INTRODUCTION

• Fibromyomas commonest of all pelvic tumours

• Benign neoplasms
• 20% of women in reproductive age and increasing with
age(20% over 20 years and 40% above 40)
• Also termed myoma or fibromyoma or fibroid
• Derived from smooth muscle cell rests

• Unicellular in origin

• Arises from somatic mutation in progenitor myocyte

• Multiple chromosomal abnormalities are detected in 50% by

cytogenetic analysis

• Commonest is translocation between long arm of

chromosome 12 to 14
• Frequently multiple and as many as 200 has been
found. More often the number is 5-30.

• Spherical in shape though surface can be lobulated.

• Surrounded by pseudo capsule which consist of

compressed normal uterine wall

• Firm to hard in consistency unless degeneration has

occurred.
•Can grow to immense size filling the whole
abdomen.

•Slow to grow (takes around 3 years to reach

the size of an orange)

•More common in nulliparous

 ANATOMY

•Spherical in shape, surface

usually lobulated

•Well circumscribed with a

pseudocapsule

•Firm in consistency

•Cut surface- pinkish white with a

whorled appearance

•Blood supply comes from the

vessels which lie in the capsule
& sends radial branches to the
tumour
 MICROSCOPICALLY
•Consists of bundles of plain muscle cells
separated by fibrous strands
 TYPES/ SITES
Depending on relationship to the
peritoneal coat and to the endometrium

SUBSEROUS

INTERSTITIAL

SUBMUCOUS
 SUBSEROUS
• Grows outwards towards the peritoneal surface

• Incidence - 10%

• Further extrusion – development of pedicle- pedunculated

fibroid

• Rarely tumour gets attached to a vascular organ – parasitic

or wandering
 INTERSTITIAL/INTRAMURAL

• Grows symmetrically within the myometrial wall

• Incidence – 75%

• Multiple or single
SUBMUCOUS

• Grows towards the cavity & is covered only by the

endometrium

• When myoma forces itself downward towards the

vagina by a pedicle – submucous myomatous polyp

• Incidence – 15%

• Usually single
 FIGO leiomyoma subclassification system
0 Pedunculated intracavitary
S- Submucosal
1 <50% intramural
2 > 50% intramural

3 Contacts endometrium; 100% intramural

4 Intramural
O-Other 5 Subserosal > 50% intramural
6 Subserosal < 50% intramural
7 Subserosal pedunculated
8 Other (specify eg cervical ,parasitic)
Hybrid leiomyomas(impact Two numbers are listed separated by hyphen ,first
both endometrium and in relationship with endometrium, second with
serosa) serosa
SYMPTOMS

• 50% are asymptomatic

• Nearer the fibroid to the endometrial cavity the

more likely it will cause symptoms especially
menstrual symptoms
General effects
Manifestations of anemia like palpitation, fatigue

Polycythemia – rare finding ,usually large and broad ligament

1.Tumour itself erythropoietic (islands of extramedullary

erythropoiesis have been documented)

2. Pressure on the ureters affects erythropoietic function of

the kidney

Hypoglyceamia ,hypokalemia– extremely rare

Tumour shows unusual cellular activity and more likely in
retroperitoneal myoma (pancreatic stimulus)
 MENSTRUAL SYMPTOMS

MENORRHAGIA Characteristic symptom

1.Increased vascularity

2.Increased surface area(normal surface area 15

square cm, may increase to 200 in fibroid)

3. Associated endometrial hyperplasia ,

Hyperoestrogenism
4.May interfere with myometrial contractility as well
as contractility of the spiral arterioles in the basalis
portion of the endometrium

5. May relate to dilatation of venules.

Bulky tumors are thought to exert pressure and

impinge on the uterine venous system, which causes
venular dilatation within the myometrium and
endometrium and sloughing of these large venules
causes menorrhagia.
6.Dysregulation of local vasoactive growth factors
are also thought to promote vasodilatation.

Disbalance between PGI 2 andTXA2 with

deficiency of TXA 2.
Spasmodic dysmenorrhoea

1. Due to myoma sited at utero tubal junction from

which uterine contractions arise

2. Submucosal tumour stimulates expulsive uterine

contraction

3. Pelvic congestion causing congestive

dysmenorrhea
PAIN

Acute pain occurs only

1.Torsion of the fibroid
2.Extrusion from the uterus as polyp
3.Degeneration
4.Sarcomatous changes
5.Adhesion to other organs
6.Associated endrometriosis
PRESSURE SYMPTOMS
Weight Of The Tumour Causes
1. Bladder Irritability

