A power point presentation on Fibroids

1. Uterine fibroids

2. Uterine fibroids
• Most common tumors of the female genital
tract
• Commonest cause of Hysterectomy

3. Uterine fibroids
• Most common benign tumor of the female
genital tract
• Risk factors- ethnicity, nulliparity, genetics and
hormonal factors, Obesity

4. • Heterogeneity in behavior of fibroids and the
symptoms attributable to them

5. Regulation of the growth of uterine
fibroids
• Estrogen and progesterone dependent
• Increased estrogen receptor gene expression
in uterine fibroids
• Role of apoptosis

6. Clinical presentation of fibroids
• Peaks in the peri menopausal years and
declines after the menopause
• More than 50% of myomas are asymptomatic

7. Common symptoms
• Abnormal uterine bleeding
• Pelvic pressure symptoms & discomfort

8. ABNORMAL VAGINAL BLEEDING
• Most characteristic of myomas is menorrhagia
• Increased endometrial surface area
• Increased vascularity of the uterus
Interference with normal uterine contractility
• Endometrial ulceration over submucous
leiomyomas, which could also cause
intermenstrual bleeding
• Compression of venous plexus within the
myometrium

9. PELVIC PAIN
• Fibroids located posteriorly- lower back pain
• Anterior tumours may cause bladder
discomfort and increased urinary frequency.
• Leiomyomas that fill the pelvis may cause
difficulty with urination, defaecation and
dyspareunia
Broad ligament may cause unilateral lower
abdominal pain or sciatic nerve pain

10. Acute pain
• Torsion
• Red degeneration-localized tenderness over
the fibroid, mild leukocytosis, pyrexia, and
nausea and vomiting

11. • Pain however is not a common feature of
fibroids
• Rule out other conditions like endometriosis,
adenomyosis

12. PELVIC MASS SYMPTOMS
• May simply put on weight
• Bladder capacity reduced- increased
frequency
• Retention of urine

13. REPRODUCTIVE DYSFUNCTION
• Infertility
• obstruct the tubal ostia
• Submucosal fibroids and intramural fibroids
distorting the uterine cavity
• Myomectomy, whether by the conventional
abdominal route or laparoscopically, appears to
be associated with improved pregnancy rates
• Bulletti C, Ziegler D, Levi Setti P et al. Myomas, pregnancy
outcome, and in vitro fertilization. Ann NY Acad Sci 2004;
1034: 84–92.

14. Fibroids and Infertility
• Despite the lack of evidence from randomized
studies it does appear that surgical
intervention for uterine fibroids does increase
pregnancy rates
• 50% of women conceiving following
myomectomy for fibroid-associated infertility.
• Palomba S, Zupi E, Russo T et al. A multicenter randomized, controlled study comparing
laparoscopic versus minilaparotomic myomectomy: short-term outcomes. Fertil Steril
2007; 88: 942–951

15. Abortion and Myoma
• Submucus or myomas distorting the cavity
• Multiple myomas
Miscarriage rates fall after myomectomy

16. FIBROIDS AND THEIR IMPACT ON
ANTENATAL COMPLICATIONS
OF PREGNANCY AND LABOUR
• Have been linked to a number of
complications
• Positive association between the presence of
fibroids and malpresentations such as
breech presentation, operative delivery and
caesarean section - demonstrated repeatedly

17. Fibroids and pregnancy
• Only few fibroids grow(20%) in pregnancy,
growth limited to first trimester
• Submucus fibroid – abortion
• Weak association with preterm labour
• Placenta previa weak association
• PPH weak association

18. POSTPARTUM SEQUELAE OF FIBROIDS
• Ischaemic degenerationanaerobic infection
• Fibroid tissue may be expelled

19. RARE ASSOCIATIONS
• Myomas may be parasitic
• secondary polycythaemia
• Ascites
• Benign metastasizing myomas
• Intravenous leiomyomatosis
• Leiomyomatosis peritonealis disseminata

20. MALIGNANCY
• leiomyosarcomas arise de novo
• 0.13 and 0.29%

21. Asymptomatic uterine fibroids
• Even with symptoms such as infertility, pelvic
pain and abnormal bleeding, it is not always
possible to be certain that a given myoma is
not simply an innocent bystander
• 40% by 35 years of age and almost 70% by 50
years of age
• 50% of fibroids are asymptomatic

22. Asymptomatic fibroid
• Why some cause symptoms and others don’t?
• Is there is any possibility of malignancy?
• Whether they need a hysterectomy?
• Whether the fibroid(s) will compromise fertility
and pregnancy outcomes?
• Whether the fibroids are likely to grow, and if
there is any therapy to stop them Growing?
• Does waiting and watching will cause any harm?

