

17. Associated conditions
Follicular cysts
Theca lutein cysts
Endometriotic cysts
Pevic inflammatory disease
Ovarian tumours
Endometrial hyperplasia
Endometrial carcinoma

18. Complications Secondary changes Sarcomatous change <0.5%
Torsion of pedunculated fibroid
Inversion due to submucous fibroid
Capsular haemorrhage
Infection of myomatous polyp

19. Differential diagnosis
Full bladder
Pregnancy
Adenomyosis
Bicornuate uterus
Endometriosis-chocolate cyst
Chronic PID
Ovarian tumour
Endometrial cancer
Chronic inversion
Pelvic kidney

20. Investigations Hb% Blood grouping and typing
Ultrasound abdomen to know site,size and number
Hysteroscopy
HSG and sonosalpingogram for submucous myoma
MRI in case of sarcoma
IVP in broad ligament fibroid

21. Ultasound picture

22. Management

23. Indications for Medical management
To control menorrhagia
To improve hemoglobin before surgery
For preoperative shrinkage of large fibroid
To reduce vascularity
To postpone surgery if woman is not fit for surgery
In elderly women until menopause is reached
To convert abdominal hysterectomy to a vaginal one by decreasing the size of uterus
Iron therapy for anaemia

24. Medical management Combined OC pills
Progestogens like MPA, Norethisterone
LNG – IUCD (MIRENA)
NSAIDS
Antifibrinolytics
Mifepristone mg daily for 3 months
Danazol daily for 3 to 6 months
GnRH analogues for 3 months
Gestrinone

25. Myomectomy Indications Women with infertility where all other causes
have been ruled out
Women desirous of child bearing
Women who wish to retain their menstrual
function
Routes
Abdominal myomectomy
Vaginal in submucous fibroid polyp
Hysteroscopic –in submucous fibroid polyp
Laparoscopic myomectomy

26. Principals of myomectomy
Preoperative Hb% restoration and to keep adequate blood ready
All other factors for infertility like azoospermia are ruled out
Consent for hysterectomy is taken
Preoperative D&C and papsmear are taken
Should be done in preovulatory phase of menstruation to reduce blood loss
Haemorrhage is controlled with myomectomy
(Bonney’s) clamp,20 units of vasopressin in 60 ml saline

27. Technique of myomectomy
Keep incision as anterior as possible
A single incision is given
As many fibroids as possible are removed through multiple tunnelling incision
Myoma cavity thoroughly obliterated with several catgut sutures
Results
Pregnancy rate of 40-50%

28. Laproscopic myomectomy

29. Complications of myomectomy
Primary ,reactionary and secondary haemorrhage
Trauma to the bladder,ureter and bowel during surgery
Adhesions and intestinal obstruction
Recurrence of fibroids and persistence of menorrhagia

30. Hysterectomy Indications Woman over 40 yrs of age Multiparous women
Associated pathology such as endometriosis, PID, adenomyosis,endometrial hyperplasia
Suspested malignancy

31. Hysterectomy Routes Abdominal Vaginal Laparoscopic
Laparoscopic assisted vaginal hysterectomy

32. Hysterectomy Indications for vaginal hysterectomy
When uterus is mobile
Size<14 weeks
No previous surgery
No pelvic pathology
Other wise an abdominal hysterectomy is done

34. Multiple fibroids

35. Laparoscopic hysterectomy
Avoids scar
Minimizes pain
Shortens hospital stay
Early recovery
Contraindications to LAVH
Uterus >14-16 weeks
Broad ligament, cervical fibroid
Extensive pelvic adhesions

36. Complications of hysterectomy
Anaesthetic complications
Primary ,reactionary and secondary haemorrhage
Trauma to the bladder,ureter and bowel during surgery
Adhesions and intestinal obstruction
Sepsis
Burst abdomen
Incisional hernia

37. Uterine artery embolization
Improves symptoms in 70-80% of women
Preoperative shrinkage
Reduces vascularity
Technique
Performed through percutaneous femoral catheterization using polyvinyl alcohol,gel foam or metal coils
Contraindicated in subserous pedunculated fibroid and in women desirous of pregnancy

38. Uterine artery embolization

39. Thank you