MARIN ARGYRIOU

DIMITRIS
BENING TUMORS OF
UTERUS

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 Benign tumors of uterus

Benign tumors of uterus

1. Endometrial
Polyps 2. Fibroid
3. Adenomyomatous
4. Placental polyp

Fibromyomas • Fibroids or Leiomyomas or Myomas

Commonest benign tumor of the Uterus and
in Female

Adenomyosis • Common condition in which islands of

Endometrium are found in the wall of the
Uterus
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a) Single or Multiple

b) Pink Swellings in Hysteroscopie

c) 1-2cm in diameter

d) Some of the can have Pedicle

 Endometrial polyp

a) Monstly arises from hyperplasia of endometrium.

b) Some of the endometrial lining protruding into the uterine

cavity as polyps, and The majority of polyps are located in the
fundus, often in the corneal area.
c) Composed of endometrial glands , blood vessels and stroma
covered with a single layer of columnar epithelium.

d) Secondary malignant change may occur, but after 40 years old.

Pathogenesis
 Placental polyp

• Formed from retained placental tissue

• May cause :
1) Secondary postpartum hemorrhage
2) An Intermmitent vaginal bleeding following an abortion or normal term
delivery
 Clinical signs

• Menorrhagia

• Metroragia

• Postmenopausal bleeding

• Postcoital bleeding (if it protrudes through the os or is located

near it)
 Diagnosis

• Clinically, uterine polyp may not be evident and the

uterus may or may not be enlarged
• It is easy to diagnose when the polypus protrudes
through the cervical canal

• Ultrasound can detect the uterine polyp

• Also Saline sonosalpingogram / Hysterosalpingogram
Ultrasound & Hysteroscopy
 Managment

• Dilatation and Curettage (D&C)

can scrape and remove the polyp

• Hysteroscopic removal when

multiple polyps exists in oder
to avoid a masive bleeding
Fibromas / Leiomyomas / Myomas
• Tumor that is composed with fibrous connective tissue
and smooth muscle

FIBROMYOMA
Types :
Submucosal, Intramural, Subserosal,
Pediculated (Submucosal / Subserosal)
• Incidence :
- At least 20% of women at the age of 30 have got fibroid in their
wombs
- 50% of them remains ASYMPTOMATIC
- Black women are more affected
- More commom in nulliparous / one child infertility

• Prelavance :
- Highest between 35 – 45 years and rarely before 20 years
Risk factors for Fibroids
INCREASE • Nulliparity
• Obesity – BMI > 35
• Hyperestrogenic state
• Black women

• Multiparity
DESCREASE
• Smoking - due to associated
hypoestrinism
• Fibroids are predominantly an Estrogen – depandent tumor

• Evidenced by :
- Potentially limited during child – bearing period
- Increased growth during pregnancy
- Rarely occur before menarche
- Cessation growth and there is no new growth at all following menopause
- Contain more estrogen receptors than the adjacement myometrium
- Frequent association of anovulation
• Growth not squarely distributed amongst the fibroids which are usually
multiple and some of them grow faster than the others.

On the whole, the rate of growth is SLOW, that’s why it takes around 3-5
years for the fibroid to grow sufficiently to felt per abdomen.

Grows RAPIDLY During Pregnancy

Amongst pill users (high dose pills)*
Due to malignant change

*The newer low dose of OCP are not associated with increase in the growth of a fibroid
• Fibroids are usually located in the body and are usually
multiple.
a) INTRAMURAL/INTERSTITIAL as position, after some of them
are pushed outward or inward. 70% persist in the initially
position.

b) SUBSEROSAL/SUBPERITONEAL are that one that are pushed

outwards towards the peritoneal cavity. After that process
can they become PEDICULATED SUBSEROSAL fibroid.

c) SUBMUCOSAL, can make the uterine cavity IRREGULAR &

DISTORTED, that’s why that type has the MAXIMUM
symptoms

d) CERVICAL , Rare 1-2%, May be anterior, posterior, lateral or

central. Also can displace the cervix or expand it so much that
external os is difficult to recognize.
SECONDARY CHANGES IN FIBROIDS

