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UTERINE FIBROID

CASE SCENARIOS
&
DISCUSSION
By
Dr. K. Haynes Raja,
Junior Resident,
Rajah Muthiah Medical College & Hospital,
Annamalai University.
DEDICATION
Dedicated to my Great Teachers
in the Dept. of Obstetrics & Gynaecology
Dr. Lavanya Kumari and Dr. Sangeereni,
Inspiring Friends Dr. Paulin Benedict,
Dr. Jeyakumar Meyyappan and Dr. Hannah Jane
and our REVELLIONZ 08 batch.
PREFACE
This presentation is prepared to meet out the
undergraduate medical student needs especially to
understand the practical aspects of uterine fibroid and to
rapidly revise some important viva questions.
CASE SCENARIO - 1
A 36 Year old woman has noticed
abdominal swelling for 10 months.
She has to wear large clothes and
people asked her if she is pregnant,
which she finds distressing having
been trying to conceive.
She has no abdominal pain and her
bowel habit is normal. She feels
nauseated when she eats large
amounts. She has urinary frequency
but no dysuria or haematuria.

Her periods are regular, every 27
days and have always been heavy,
with clots and flooding on the second
and third days. She has never
received any treatment for her heavy
periods.


She has been with her partner for 7
years and despite not using
contraception she has never been
pregnant.



Examination
The woman has a very distended
abdomen. A smooth firm mass is
palpable extending from symphysis pubis
to midway between the umbilicus and the
xiphisternum (equivalent to a 32 week
pregnancy). It is non-tender and mobile.
It is not fluctuant and it is not possible to
palpate beneath the mass.
On speculum examination it is not
possible to visualise the cervix.
Bimanual examination reveals a
non-tender firm mass occupying the
pelvis.
Investigations
Haemoglobin 6.3 g/dL
Mean cell volume 68fl
White cell count 4.9 * 10
9
/L
Platelets 267 * 10
9
/L
Magnetic resonance imaging

Diagnosis
The woman has a large uterine
fibroid. This is causing menorrhagia
and hence the microcytic anaemia
from iron deficiency. It is also likely
that fibroid is accounting for her
infertility history.
DISCUSSION
What is the differential diagnosis?
Uterine fibroids
Pregnancy
Full bladder
Haematometra/pyometra
Adenomyosis
Bicornuate uterus
Bilateral tubo-ovarian masses
Ectopic pregnancy
Pelvic Endometriosis
Endometrial carcinoma
Uterine sarcoma
Ovarian neoplasms

What is fibroid?
Fibroid is the commonest benign tumour of uterus
Arises from smooth muscle cells and hence called
as Leiomyoma

What is the incidence?
At least 20% of women in the reproductive age group
Whether fibroid is hormone
dependant?
Fibroid is hormone dependant. Predominantly
oestrogen dependant.
Other hormones implicated are growth hormone,
human placental lactogen
What are the hyperoestrogenic
states?
Nulliparity
Obesity
Polycystic Ovarian syndrome
Endometrial hyperplasia
Explain the Anatomy & pathology
of fibroid?
Derived from smooth muscle cell rests, either from
vessel walls or uterine musculature
Well circumcised, firm, round tumours with a
pseudocapsule
They become soft and cystic when degenerative
changes occur
They may be single or multiple
Usually arises from body of uterus and less
commonly from cervix
The vessels which supply lie in capsule and send
radial branches, so innermost part receives least
blood supply
The innermost part is the first to undergo
degeneration whereas the outermost part is the
first to calcify
Cut surface shows whorled appearance

Explain the Anatomy & pathology
of fibroid?
What are the synonyms of fibroid?
Fibromyoma
Leiomyoma
myoma

What are the types of fibroid?
Uterine Extrauterine
Body of uterus Cervix Ovary
Subserous (10%) Broad ligament fibroid
Intramural(75%) 1. True (originates in broad
Submucous (15%) ligament)
2. False (arises in uterus &
grows into broad ligament)