2. Retention Of Urine with compression of urethra

and bladder neck against pubic symphysis by
impacted fibroid

3. Broad Ligament Fibroid Can Cause Hydroureter

& Hydronephrosis

4. Constipation with compression of rectum

Continuous and irregular bleeding with
discharge

•Surface ulceration of myoma

•Sarcomatous change

•Coincidental Pregnancy state

•Coincidental endometrial polyp,endometrial

carcinoma
SYMPTOMS RELATED TO
PREGNANCY
•Abortion ,premature labour (interferes with
enlargement of uterus, initiates abnormal
uterine action, prevents efficient implantation)

•Malposition & Malpresentation( distortion of

shape )

•Obstructed Labour (cervical)

•PPH

•Subinvolution
CAUSES OF INFERTILITY

• Infertility (sole cause in <3%)

• Submucous myoma is mostly responsible

• Interferes with implantation

• Hinders the ascent of spermatozoa by distorting

shape of the uterus & tubes
Symptoms to be elicited at the time of taking
history
• Excessive or prolonged menstrual bleeding: Nature of bleeding,
amount of bleeding, duration of bleeding, pattern of bleeding and
timing of bleeding
• symptoms such as palpitations, lassitude, loss of weight
• Pressure symptoms: These may include symptoms such as
backache (due to the pressure on spinal nerves); urinary
symptoms, such as increased diurnal frequency and urgency (due
to bladder irritability); bowel dysfunction (due to pressure on
intestines); rectal tenesmus and constipation (due to pressure on
rectum
• Pain
• Infertility or pregnancy-related complications
 Details to be noted
• Patient’s age
• Obstetric history
• History of contraceptive use
• Presence of any coagulation related disorder
• Symptoms of thyroid dysfunction
• History of intake of any medications
• Plans regarding future fertility
• History of undergoing Pap smears in the past.
• History related to risk factors, which can result in the
development of fibroids Heredity ,Race
 PHYSICAL SIGNS
• Signs of anaemia

• Rule out the presence of any systemic anomaly (e.g.

hypertension, diabetes, asthma, etc.), which could affect the
patient’s fitness for gynecological/surgical treatment

Abdominal Examination

Leiomyoma has to attain the size of approximately 12–14

weeks before the abdominal swelling becomes palpable per
abdominally.
P/A
Abdominal lump arising from the pelvis

Firm in consistency, non tender

Well defined margins

Smooth to bossy surface

Movable from side to side but not from above downwards

Dull to percussion
Per Speculum Examination To look for any cervical
erosion, ulcer, growth, polyp

Bimanual examination
• Enlarged uterus

• Regular or bossy surface

• Cervix moves with the swelling

• No groove felt between mass and cervix.

 DIFFERENTIAL DIAGNOSIS
• Pregnancy – commonest and first possible cause to be
considered in reproductive age.
• Adenomyosis –uterus > 12 weeks size & irregular surface
goes more in favor towards myoma. USG confirms the
diagnosis.

• Endometriosis – c/f are same but uterus is normal in size but

adherent to pelvic mass

• Haematometra, Pyometra

• Ovarian tumour – a sub serous or pendunculated fibroid

may resemble an ovarian tumour

• Endometrial cancer – coexist in elderly woman.abnormal

bleeding requires D&C to rule out malignancy
Continuation of differential diagnosis

• Chronic PID – history & c/f will be identical but uterus

is normal size & due to inflammatory reaction the
uterus & adnexae may be fixed & tender

• Bicornuate uterus – diagnosed hsg,hysteroscopy &

usg
Diagnosis

• Complete blood count, iron studies for anaemia

• Endometrial sampling for histopathological

examination in case of AUB and HMB

• Pap smear in AUB

• Imaging studies
Investigations
Ultrasonography
TAS +TVUS is the best to assess fibroid
growth and adnexa

Well defined hypoechoic lesions

Circumferential vascularity is seen on

doppler.

Rule out hydronephrosis

Saline infusion sonography
• Adjunct to ultrasonography in sub mucosal

• Prevents overestimation of Endometrial

thickness

• Differentiates from mucosal polyp/blood clots

• Specificity and sensitivity of 98-100% for

submucosal lesions
 Hysteroscopy
May be required to differentiate intracavitary
myomas and large endometrial polyp

Diagnostic and therapeutic.