• Degeneratios
• Atrophy
•
•
Necrosis
Infection
DANIVaS
• Vascular changes
• Sarcomatous changes
DANIVAS
 Other Complications
• Hemorrhage
- Intracapsular
- Ruptured surface vein of subserous fibroid intraperitoneal
• Polycythemia
- Erythropoietic function by the tumor
- Altered erythropoietic function of the Kidney through
ureteric pressure.
 Other Complications
• Torsion of subserous pendunculated fibroid
• Inversion of uterus
• Endometrial carcinoma associated with fibromyoma
• Endometrial and Myohyperplasia
• Accompanying adenomyosis
• Parasitic fibroid
Symptoms and Physical Signs
• Anemia
• Menstrual disturbances
• Abdominal lump
• Infertility, recurrent abortions
- Arising from pelvis
• Pain – usually painless
- Well-defined margins
• Pressure symptoms upon
- Firm in consistency
Bladder, Rectum, Ureter.
- Smooth/bossy surface
• Abdominal lump
- Mobile from side to side
• Vaginal discharge
unless is fixed by adhesions
 Bimanual Examination
• Enlarged Uterus

• Cervix moves with the swelling which is not

felt separate from uterus unless it is
pedunculated.
• In cervical fibroid, the normal uterus is
perched on top of the tumor
• Broad ligament fibroid displaces the uterus to
the opposite side.
Ultrasound diagnosis
Ultrasound diagnosis
Investigations
Management
Main purpose of Management
Reduce the Menorrhagia and correct
anaemia before an eventual surgery

To minimize the size and vascularity of the

tumor to facilitate an eventual surgery

An alternative to surgery in postmenopausal

women or woman with high-risk for surgery.
To minimize blood loss
• Antiprogesterones
- Mifepristone (daily dose of 25– 30mg for 3 months

• Danazol
- 200 – 400mg divided dose for 3 months

• GnRH analogs
- Agonists (luporelin, goserelin, buserelin, nafarelin)
- Antagonists (cetrorelix, ganirelix)

• PG synthetase inhibitor – to relieve pain

 Levonorgestrel - IUD
• Reduce the size
and vascularity of Reduce the pain
the fibroid

Can help also the irregularity

of cycles and the abnormal
bleeding

After 6 Weeks of delivery,

a woman can attend for
because it is not after the
lactation
Fibroids complicating pregnancy
Pregnancy generally cause an INCREASE in
SIZE of the fibroids
• Increase vascularity
• High tendency to undergo degenerative
changes
(Red degeneration)
Do not forget that a fibroid can also
complicate the pregnancy if it has a
submucosal or pediculate submucosal
position
 Red / Carneous degeneration
of Fibroids

Severe acute
Result of the Blood effuses into
abdominal pain.
softening of the Capillaries tend to the myoma
(restricted to
surrounding rupture (diffuse reddish
the site of fibroid
supportive tissue discolouaration)
uterus)
Red / Carneous degeneration
Ultrasound & MRI
 Adenomyosis
Common condition in which islands of endometrium
are found in the wall of the uterus (myometrium)

Also known: Uterine ENDOMETRIOSIS

 General
Observed frequently in elderly
women and women > 40

Women are usually parous

The disease often coexists with uterine

Fibromyomas, Pelvic endometriosis (15%) and
endometrial carcinoma
Pathogenesis theories
 Gross examination
• Uterus appears symmetrically enlarged
to not more than 14 weeks size

• Cut section may show only a localized

nodular enlargement.

• Affected area reveals a peculiar, diffuse,

striated and non-capsulated involment
of the myometrium, with tiny dark
haemorrhagic areas interspersed
between.
 Histological examination
• Under the microscope
Islands of endometrial
glands surrounded by
stroma, in the midst of
endometrial tissue beyond
the myometrial junction
Types of ADENOMYOSIS
Adenomyosis
 Differential diagnosis
• A localised adenomyosis can lead to asymmetrical
enlargement of uterus - resembles myoma

• A myoma of this size is rarely painful

• Therefore , menorrhagia , with painful, asymmetrical

enlargement of the uterus suggests adenomyosis
 Investigations
Pelvic Ultrasound MRI
Medical Treatment
 Surgical treatment
• Diagnostic hysteroscopy + D&C
- Initial step in the management of adenomyosis because of menorrhagia
• Total Hysterectomy (elderly women who passed the age of
childbearing)
• Localized excision
- Younger women with localized adenomyosis
- Anxious to have child
• Transcervical resection of endometrium (TRCE)
- Effective for about 2 years.
 Take home message !!!
ADENOMIOSIS UTERINE FIBROMAS
Thank you for your
Attention!!!

Bibliography
1. Williams ginecologie edition 2
2. [Th.-2013; Aufl. 4] Duale Reihe –
Gynäkologie und Geburtshilfe
3. Tratat de chirurgie, Ed. a II-a, Vol. V
Obstetrică și Ginecologie, 2014 –Peltecu
4. https://www.google.com