What are the types of fibroid?
What is parasitic fibroid?
Rarely, a extruded fibroid gets detached from
uterus and attaches to a vascular organ (omentum or
bowel). This fibroid is called parasitic fibroid or
wandering fibroid.
CASE SCENARIO - 2
A 32 year old woman complains of
increasingly long and heavy periods
over the past 5 years. Previously she
bled for 4 days but now bleeding lasts
up to 10 days. The periods still occur
every 28 days. She experiences
intermenstrual bleeding between most
periods but no postcoital bleeding.
The periods were never painful
previously but in recent months have
become extremely painful with
intermittent cramps. She has had four
normal deliveries and had a
laparoscopic sterilization after her last
child.
Her smear tests have always been
normal, the most recent being 4
months ago. She has never had any
previous irregular bleeding or other
gynaecological problems.

Examination:
The abdomen is soft and non-
tender with no palpable mass.
Speculum examination shows a
normal cervix. On bimanual palpation,
the uterus is bulky (approximately 8
week size), mobile and anteverted.
There are no adnexal masses.
Investigations
Haemoglobin 9.2 g/dL
Mean cell volume 75 fl
White cell count 4.5 * 10
9
/L
Platelets 198 * 10
9
/L

Hysteroscopy

Diagnosis
This woman has a Submucosal fibroid.
Submucosal fibroids are a common cause
of menorrhagia and can cause, as in this
case, intermenstrual bleeding.
Fibroids usually dont cause
intermenstrual bleeds other than when
there is ulceration or it is submucous or
cervical fibroid

DISCUSSION
What are the clinical manifestations?
Menorrhagia, polymenorrhoea, metrorrhagia
Infertility, recurrent abortions
Pain spasmodic dysmenorrhoea, backache, due
to pyelitis
Pressure symptoms bladder, ureter, rectum
Abdominal lump or mass protruding at introitus
Vaginal discharge

As many as 50% women are asymptomatic
How do they cause menorrhagia?
Increased surface area of endometrium
Hyperoestrogenism
Intramural fibroid prevents adequate contraction
and retraction of uterus
Associated pelvic inflammatory disease
Can fibroids cause polycythaemia?
Yes. Huge fibroid compresses renal artery
Reduced renal perfusion Hypoxia activation of
Renin- angiotensin aldosterone Renal
erythropoietin secretion increases polycythaemia
How do they cause infertility?
Cervical fibroid does not allow nidation of sperms
Fibroid in Cornual end does not allow fertilised
ovum to enter uterine cavity
Increased chances of abortion is seen with
submucous fibroid due to improper implantation
Associated Hyperoestrogenic state can cause
infertility

When do they cause pain?
Acute torsion of a pedunculated fibroid or
degeneration are the main causes of pain
Intracapsular haemorrhage
Rarely, a submucous fibroid trying to get expelled
from the cervix will produce pain
When do fibroids present as
emergency?
CLINICAL SCENARIO - 3
A 33 Year old women complains of
worsening abdominal pain for 4 days.
She is 16 week pregnant in her third
pregnancy. She has a 10 year old son,
by normal delivery and a miscarriage
8 years ago. Her pregnancy has been
uneventful until now with an
unremarkable first trimester scan.
The pain is in the left lower
abdomen and is constant and sharp.
She has taken paracetamol with little
effect and she is unable to sleep due
to pain.
She has had no vaginal bleeding and
reports urinary frequency since the
beginning of the pregnancy. She is mildly
constipated and has no nausea and
vomiting. There is no history of trauma.
She has not felt the baby moving yet.
EXAMINATION
The woman is apyrexial and pulse
rate is 125/min, with blood pressure
110/68 mm Hg. The uterus is palpable
just above the umbilicus. There is
significant tenderness over the left
uterine fundal region, where it also
feels firm. The abdomen is otherwise
soft and non-tender.
There is voluntary guarding but no
rebound tenderness. Bowel sounds
are normal. Speculum examination
shows a normal, closed cervix and no
blood. The fetal heart beat is heard
with hand-held Doppler.