In case of irregular bleeding can be combined with

endometrial biopsy
Magnetic Resonance Imaging
•Helps in fibroid mapping (localization, measurement,
characterization)

•Various degree of cellularity,degeneration,necrosis

and calcification can be identified

•Sarcomatous change can be suspected

•Sensitivity of nearly 100% and specificity of 91%

Treatment
Treatment modality depends on
•Symptoms and severity
•Age of the woman
•Size and Location
•Patients desire for fertility or uterine
preservation
•Availability of treatment modality
•Experience and expertise of the care provider.
 INDICATIONS FOR TREATMENT IN AN
ASYMPTOMATIC FIBROID
• Uterus > 12-14 weeks size

• The potential for better fertility if myomectomy is

performed.

• An asymptomatic fibroid causing pressure on the

ureter eg broad ligament fibroid

• Grows rapidly

• Subserous pedunculated fibroid prone to torsion

• Doubt about its nature

 Treatment options for symptomatic fibroid
Expectant

Medical therapies
NSAIDs
Tranexamic acid
Danazol
LNG-IUS
GnRH agonists
SPRM
 Conservative treatments

Uterine Artery Embolization(UAE)

Radiofrequency myolysis

Magnetic Resonance guided Focused Ultrasound surgery

(MRgFUS)
Surgical therapies

Myomectomy
Abdominal
Laparoscopic
Hysteroscopic
Robotic assisted laporscopic

Hysterectomy
Abdominal
Laparoscopic/RA
Vaginal
 PROGESTOGENS

Norethisterone,medroxyprogesterone acetate

•Dose : initial high dose of 10-30mg / day for 24 – 48

hrs, followed by 5 mg a day for 20 days

•Second course of 5 mg daily from 5 th day for 21 days

•Cyclical treatment – 3 to 6 months

Levonorgestrel –releasing intrauterine device(LNG-
IUD):
•Contain 52 mg of levonorgegestrel.20mcg a day
are delivered to endometrium.

•Very small amount is absorbed into the blood

stream and rarely leads to side effect.

•Decrease blood loss in 85% after 6 months and

97% after 12 months.
 DANAZOL
• Used before myomectomy to decrease uterine
blood flow

• Dose : 400- 800mg for 4 – 6 months

• Androgenic , not the recommended drug of choice

for young women
 GnRH ANALOGUES

• Inhibit the secretion of gonadotropins (FHS,LH) and

sex steroid by pitutary desensitization and down
regulation.

• Creates pseudomenopause like state.

• Also affects leiomyoma by reducing vascularity and

the individual cell size.

• Drugs commonly used:goserelin,luporelin,buserelin or

nafarelin
Reduction in volume of fibroids 40-50% after 3-
6 months treatment.

• In Two third of patient induce amenorrhea.

• Increases chances of osteoporosis

• Capsule thins out making enucleation difficult,

smaller fibroids disappear, which recur later
 RU486(MIFEPRESTONE)

Antiprogesterone

10 – 25 mg daily for 3 months

Reduced bleeding but no significant reduction in

tumour volume.
Current medical management options
SPRMs
Progesterone stimulates proliferative activity
in fibroid cells and exogenous progesterone
increases mitotic activity and cellularity in
tumour

Fibroid overexpress ERs and progesterone

receptors
Ulipristal acetate is a synthetic steroid derived from
19-norprogesterone

UPA is tissue selective with preferential binding

noted in uterus, cervix, ovaries ,hypothalamus

Uterine bleeding was controlled in more than 90%

Median time to control bleeding was 5-7days

UPA 5mg OD up to 6 months

Uterine artery embolization
First used in 1995 to treat uterine fibroids in women
wishing to preserve uterus.

Induces ischemic necrosis of fibroid ,while

myometrium revascularizes.

Improvement in symptom 80-90%

Reduction in fibroid size 40-70%

•This is an angiographic interventional
procedure that delivers polyvinyl alcohol
(PVA) microspheres or other particulate
emboli into both uterine arteries.

•An angiographic catheter is placed in either

femoral artery and advanced under fluoroscopic
guidance to selectively catheterize both uterine
arteries

Uterine blood flow is therefore obstructed,

producing ischemia and necrosis.
These microspheres are
preferentially
directed to the tumors,
sparing the surrounding
myometrium
Side effects and complication

•Post procedure pain :68% felt pain and was worse

than dysmenorrhoea
•Post embolization syndrome: pain ,fever,
vomiting, nausea and anorexia. All symptoms
resolve within 7 days.
•Infective complication: rare
• infraction of fibroid and sloughing may occur.
• Massive vault necrosis with a bladder fistula
 Myolysis
First performed by Mergui in France in 1987
•Laparoscopic Myolysis involves delivering laser
energy or cryoprobe(-90 degree C) or bipolar
electrodes to myomas

•Reduction or suppression of primary blood

supply and the devascularized myoma becomes
cyanotic, loses viability and fibroses.