23. Fibroid – C section
• Fibroids should be left well alone at the time
of caesarean section

24. The
Management of Uterine FibroidsWorking Party
of the New Zealand Guidelines Group
• Size less than 16 weeks observe after
excluding other pathology
• Concern about possible complications related
to fibroids in pregnancy is not an indication for
myomectomy, except in women who have
experienced a previous pregnancy with
complications related to these fibroids
• Trial of conception for 6 months

25. The
Management of Uterine
FibroidsWorking Party of the New
Zealand Guidelines Group
• Myomas that disturb the cavity may be
removed before IVF

26. Imaging
• Aim
• Determination of the number, size and
position ofmyomata, as well as the
dimensions of the uterus
• To rule out other pathology

27. USG
• Preferred method
• Well demarcated mass with in myometrium
• May be hypo/hyper
• Adenomyosis.-minimal or no mass effect
elliptical shape of uterus maintained
• Colour doppler diffuse vascularity in
adneomyosis

28. USG
• Both TAS and TVS
• TVS endometrium small fibroids
• Sonohysterography submucus myomas

29. MRI
• Submucus myomas
• Cervical myomas

30. Rule out
• Leiomyosarcoma no sharp margins
• Sample endometrium if ET > 15 mm in
premenopausal woman
• Adnexal masses may be confused with
subserosal pedunculated leiomyomata – CT
MRI Laparoscopy

31. Medical management of fibroids
• Fibroid growth is hormone dependent
• Medical treatments mainly involve hormonal
manipulations

32. Indications for medical therapy
• Treatment for temporary relief of symptoms
for short period
• Pre-operative adjunct to reduce the size of
fibroids, to control bleeding and to improve
haemoglobin levels

33. GnRH analogues
• Symptoms of estrogen deficiency limit the
standard use of GnRHa to 6 months
• Fibroids returning to their original size or even
enlarging more rapidly upon cessation of
therapy
• Add back -tibolone, raloxifene, progestogens
alone, oestrogens alone, and combined
oestrogens and progestogens

34. Preoperative use of GnRHa
• GnRHa render surgical planes less distinct,
making enucleation difficult
• large and multiple fibroids (level of the
umbilicus and beyond) responds poorly
• GnRHa increases the risk of recurrence since
smaller fibroids regress and missed
• Not cost effective (Vassopressin cheaper)

35. GnRH analogues
• Only indication of GnRH analogues is to
reduce the size of submucus myoma before
hysteroscopic myomectomy

36. GNRH ANTAGONISTS
• Not studied well

37. SELECTIVE OESTROGEN RECEPTOR
MODULATORS
• Insufficient evidence to conclude that SERMs
reduce the size of fibroids or improve clinical
outcomes in premenopausal women

38. AROMATASE INHIBITORS
• Anastrozole
• Confined to case reports
• Not very effective in premenopausal women
• long-term use and risk of bone loss and
fracture risk

39. LEVONORGESTEROL INTRA-UTERINE
DEVICE
• Reduction in menstural blood loss& symptoms
• Not suitable fro sunmucus and large myomas

40. ANTIPROGESTERONES
No change in bone mineral density
5 or 10 mg/day for 1 year

41. Myomectomy
• Sole purpose of myomectomy is to improve
fertility
• In 2/3 of women who have had myomectomy
menstrual symptoms does not subside

42. Conventional myomectomy
• Contrary to popular belief, this is an operation
which demands considerable skill if it is to
yield optimal outcomes

43. Pre-operative assessment
• USG , MRI for cervical fibroids
• Submucus fibroids hysteroscopy

44. Preoperative assessment
• Small risk of needing to progress to
hysterectomy
• Pre-existing anaemia should be corrected

45. Intra-operative measures and surgical
technique
• Transverse incision
• Pull sow with myoma screw

46. Uterus is “bloody” organ

47. Physical occlusion of blood flow
• Boneys clamp

48. • Single tourniquet around
uterine A the cervix to
achieve haemostasis
• Occlude the ovarian
arteries, and one to occlude
the uterine arteries

49. • Preoperative Uterine A Embolisation?