Investigations
Haemoglobin 10.6 g/dL
Mean cell volume 79 fl
White cell count 7.2 * 10
9
/L
Platelets 378 * 10
9
/L
C-reactive protein <5 mg/L

Diagnosis
The patient has fibroid undergoing Red
degeneration. The uterine size is larger
than dates and the localised uterine
tenderness are the important features in
making this diagnosis.
Red degeneration happens almost
exclusively in pregnancy
DISCUSSION
What are the obstetric complications
of fibroid?
a) Increased risk of Abortions
b) Threatened preterm labour
c) Premature delivery
d) Abruptio placenta.
e) IUGR
f) Intrapartum problems if fibroid large & located in the lower
uterine segment. Cervical fibroid caesarean delivery.
g) Interference with propagation of myometrial contractility
uncoordinated uterine contraction or PPH.

What are the general complications
of fibroid?
Degeneration
Torsion
Inversion of uterus
Capsular haemorrhage
Infection
Associated endometrial carcinoma
What are the secondary changes
in fibroid?
Atrophy
Hyaline/cystic/fatty degeneration
Calcareous degeneration
Red degeneration
Sarcomatous degeneration
What is red degeneration?
Occurs most frequently during pregnancy
Becomes tense and tender and causes severe
abdominal pain with constitutional upset and
fever.
Fibroid becomes reddish with a particular fishy
smell.
Leucocytosis and raised ESR may be present but
this is an aseptic condition
Examination of fibroid shows thrombosed vessels
Differential Diagnosis:
Acute appendicitis
Torsion of ovarian cyst
Acute pyelonephritis
Accidental haemorrhage
Treatment: Self limiting and resolves by itself

Differential diagnosis and
management for red degeneration
In sarcomatous degeneration (not more than 0.5%)

When do fibroids grow rapidly?
What are the investigations to do?
General Investigations:
Blood investigations:
Haemoglobin & Haematocrit to rule out anaemia
Random Blood sugar to know the diabetic status
Blood grouping and Rh typing for transfusion if
necessary
Serum urea and Creatinine for assessing the renal
function
Urine Examination:
albumin, sugar and deposit
Special investigations:
Intravenous pyelogram:
To trace the course of ureter to avoid injury during
surgery
To rule out renal abnormalities (Eg. pelvic kidney)
Ultrasound abdomen:
To know the site and number of fibroid
What are the investigations to do?
Other investigations
Hysterosalpingography and sonosalpingography
Hysteroscopy
Dilatation and curettage to rule out endometrial
cancer
Magnetic resonance imaging

When do you treat a fibroid?
Indications for treating an asymptomatic fibroid
are
Infertility caused by cornual blocking or abortion
caused by submucous fibroid
Fibroid more than 12 weeks size or a pedunculated
fibroid which can undergo torsion
Fibroid causing pressure on ureter
Rapidly growing fibroid
If the nature of tumour cant be assessed clinically
All symptomatic fibroid needs treatment which
can be Medical or surgical
When do you treat a fibroid?
Iron therapy for anaemia
Surgery is the definitive treatment modality but
the use of medical management is to control
menorrhagia and to improve haemoglobin before
surgery
Drugs can also be used in women nearing
menopause or who are not fit for surgery
Drugs used are low dose OCPs(have minimal
oestrogen), mifepristone(RU 486), GnRH
analogues like leuprolide
How will you manage Medically?
What are the indications for use
of GnRH agonists in women with
leiomyomas?
Preservation of fertility before attempting conception or
preoperative treatment before myomectomy
Treatment of anaemia to allow recovery of normal
haemoglobin levels before surgical management or
allowing autologous blood donation
Treatment of women approaching menopause in an effort
to avoid surgery
Preoperative treatment of large leiomyomas to make
vaginal hysterectomy, hysteroscopic resection or
ablation, or laparoscopic destruction more feasible
Treatment of women with Medical contraindications to
surgery
GnRH analogues causes rapid shrinkage of tumour
and reduces vascularity
Hence it decreases the need of surgery in young
women with infertility for cornual blockade
It also facilitates vaginal hysterectomy or surgery
with minimal blood loss
The main disadvantage is cant be extended beyond 6
months (causes osteoporosis), fibroid capsule
becomes thin and enucleation is difficult, recurrence
of fibroid is high.

