FIBROID UTERUS Presented by : - PowerPoint Presentation

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FIBROID UTERUS

Presented by : Dr. Piyali Mondal, Dr. Yashi SharmaModerator: Prof. (Dr.) Sibani Sengupta

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Fibroid

Synonyms: Myoma, Leiomyoma, FibromyomaMost common benign neoplasm of uterusIncidence: 20 to 25% of reproductive age women. (Ref: Williams Gyne) 50% remain asymptomatic)Composition: Smooth muscle cells & Fibrous tissue.

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Histogenesis

It arises from smooth muscle cell of myometrium.Exact etiology not known.Monoclonal origin ( arising from single cell)Genetic basis definiteVarious peptide growth factors like EGF, IGF-1, TGF

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Genetic basis

Responsible for (40-50)% cases of fibroids Translocation between chromosome 12 &14,Trisomy 12,Rearrangement of short arm of ch.6,Rearrangement of long arm of ch.10,Deletion of ch.3 or ch.7Specific gene mutations : MED12, HMGA2, COL4A5-A6, FH gene ( associated with HLRCC: Hereditary leiomyomatosis and renal cell cancer syndrome) (J Reprod Infertil.2011; 12(3):181-191)

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Epidemiological risk factors

Increased risk: NulliparityEarly menarcheObesity ( increased BMI, PCOS)Hyperestrogenic stateBlack womenHigh fat dietFamily HistoryReduced risk :MultiparityEarly age at first birthMenopause

OCP

Smoking (

lowers physiologically active

estrogen

)

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Etiology

It is predominantly an estrogen & Progesterone sensitive tumour. Estrogen dependency is evidenced by:Growth potentiality is limited during childbearing period.Increased growth during pregnancy.They do not occur before menarche.Following menopause, there is often cessation of growth and there is no new growth at all.It contains more estrogen receptors than the adjacent myometrium.Frequent asssociation of anovulation.

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Leiomyomas

also carry a higher progesterone receptor density compared to adjacent myometrium.Progesterone is considered as critical mitogen for fibroid.Estrogen functions to upregulate & maintain progesterone receptors.Role of progestrone supported by the evidence that antiprogestin Mifepristone & Ulipristal induce atrophy in most myomas.

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Types of fibroids

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Interstitial or Intramural(75%):

Initially the fibroids are intramural in position. Some are pushed outward or inward.In about 70% , they persist in that position.Submucous(5%)Intramural fibroids are pushed toward the uterine cavity and is lying underneath the endometrium.It can make the uterine cavity irregular and distorted.This variety is least common but produces maximum symptoms.

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Subserous

or subperitoneal(15%):Intramural fibroids are pushed towards the peritoneal cavity.The fibroids are partially or completely covered by the peritoneum.When completely covered by peritoneum , attains a pedicle- called Pedunculated subserous fibroid.On rare occasion pedicle may be torn through – Wandering or Parasitic fibroid

.

Sometimes it may be pushed out in

between

the layers of Broad ligaments called

Pseudo Broad Ligament fibroid.

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It is rare (1-2%).Supravaginal

part of cervix: Intramural or subserosalVaginal cervix: usually pedunculated and rarely sessile.In central cervical fibroids, uterus sits on top of the circumferential massive mass. (Lantern on the dome of St. Paul’s cathedral)Cervical Fibroid

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Leiomyoma classification system (FIGO)

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Smooth muscle tumor

of uncertain malignant potential (STUMP) Tumors of myometrium which fall between benign leiomyoma and leiomyosarcoma.< 5 mitotic figures/10HPF Leiomyoma>10 mitotic figures/10HPF Leiomyosarcoma5-10 mitotic figures/10HPF STUMPDiagnosis is made after surgeryTreatment: HysterectomyExcellent prognosis

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Leiomyomatosis

Extrauterine smooth muscle tumors, which are benign yet infiltrative, may occur in women with concurrent or prior myomaTypesIntravenous leiomyomatosisBenign metastasizing leiomyomasDisseminated peritoneal leiomyomatosis(DPL)

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Pathology

Gross :Nodular structureOval or rounded shapedCut section – whorled appearance & trabeculationThe false capsule is formed by the compressed adjacent myometriumThe centre of the tumor is least vascular

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Microscopy

Smooth muscle cell bundles arranged in whorled pattern with variable amount of connective tissue.Predominance of fibrous tissues rarely seen

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Secondary changes in Fibroid

DegenerationsAtrophyNecrosisInfectionVascular ChangesSarcomatous Changes (in less than 0.1% cases)

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Degenerations

1.Hyaline Degeneration:Most common type(65%)Affects all size of fibroids except the tiny onesCommonest site – central part of fibroidThe feel becomes soft elastic2.Cystic degeneration :occurs following menopausecommon in interstitial fibroidsformed by liquefaction of areas with hyaline degeneration.