50. Preop GnRH
• Small fibroids may be missed
• Planes unclear
Not generally recommended
Huge fibroids respond poorly
Not cost effective
Planes destroyed, increase the risk of recurrence
Only indication may be sub mucus fibroid, where it
may facilitate an hysteroscopic removal

51. • 1 g tranexamic acid by slow intravenous
infusion at the time of induction of
anaesthesia
• Dilute 20 units vasopressin in 100 mL normal
saline
• Avoid injection directly into blood vessels

52. • Intravaginal misoprostol 400 microgram

53. Vasopressin vs. physical occlusion
• o difference in operative blood loss, operative
time, postoperative febrile morbidity,
preoperative, and postoperative hematocrits
or transfusion rates.
• Ginsburg ES, Benson CB, Garfield JM, Gleason RE &
FreidmanAJ (1993). The effect of operative technique and
uterine size on blood loss during myomectomy: a
prospective randomized study. FertilSteril 60:956-62

54. Uterine incision
• Single, anterior, midline
vertical incision
• multiple incisions are
minimum.
The incision should extend
through the serosa,
myometrium and into the
capsule of the leiomyoma

55. • “Stay with in the pseudocapsule and myoma”

56. • Every effort should be made to remove all
visible and/or palpable myomas
• If the endometrial cavity is breached, the
repair it with fine interrupted extramural
sutures using 2/0 vicryl

57. Closure
• 1/0 vicryl sutures
• Interrupted figure of eight
sutures

58. Bonney's hood

59. Myomas in special locations
• Broad ligament myoma
• Incise round ligament
• Work with in the capsule

60. Cervical myomas
• Real challenge
• Accurate location of myoma by MRI
• Preoperative GnRH
• Central divide UV fold and bisect the Uterus
• Posterior myoma-low posterior incision
at the back of the uterus

61. RISKS AND COMPLICATIONS OF
CONVENTIONAL MYOMECTOMY
• Bleeding
• Exceptionally rare to have to resort to
hysterectomy
• Infectious morbidity is infrequent
• Adhesions-meticulous haemostasis
• Use of minimally reactive absorbable sutures;
copious irrigation at the time of myomectomy;
paying attention to suturing techniques and,
possibly, use of intraperitoneal drains

62. Risk of recurrence after myomectomy
• 40% and 50%
• Risk decreased with
• Single myoma
• Pregnancy

63. Endoscopic management of uterine
fibroids
• Less adhesions, rates of conception,
miscarriage, preterm birth and caesarean
section were similar
Seracchioli R, Rossi S, Govoni F et al. Fertility and obstetric
outcome after laparoscopic myomectomy of large fibroid: a
randomized comparison with abdominal myomectomy. Hum
Reprod 2000; 15: 2663–2668.

64. Lap myomectomy
• Less than 15 cm(6-10cm)
• 3 fiborids less than 5 cm
• Surgeon loses the ability to palpate uterine
tissue to detect smaller myomas
• Incidence of rupture uterus in pregnancy
similar with open myomectomy

65. Lap myomectomy

66. Lap myomectomy
• Not adhesion free
• But incidence of adhesion is less compared to
laparotomy
• Conversion rate to open myomectomy 5%

68. • Fibroid myolysis

69. LAPAROSCOPIC THERMOMYOLYSIS
• Rupture
• Adhesion

70. Radiological treatment of symptomatic
uterine fibroids
• Uterine artery embolisation
• Menorrhagia is controlled in 85–95% of
patients, and bulk-related symptoms are
controlled in 70–90% of patients
• Sub mucus forbids are better treated with
hysteroscopic resection

71. UAE and Fertility
• Premature menopause induced by UAE has
been estimated at up to 25% in women above
the age of 45 years and 1% in younger women
• Procedure should not be offered routinely to
women who wish to preserve their
reproductive potential
• Ahmad A, Qadan L, Hassan N et al. Uterine artery embolization treatment of uterine
fibroids: effect on ovarian function in younger women. J Vasc Interv Radiol 2002; 13:
1017–1020

72. UAE and fertility
• Concerns of preterm labour,abnormal
placentation
• Carpenter TT & Walker WJ. Pregnancy following uterine artery embolisation for
symptomatic fibroids: a series of 26 completed pregnancies. Br J Obstet Gynaecol
2005; 112: 321–325