•Reduction in fibroid volume of around 70%

Magnetic Resonance guided
Focussed Ultrasound
surgery(MRgFUS)
High intensity focussed ultrasound that passes
through the anterior abdominal wall and
converge into a precise target point within the
fibroid to cause temperature rise (55-90 C)

Coagulative necrosis within a few seconds.

MRgFUS

Patient selection
•1-5 fibroid with total
volume <500
•No bowel loops,
adhesion anterior to
uterus
•No other pelvic
disease
Advantage
Non-invasive

Success rate 75-85%

Disadvantage
Fibroids located
beneath the anterior
abdominal wall only

Expensive
 Myomectomy

Basic Principles
•Consent of hysterectomy for unforeseen
intraoperative problems
•Adequate blood to be arranged
•Intraoperative adjuncts for reducing blood loss to
be used.
•Anterior uterine incision is preferred with an
attempt to remove maximum fibroids through
minimal tunneling incision
• Operative field to be kept moist and free of clots,
traumatic instruments to be avoided.

• Enucleation to be performed by identifying

appropriate plane.

• Haemostasis to be maintained through obliteration of

myoma cavity by multilayering with delayed
absorbable suture
Adjuncts for reducing blood loss
• Occlusion of blood flow by use of tourniquete

• Misoprostol 400µg per vaginum an hour before

surgery.

• Controlled hypotensive anaesthesia with reduction of

venous tone (nitroglycerine,sodium nitroprusside)

• Vasopressin Intramyometrial into planned incision site

(20U in 20 ml of NS)
• Tranexamic acid 1gm 15 min before skin
incision

• Occlusion of uterine artery intraoperatively

• Trendelenburg position
Hysteroscopic myomectomy

Symptomatic fibroids
AUB,HMB
Infertility
recurrent pregnancy loss

Type 0, I and II myoma(FIGO)

Up to 5cm in size
Procedure

Distending media
Hypotonic media 5%
glycine, 3% sorbitol)
for monopolar loop
resectoscope.

Isotonic fluid (NS, RL)

for bipolar
resectoscopes.
 Complications

0.8-2.6% Uterine
perforation

Excessive distension fluid

absorption

Burns

Adhesion formation
Laparoscopic Myomectomy

• Symptomatic fibroids – Intramural/Subserosal

• Size <15cm
• Myoma type 2-5
• Associated abdominal pathology with fibroid.

Reduced blood loss and postoperative pain

Quicker recovery
Cosmetically advantageous
Procedure
Robotic Surgery

Use of robot in
gynaecological surgery
was first reported in
2000 by Falcone et al.

RA-Laparoscopic
myomectomy

Benefit of ease and

speed of suturing .
Length of hospital stay was shorter and
postoperative blood transfusion was reduced but
there was a significant increase in the overall cost
of surgery
Vaginal Myomectomy

• In 1845, Atlee performed the first successful vaginal myomectomy

Abdominal myomectomy
First performed by Atlee brothers in 1844

Hysteroscopic or laparoscopic myomectomy is not

appropriate
Large >10cm fibroid
Fibroid in lower segment or cervical

Associated abdominal pathology requiring

laparotomy
Comparison of open and minimally invasive
myomectomy
According to multiple studies ,laparoscopic approach was
noted to be associated

•with less amount of blood loss

•less need for blood transfusion

•Less postoperative pain

•Shorter hospital stay

• Recurrence rate is 5-10% after myomectomy

• 20-25% land up in hysterectomy

• 25-30% become pregnant

Hysterectomy
• As repeat therapy in patients who have failed
previous conservative treatment.

• During myomectomy with uncontrolled

haemorrhage.
Route

Should be least invasive approach ,feasible in

each case.
•Vaginal route

•Laparoscopic (TLH/LAVH/RA-TLH)

•Abdominal
 VAGINAL HYSTERECTOMY

• Uterine size less than 12 weeks

• Mobile uterus

• No other pelvic pathology

Abdominal hysterectomy is indicated

Large uterine fibroid

Large broad ligament fibroid

Cervical fibroid

Dense adhesions
 COMPLICATIONS OF FIBROID
• TORSION

• HAEMORRHAGE

• SARCOMATOUS CHANGE

• DEGENERATION
TORSION
• Torsion interrupts first venous and then
arterial supply

• Leading to extravasation of blood and

gangrene

• Emergency
 Haemorrhage
• Rupture of large vein on the surface of
pedunculated tumour causing intraperitoneal
hemorrhage

• Uncommon
 DEGENERATION

•Normal muscle tissue is replaced with

various degenerative substances following
hemorrhage and necrosis following
interference with the capsular circulation

•Becomes painful,tender, softened and

enlarged.
Red degeneration

• Red or carneous degeneration is seen occasionally,

especially in association with pregnancy.

