UTERINE FIBROIDS Flashcards
Where do Uterine fibroids arise from?
Uterine fibroids are the commonest tumours in the female genital tract and in the body as a whole.
•They are benign neoplasms arising from smooth muscle of the uterus.
PATHOGENENESIS
There is evidence that each individual leiomyoma is unicellular in origin (unique clonal neoplasm).
Leiomyoma contain estrogen receptors in higher concentration than surrounding myometrium but in lower concentration than endometrium.
•The hormone sensitivity of leiomyomas is indicated by the fact they develop during the reproductive years and regress after menopause and also by the fact that treatment with GnRH antagonist induce a hypogonadal or hypoestrogenic state that often cause shrinkage of myomas.
Under the influence of circulating E2, tumour may enlarge & weigh >10kg. Atrophy usually occurs after menopause. HRT, OCP ->rapid increase in size.
Progesterone increases the mitotic activity of myomas in young women and by down – regulating apoptosis in the tumor.
Which chromosomal abnormalities leads to having a large myeloma and smaller myeloma.
T(12,14)– larger myeloma. Del (7)long arm– small myeloma.
Pathology of uterine fibroids
Fibroids are usually multiple, discrete and either spherical or irregularly lobulated.
•They are falsely encapsulated and clearly demarcated from the surrounding myometrium.
•They therefore pout above surrounding myometrium when cut.
•Between tumor and normal myometrium, is a thin layer of areolar tissue which forms a pseudo-capsule through which blood vessels enter the myoma.
•Because entire blood supply is derived from these few vessels, growth of tumor often outstrips the blood supply, leading to degenerative changes.
Types of degeneration?(5)
•a. Hyaline degeneration
•b. Cystic
•c. Calcification over time.
•d. Red degeneration:
In pregnancy, extravasation of blood through the tumor (venous infarction) gives a raw beef appearance.
•e. Sarcomatous change: Less than 0.1%
Macroscopic and microscopically ?
•Macroscopically, fibroids are greyish in colour, rounded, smooth, and usually firm.
•Lighter than surrounding endometrium.
•Cut section shows the characteristic whorled appearance of smooth muscle bundles
•Microscopically, the individual muscle cells are usually uniform in size and have the characteristic oval nucleus and long, slender bipolar cytoplasmic processes.
•Mitotic figures are scarce
RISK FACTORS?
➢ Race:3-9x commoner in black women than whites
➢ Obesity
➢Nulliparity; At least 2 full term pregnancies reduces risk by half
➢Diet and environmental factors
➢Onset of menstruation before the age of 12yrs
➢Sedentary women with higher risk
➢Smoking decreases risk
➢HRT does not increase risk
Classification?
➢Submucous
➢Intramural
➢Subserous
➢Others
➢Intraligamentary
➢Parasitic
➢Cervical
CLINICAL PRESENTATION
Asymptomatic: Small (and some large ones) – detected on routine examination
•Symptomatic ones may present as:-
–Menorrhagia. May lead to anaemia, with symptoms.
–Abdominal mass
–Crampy pains may result from contraction of the uterus.
–Pressure symptoms from large fibroids
–Dysuria
–Constipation or backache
–Pelvic pain and sometimes, impossible intercourse from cervical myoma
–Subfertility and Recurrent miscarriage from submucous fibroids
INVESTIGATIONS
Full blood count
-Haemoglobin estimation
-white blood count- leucocytosis may indicate presence of infection.
•Grouping and cross matching of compatible blood
•Midstream urine for microscopy, culture and sensitivity
•Abdominopelvic ultrasound scan
-localize the fibroid and to differentiate from other pelvic masses. Also, KUB evaluation
Hysterosalpingography
•May pick up submucous fibroids and to predetermine the patency of the tubes especially when dealing with an infertile woman.
Laparoscopy
•Subserous fibroid and associated investigation of tubal patency
Hysteroscopy
EUA & Endometrial biopsy
Magnetic resonance imaging
Computerized axial tomography
DIFFERENTIALS
Adenomyosis
•Endometriosis
•Pregnancy
•Abortion
•Tubo Ovarian mass
•Ovarian tumour
•Endometrial Carcinoma
•Leiomyosarcoma
•Pelvic Kidney
•Congenital Abnormalities
MANAGEMENT
Modalities of Treatment include(?)
Modalities of Treatment include:
➢Expectant
➢Non-Surgical
●Medical;
●Radiological Intervention
➢Surgical
Laparotomy
●Myomectomy
●Hysterectomy
Hysteroscopy
●Myomectomy
●Endometrial ablation or resection
Laparoscopic
●Myolysis
●Myomectomy
PRINCIPLES OF TREATMENT
•Patient’s Age
•Size of the fibroid
•Severity of the symptoms
•The reproductive desires of the patient
EXPECTANT MANAGEMENT
Indications and follow up by?
Indications:
Small fibroid 6-8cm in diameter
Fibroid outside endometrium
Asymtomatic fibroid
Myoma co-existing with pregnancy
Post menopausal woman
Follow up by;
•Reviewing patient quarterly
•Postmenopausal women should be seen regularly.
NON SURGICAL;
1) MEDICAL…indications?
•For elderly women- after diagnostic curettage and ablation
•For patients who are unsuitable for surgery:
Drugs are used to shrink the fibroids and control symptoms.
DRUGS USED Include:
Danazol
Fadrozole
Danazol;
Dosage, MOA, effects and side effects
(Synthetic androgen) 400mg-800mg daily in divided doses for 6-9 months.