73. Uterine artery embolization as a
surgical adjuvant
• Not recommended before myomectomy
chances of rupture
• May help to convert midline incision to
transverse incision in hysterectomy

74. Complications
• Chronic vaginal discharge 4-7% of patients
• Fibroid extrusion through the vagina
• Premature ovarian failure or severe pelvic
sepsis
• Postembolization syndrome

75. Edwards RD et al UAE vs Surgery for
symptomatic fibroid N E J M
2007:356(4):360-370
• 13% had intervention after 1 year in the UAE
group

76. REST trial (Randomized controlled trial
of Embolization vs Surgical
Treatment for fibroids
• Need for re-intervention for persistent
symptoms at around 10% at 1 year
• Complication rates similar

77. UAE
• Recommended by the National Institute for
Clincial Excellence (NICE) in the UK as an
alternative therapy to hysterectomy

78. Long term outcome of UAE
• On 5-7 year follow 12-20% needs intervention
• Spies JB, Bruno J, Czeyda-Pommersheim F et al. Long-term
outcome of uterine artery embolizationof leiomyomata.
Obstet Gynecol 2005; 106: 933–939.
• Katsumori T, Kasahara T & Akazawa K. Long-term outcomes
of uterine artery embolization using gelatin sponge particles
alone for symptomatic fibroids. AJR Am J Roentgenol 2006;
186: 848–854
• Walker WJ & Barton-Smith P. Long-term follow up of uterine
artery embolisation – an effective alternative in the
treatment of fibroids. Br J Obstet Gynaecol 2006; 113: 464–
468

79. Magnetic-resonance-guided focused
ultrasound surgery
• Causes heat within the tissues and causes
coagulative necrosis of tissue
• Symptomatic uterine fibroids and who have no
desire for future pregnancy
• Volume reduction is less than UAE
Mean time in return to normal activity 1 day

80. Laparoscopic uterine artery occlusion
• 50% reduction in menorhaghia
• Uterine volume was reduced by 35-40%

81. Hysterectomy
• The need to treat symptoms—abnormal
uterine bleeding, pelvic pain, or pelvic
pressure
• “Rapid” uterine enlargement , ureteral
compression, or uterine growth after
menopause
• ?Based on size > 12 weeks

82. Hysterectomy-Choice of Approach:
Abdominal, Vaginal, or Laparoscopic
• Fibroids up to 12 weeks VAGINAL
• 12-16 weeks VH,LAVH>TLH
• > 16 weeks Abdominal Hystercetomy
• Lateral enlargement of uterus -TLH difficult

83. Hysterectomy for cervical fibroids
• Anterior
• Posterior
• Central-‘the lantern on the top of St Paul’s’
• Pseudocervical fibroid
• Lateral
• Hysterectomy cant be done until myoma is
removed by myomectomy

84. Cervical fiborid
• ??GnRH analogues
• Destroy planes and elimines one of the very
few ‘godsends’

85. Hysterectomy for an anterior
cervical myoma

86. Central cervical myoma Hemisection

87. Posterior myoma

88. CONTRACEPTIVE OPTIONS IN THE
PRESENCE OF FIBROIDS
• OCP,POP,DMPA ARE OPTIONS
• LNG-IUS-effective in controlling bleeding,may
reduce the size of fibroids
• Contraceptive efficacy of LNG IUS in women
with fibroids, with or without menorrhagia,
appears to remain intact

89. References
1) Uterine fibroids- Best Practice & Research
Clinical Obstetrics and Gynaecology Vol. 22, No.
4,2008
2) Malcolm G. Munro Uterine Leiomyomas,
Current Concepts:Pathogenesis, Impact on
Reproductive Health and Medical, Procedural,
and Surgical Management Obstet Gynecol Clin
N Am 38 (2011) 703–731

90. 3) Uterine myoma Obstetrics Gynaecology
clinics of north America Volume 33, Issue 1
(March 2006)
4) Te Lindes operative Gynaecology Rock, John
A.; Jones, Howard W 10th edition Lippincott
Williams & Wilkins
5) Bonney’s gynaecological surgery.—10th ed.
John M. Monaghan,Tito Lopes, Raj Naik.
Blackwell Science Ltd

91. • 6) Togas Tulandi Uterine fibroids Embolisation
and other treatment 2003 Cambridge
univeristy press