• This condition is thought to result from poor

circulation of blood through a rapidly growing tumor.
• Thrombosis and extravasation of blood into the
myoma tissue are responsible for the reddish
discoloration
Common in mid pregnancy

•Painful,enlarged and tender

•Vomiting

•Malaise

•pyrexia
• Conservative management

• Rest

• Analgesics

• Subsides in 3-10 days

Fatty degeneration
The cut surface may have a yellowish discoloration.

Hyaline degeneration(commonest)
•Fibrous tissue replaced by homogeneous substance

•Muscle fibres becomes isolated and die

•Tumour become structureless

•Hyaline material liquefies leaving cavities filled with

colourless/bloodstained fluid
 Infection
• Leiomyomata may undergo changes as a result of
infection.

• Submucous leiomyomata are most commonly

infected when they protrude into the uterine cavity,
or especially into the vagina
calcification
• Over time, with continued diminished blood supply
and ischemic necrosis of tissue, calcium phosphates
and carbonates are deposited in myomata.

• If it is deposited at the periphery of the tumor, the

leiomyoma may resemble a calcified cyst.

• When the degenerative change is advanced, the

leiomyoma may become solidly calcified. Such
calcified tumors have been called “wombstones.”
Sarcomatous changes

Found in only 0.2 % of tumours

Process usually begins at the centre of tumour

Histological diagnosis
 Case

• Mrs XYZ, a 33-year-old P1+0 woman, resident of ABC,

married since last 5 years, presented with complaints of
excessive menstrual bleeding since last 6 months.
Despite of heavy bleeding during the periods, the
periods were otherwise regular. The patient was
prescribed mefenamic acid, but did not show any
response to treatment. A D&C was done a month ago
which showed benign pathology. Pelvic examination
revealed an enlarged uterus (about 6 weeks in size).
The mass was contiguous with the cervix and could not
be moved away from the cervix
 Questions
• What is the most likely diagnosis in the above-mentioned
case study?

• What is menorrhagia?
• What are the various probable causes of menorrhagia?
• What are uterine myomas and what are the different types?
• What investigations are required in the cases of uterine
leiomyomas?
• What is the management in cases of fibroid uterus?
• What would be the best treatment option in the previously
described case study?
• What are the various medical therapeutic options for
controlling menorrhagia?
• What are the various surgical options to be used in cases of
uterine leiomyomas

• What could be the various complications associated with

myomas?

• What are the possible effects of fibroids on pregnancy?

• Can fibroids cause infertility?

 Adenomyosis
• Adenomyosis usually involves the corpus, sometimes only
one of its walls or a part of it.
• Adenomyoma is composed of basal type endometrium
which is normally insensitive to an endocrine stimulus.
• Fibromyomatous tissue reaction is well developed and, to
the naked eye, the resulting tumour looks like a myoma, its
cut surface having a similar striated and whorled appearance
• Adenomyosis has no capsule, and it usually produces a
diffuse enlargement of the uterus in contrast to the well
circum-scribed nodules characteristic of leiomyomas.
When adenomyosis is localised it is most likely to be situated
in the posterior wall of the uterus.
 Symptoms

• The most common symptom is menorrhagia which is

found in approximately 75 per cent of cases.
• It is gradually progressive over several years and is
caused by
Enlargement of the uterine cavity (bleeding area) and
by an increased blood supply.

Impaired contractility of the myometrium and

associated endometrial hyperplasia
• Dysmenorrhoea is noted by only 30 per cent of patients and,
when it occurs, is mainly intramenstrual.

• It is more likely when the myometrium is deeply penetrated

andis probably caused by disturbed uterine contractions

• The increased size of the uterus can cause diurnal

frequency, a sensation of weight in the pelvis, and a
noticeable abdominal tumour.

• The patient may also complain of infertility

Pointers in favour of adenomyosis from fibroid are:

•It tends to occur at a younger age

• Rarely enlarges the uterus to more than the size of

a 12- 14 weeks’ pregnancy
•It causes a regular rather than a nodular uterine
enlargement.
Diagnosis
Ultrasonography (TAS,TVUS)

MRI

Blurring’ of endomyometrial interface

subendometrial linear striations
echogenic nodules
asymmetric myometrial thickness
myometrial cyst
 Treatment

The LNG-IUS releases 20 mg levonorgestrel per day.

Associated with decidualisation of the endometrium
followed by atrophic changes. As a result there is a
marked reduction in menstrual blood loss.

Hysterectomy
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