•Suppresses –FSH/LH secretion ovaries leading to low estrogen and progesterone
•Causes endometrial atrophy.
•May reduce tumour size.
Side effects:-Increase LDL, decrease HDL, weight gain, oedema, reduced breast size, oily skin and hirsutism.
Fadrozole……MOA?
Fadrozole : A non steroidal aromatase inhibitor, blocks the conversion of testosterone to oestrogen.
Hormones used; (5)
•Levonorgestrel Intrauterine System (LNG IUS)
•Mifepristone
•Gestrinone
•Depomedroxy progesterone acetate
•GnRH agonists
LNG-IUCD…MOA
LNG-IUCD atrophies the endometrium and inhibits the insulin like growth hormones thereby reduces the fibroid
Mifepristone (RU-486):
Causes a significant decrease in size of myomas and often stops abnormal uterine bleeding.
• Its use is promising but it is not currently widely marketed
Depomedroxy progesterone acetate…MOA?
All cause atrophy of the endometrium and reduce uterine bleeding.
GnRH agonists
MOA,
Peptides synthesized by substituting the 6th and 10th amino acid in the native GnRH molecule to achieve longer action and better binding to receptor site.
•Used for decades
•Decreases symptoms and size by 30-60% within 3 months of use
•The agent acts by down regulating pituitary GnRH receptors leading to induction of pseudomenopause.
Specific indications for GnRH agonists…?
Perimenopausal women who are not willing to have surgical intervention.
•Pre-operative short-term measure to regress the fibroid and reduce its vascularity.
•Its use in shrinking fibroids in grossly obese women with a view of performing a vaginal hysterectomy could be advantageous.
•A more cosmetic incision (eg Pfannenstiel) is more feasible following fibroid shrinkage.
DRAWBACKS ofGnRH agonist?
•Induction of hypoestrogenic state leading to undesirable side effects:
–Amenorrhoea
–Nausea
–Vomiting
–Osteoporosis
•Rebound growth
•very expensive
RADIOLOGICAL INTERVENTION
Done under conscious sedation & Fluoroscopic Guidance
•It uses micro particles (polyvinyl alcohol) via a catheter through the femoral artery to selectively occlude the uterine artery.
•Leads to ischaemic fibrosis of the fibroid: 40-70% at 3-12months
•Can be used for fibroid size < 24wks .
•Not used for pedunculated or infected fibroid.
•Menorrhagia is rapidly reduced.
COMPLICATIONS of RADIOLOGICAL INTERVENTION
•Angiographic
•Pelvic infection
•Decrease ovarian function
•Treatment failure
SURGERY;
OPEN MYOMECTOMY
•This involves the enucleation of myomas from the uterus .
Indications:
•Fibroid polyp
•Symptomatic fibroid in a patient who desires to conserve her reproductive and menstrual function
Techniques to reduce blood loss
•Pre operation:-
–Optimize patients PCV
–Surgery done in the proliferative phase of menstrual cycle.
–Haemodilution with normal saline
–Autologous blood transfusion
Techniques to reduce blood loss;
Intraoperatively
Hypotensive anaesthesia (spinal anaesthesia).
–Application of rubber tourniquet at the anterior posterior lower uterine isthmus occluding the uterine vessels for 40 – 45mins.
–Fast surgery
–Use one incision to remove as many fibroid nodules as possible
–Careful obliteration of all dead spaces
PREVENTION OF ADHESIONS
Gentle/minimal handling of tissues
•Reducing number of incisions to one single anterior incision
•Covering uterine surface with cellulose material
•Washing off all blood clots
•Instilling into peritoneal cavity some normal saline or dextran 70 postop
COMPLICATIONS of OPEN MYOMECTOMY
•Haemorrhage
•Trauma to bladder, GIT, Ureters
•Infections
•Adhesions (55-95% at 1yr follow up)
•Infertility-(38-65% pregnancy rates)
•Recurrence-27% at 10 years follow up.
•Rupture of scar during labour
HYSTERECTOMY;
Indications?
:
•Huge uterine fibroid > 12wks
•Patient who has completed her family with symptomatic fibroid
•Recurrent symptomatic fibroids
•Rapidly growing fibroid in the menopausal period
•Fibroids with recurrent PID
HYSTEROSCOPIC RESECTION
Submucous fibriods provided they are <10cm in diameter
•Give GnRH analogues by nasal inhalation or subcutaneous injection for 2-8 weeks
•Fibroids are resected using wire loop passed down an operating hysteroscope
•Diathermy/ laser can also be used to cut through fibroid base
•At higher power setting, can completely vaporize smaller fibroids
OTHER MODALITIES
•LAPAROSCOPIC UTERINE MYOLYSIS
•COAGULATION OF UTERINE VESSELS
•BILATERAL UTERINE ARTERY LIGATION
LAPAROSCOPIC UTERINE MYOLYSIS
•A laser fibre or more commonly an electrical device is placed into the fibroid through a laparoscope
•This is used to coagulate the myoma or the blood vessels feeding it
•The dead tissue is then gradually replaced by scar tissue
•Initial weakening of the myometrium and the formation of dense fibrous adhesions which might predispose to uterine rupture
COAGULATION OF UTERINE VESSELS
•To treat symptomatic myoma
BILATERAL UTERINE ARTERY LIGATION
•Low technology alternative to UAE
•Has a transvaginal approach
•Cheap
•The preliminary report suggests that it is effective in reduction of size and symptoms.