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3.Fatty degeneration:Usually found at or after menopause.Fat globules are deposited mainly in the muscle cells.4.Calcific degeneration(10%):Usually involves the subserous fibroids with small pedicles in postmenopausal women. There is precipitation of calcium carbonate or phosphonate

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5. Red

deneration(carneous degeneration):Mainly during second half of pregnancy and puerperiumCan occur after 40 yrs of age (with use of COCs,GnRH analogue), after UAE.Probably vascular in origin. (Thrombosis of the vessels supplying the myoma resulting in infarction)Self limiting

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Clinical features

Majority (50%) of fibroids are asymptomatic.The symptoms are related to anatomic type & size of the tumor.The site is more important than the size. Symptoms :Menstrual abnormalitySubfertilityPain & Pressure symptomsRecurrence pregnancy losslower abdominal or pelvic painAbdominal enlargement

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Menstrual abnormalities

a.Menorrhagia (30%) :It is the classical symptom of symptomatic fibroid. The causes are:Increased surface area of the endometriumInterference with normal uterine contractilityCongestion & dilatation of the subjacent endometrial venous plexusesEndometrial hyperplasiaImbalance of TXA2 and PGI2.Aberrant angiogenesis.

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b.

Metrorrhagia:Ulceration of submucous fibroid or fibroid polypTorn vessels from the sloughing base of polypAssociated endometrial CADysmenorrhea: Mainly of congestive variety, sometimes spasmodic type.

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Infertility

Infertility (30%)- a major complaint.Attributing factors:UterineDistortion & elongation of cavity – difficult sperm ascentPreventing rhythmic contraction of uterus – impaired sperm transport.Congestion & dilatation of endometrial venous plexuses – defective implantation.Atrophy & ulceration of endometrium of submucous fibroid- defective nidation

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Tubal :

Cornual block due to position of fibroidMarked elongation of the tube over big fibroidAssociated salpingitis Ovarian : AnovulationPeritoneal: Endometriosis

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Pain lower abdomen

Due to tumor :DegenerationTorsionExtusion of polyp Acute retention of urineDeep vein thrombosisDue to associated pathology : Endometriosis , PIDPressure SymptomsCommonly seen in cervical fibroids, rare in body fibroidsPosterior wall fibroid

– constipation, dysuria ,retention of urine

Broad ligaments fibroids – ureteric compression

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Pregnancy related problems:

AbortionPreterm laborMalposition & malpresentationIUGRRed degeneration & torsion of subserous pedunculated fibroidLabor dystociaIncreased operative deliveryPPH

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Signs

General Examination: Pallor Abdominal examination:Feel : Firm, more toward hard; may be cysticMargins : well defined except lower poleSurface : Nodular or uniformly enlargedMobility: restricted from above downwardPercussion :

Dull

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Pelvic examination:

The swelling is uterine evidenced by-Uterus not felt separately from the swellingThe cervix moves with the movement of the mass felt per abdomen.

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Complications of fibroids

Degenerations NecrosisInfection Sarcomatous changesTorsionHemorrhagePolycythemia

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Life threatening complications of fibroid

Severe AnemiaSevere Intraperitoneal HemorrhageSevere infection leading to peritonitis or SepticemiaSarcoma

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Differential diagnosis

PregnancyFull bladderOvarian TumorBroad ligament CystTubo ovarian massChocolate cystAdenomyosisPyometra, Hematometra, LochiometraEncysted peritonitis or ascitisCA endometrium with pyometraHydronephrosisRetroperitoneal Growth

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Investigations

To confirm the diagnosis:Ultrasound & color doppler findings-1. Uterine contour is enlarged &distorted2. Echogenicity : well defined hypoechoic (hyperechoic if fibrous tissue more)3. Vascularisation is at the periphery of the fibroid4. Central vascularisation indicates degenerative changes

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TVS

provides superior resolution than TAS for pelvic tumoursTAS required for large myomas3-D TVS can locate fibroid accuratelyColor & power doppler identify the vascular pattern ,can be used to differentiatea)Extrauterine leiomyoma from another pelvic massb)Submucuos fibroid from an endometrial polyp

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Saline infusion Sonography(SIS) : detect any submucous fibroid or polyp

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HSG or

HyCoSy (Hysterosalpingo-contrast sonography): Evaluate the endometrial cavity

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MRI –

more accurate compared to USGHelps to differentiate adenomyosis from fibroid

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Laparoscopy :

It is helpful , if the uterine size is less than 12 wks & associated with pelvic pain and inferility.