What are the advantages and
disadvantages of GnRH analogues?
What are the potential indications of
surgery?
Abnormal uterine bleeding with resultant anemia,
unresponsive to hormonal or other conservative
management
Chronic pain with severe dysmenorrhea, dyspareunia, or
lower abdominal pressure or pain
Acute pain, as in torsion of a pedunculated leiomyoma
or prolapsing submucosal fibroid
Urinary symptoms or signs such as hydronephrosis
after complete evaluation
Infertility with leiomyomas as the only abnormal
finding
Recurrent pregnancy loss with distortion of
endometrial cavity
Markedly enlarged uterine size with compression
symptoms or discomfort

What are the potential indications of
surgery?
What are the surgical management
options?
Myomectomy Laparotomy / Laparoscopy /
Hysteroscopy
Hysterectomy Abdominal / vaginal /
laparoscopic
Uterine artery embolization
What is myomectomy?
Removal of fibroids leaving behind the uterus
Indicated in infertile women or a women desirous
of childbearing and wishing to retain uterus
What are the preoperative requisites
of myomectomy?
Haemoglobin should be restored
In infertility cases, other causes should have been
excluded
SIGNATURE FOR HYSTERECTOMY IS REQUIRED IN
DIFFICULT CIRCUMSTANCES
Should be performed in preovulatory period
Endometrial cancer to be ruled out by D&C
Explain the steps of myomectomy
Patient in supine position
The abdomen is draped and opened by pfannenstiel
incision
Confirm the feasibility of myomectomy
Anterior uterine wall is incised and as many fibroids are
removed by tunneling incisions
Haemorrhage is controlled by myomectomy clamp
The capsule should be incised and fibroid enucleated
with the help of myoma screw
Following enucleation, cavity is obliterated with catgut
Release the clamp and secure haemostasis


What are the complications of
myomectomy?
Haemorrhage primary, secondary and
reactionary
Trauma to adjacent structures ureter, bladder,
bowel
Infections
Adhesions and intestinal obstruction
Recurrence of fibroids and persistent menorrhagia
When do you employ laparoscopic
myomectomy?
Pedunculated fibroid
Subserous fibroid not exceeding 10 cm in size and
not more than 4 in number

What are the advantages of subtotal
hysterectomy over total hysterectomy?
Cervix is retained for sexual function
Vault prolapse is less
Less surgical morbidity
Will you remove ovaries during
hysterectomy for fibroid?
Ovaries should be retained to avoid menopausal
symptoms in a premenopausal woman provided they
look normal.
What is panhysterectomy?
Removal of uterus, cervix and ovaries
What is LAVH? Contraindications
for this procedure?
LAVH stands for Laparoscope assisted vaginal
hysterectomy.
Contraindications are
Uterus more than 14 16 weeks size
Fibroid located in broad ligament, cervical fibroid and
extensive pelvic adhesions, endometriosis
What are the complications of
hysterectomy?
Haemorrhage Primary, secondary and reactionary
haemorrhage
Trauma to adjacent organs bladder, ureter, bowel
and ureter
Postoperative infection and Sepsis
Anaesthetic complications
Paralytic ileus, intestinal obstruction or chronic
abdominal pain due to postop adhesions
Thrombosis, pulmonary embolism, chest infection
Burst abdomen, scar, hernia
Residual ovarian syndrome
Dyspareunia

Explain about uterine artery
embolization?
Through percutaneous femoral catheterisation,
Polyvinyl alcohol (PVA), gel foam particles or
metal coils are injected.
This reduces vascularity and size(40% at 6 weeks
and 75% at 1 year)
Contraindications:
Subserous, submucous and pedunculated fibroids
Infertility and desire of pregnancy

Explain about uterine artery
embolization?
Advantages:
No major surgery, intraoperative bleeding, adhesions
Short hospital stay
75 80% women are satisfied

Explain about uterine artery
embolization?
Can fibroids grow beyond Menopause?
Yes. If the woman is on hormone replacement therapy.
Polypectomy