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Hysterescopy: helps to detect submucosal fibroid in unexplained infertility & repeated pregnancy wastage, AUB

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Management

Medical management: Objectives 1. Young women desirous of pregnancy.2. To improve menorrhagia & correct anemia3. To minimize the size & vascularity before surgery4. In selected cases of infertility to facilitate hysteroscopic or laparoscopic surgery5. An alternative to surgery in perimenopausal patient or women with high risk for surgery6. Postponement of surgery in planned temporarily

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Drug used to minimize blood loss

1.Antiprogesterones (Mifepristone)2.Antigonadotropins :Danazol, Gestrinone3.GnRH receptor agents:Agonist : Leuprolide, goserelin, buserelin, nafarelinAntagonist: Cetrorelix, Ganirelix (FDA approved) Elagolix (Newer drug)4.LNG-IUS5.COCs & Progestins

6.SPRM (

Ulipristal,Aloprisnil

)

7.Non hormonal ( TXA, NSAIDS)

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Antiprogesterones

:Mifepristone (RU486) reduces size of fibroid & menorrhagia.A daily dose of 2.5 -10 mg for 3 -6 months found to be effective.Long term therapy – causes endometrial hyperplasia.SERM(Selective estrogen receptor modulator):Ormeloxifene 60 mg twice a week followed by 60 mg once a week for next 3 months.

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SPRM (Selective progesterone receptor modulator)

5-10 mg daily oral doses (Ulipristal acetate) reduces menorrhagia in 90% of patientsCan be given upto 4 cycles (3 months each) with a gap of 3 months after each cycle.Mechanism: (Antiproliferative & Proapoptotic) Induces apoptosis through activation of TRAIL Up regulation of caspase3 & down regulation of Bcl2Suppression of collagen synthesisModulation of extracellular matrix enzymes(MMPs)Associated with morphologial changes in the endometrium-

PAEC

(

Progestrone

receptor modulator associated endometrial changes)

RCOG cautioned its use in women with liver disease due to incidence of

fulminant hepatitis

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GnRH

agonists:sustained pituitary down regulation & suppresion of ovarian function.Optimal duration of therapy -3 monthsAdd back therapy may be needed to combat hypoestrogenic side effectsGnRH antagonists:Immediate suprresion of pituitary & the ovaries. Don’t have initial stimulatory effect.Onset of amenorrhea is rapid.Limitation: They are daily

injectables

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LNG IUS

It reduces blood loss and uterine sizeNot recommended if-Uterine size>12 wksUterine cavity distortedCavity length>10cmCOCs & Progestins:Both induces endometrial atrophy & reduces prostaglandin synthesis

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Surgical management

Hysterectomy (Abdominal/Vaginal/LAVH/TLH)Myomectomy(Abdominal/Vaginal/ Hysteroscopic/ Laparoscopic)EmbolotherapyLaparoscopic uterine artery ligationMyolysisEndometrial ablation

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Myomectomy

Important consideration prior to myomectomy1. Counselling : 50% risk of recurrence in next 5 years, chance of persistence of heavy menstrual bleeding and infertility, switch over to hysterectomy ( In case of excessive bleeding, grossly distorted uterus, associated suspicious adnexal mass, difficulty to shell out myoma due to dense adhesion etc.)2. It should be mainly to preserve the reproductive function3. More risky operation when fibroid is too big and too many4. Risk of re-laparotomy 20-25%5. Pregnancy rate following myomectomy 40-60%

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Contraindications of Myomectomy

Infected fibroidGrowth of myoma after menopauseSuspected malignant changes(sarcoma)Parous women where hysterectomy is safer & is definitive treatment.Pelvic or endometrial tuberculosisDuring pregnancy or during caesarean section (relative)

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Endoscopic surgery

Hysterescopy : For submucous myomaCriteria:1.<5cm in size 2.<50% intramural component 3.<12 cm uterine sizecomplications- Uterine perforation, fluid overload,hemorrhageLaparoscopy: Subserous & intramural fibroids could be removed laparoscopically. Leiomyomas can be desiccated using laser or bipolar diathermy (Myolysis)

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Uterine artery embolization(UAE)

Method :Uterine arteries are occluded by injecting polyvinyl alcohol particles through percutaneous femoral catheterizationResult:1.Improvement of menorrhagia (80-90%)2.Reduction of size(60%)Complications:Post embolization syndrome, pain, fever,sepsis, myometrial infarction, necrosis.Contraindications:Acute pelvic infection, women desirous for future pregnancy, genital tract malignancy, drug allergy

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Magnetic resonance guided focussed ultrasound (MRgFUS

)Focussed high energy ultrasound waves induce coagulative necrosis in myomas. (FDA approved)Session : 2-3 hrs Contraindications:PregnancyAbdominal wall scarsUterine size >24 wks sizeDesire for future fertilityMyoma size >10cm

Current pelvic infection

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Hysterectomy

Indications:Most effective and definitive therapy for large symptomatic fibroids in women who have completed their familyAlso indicated when medical methods or minimally methods failRecurrence of myoma after prior consevative surgery(myomectomy)

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