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(LEIOMYOMATAS)
Patient Characteristics
Age:
30-40 years.
Rare before 30 or after 40 years
Parity:
Common in nulliparas, patients with low parity.
It is rare in multiparas.
Race:
3-9 times more common in negroids.
Family history:
Usually positive.
Hyper-estrenemia:
Estrogen receptors (ER) more than the surrounding myometrium but
less than those in the endometrium
Common in low parity.
Atrophies and shrinks after menopause.
Common association with other hyper-estrenic conditions as
endometriosis, endometrial hyperplasia and endometrial carcinoma.
Fibroids
Uterine [99%]
Corporeal [95%]
Cervical [4%]
Extrauterine [1%]
Genital
Extragenital
Interstitial [60%]
Parasitic Fibroid
Submucous [ 20%]
Others
Subserous [15%]
[60%]
[20%]
[15%]
Characteristics
Size
Shape
Cut section:
from microscopic to very huge size filling the whole abdominal cavity (up to 40 kg
was recorded).
On cut section,, whorly in appearance, and more pale than the surrounding uterine
muscle.
Consistency:
firmer than the surrounding myometrium.
Soft fibroid occurs in pregnancy, cystic changes, vascular, inflammatory, and
malignant changes.
Hard fibroid occurs in calcification.
Capsule:
Is a pseudo-capsule formed by compressed normal surrounding muscle fibres.
the blood supply comes through it,
it is the plain of cleavage during myomectomy
its presence differentiate the myoma from adenomyosis.
Blood supply:
Nourishes the myoma from the periphery,
The tumor itself is relatively avascular.
Which of which?
Presentations
Asymptomatic:
Accidentally discovered during examination.
It is the commonest presentation, especially in subserous and interstitial fibroids.
Post-menopausal bleeding:
Presentations
Discharge:
Leucorrhea and mucoid discharge due to pelvic congestion.
Muco-sanguinous discharge with ulcerated fibroid polyp.
Muco-purulent discharge due to secondary infection.
Swelling:
Either abdominal swelling due to large fibroid or vaginal swelling due to a polyp.
Pain: uncommon
Intermittent colicky pain in submucous fibroid (acts as F.B. in the uterine cavity).
Dull-aching pain and congestive dysmenorrhea due to pelvic congestion.
Acute abdomen in red degeneration, torsion, ruptured vessel, and inflammation.
Presentations
Pressure symptoms
Cervical fibroid:
Anteriorly on the urethra causing acute retention of urine, or the
bladder causing frequency of micturition.
Laterally on the ureters causing colic and back pressure on the
kidneys.
Posteriorly on the rectum causing dyskasia, constipation, and
sense of incomplete defecation.
Huge fibroid:
On the pelvic veins causing edema, pain, and varicose veins in
the lower limbs.
On the GIT causing distension and dyspepsia.
On the diaphragm causing dyspnea.
Spontaneous abortion:
Before myomectomy [ 40%]
20% after myomectomy.
Signs of fibroid
General examination:
signs of chronic anemia.
Abdominal examination:
large pelvi-abdominal swelling in huge fibroids.
Pelvic examination:
symmetrically or asymmetrically enlarged
uterus.
Speculum examination
fibroid polyp.
Differential Diagnosis
Causes of symmetrically enlarged uterus:
Pregnancy
Subinvolution of the uterus.
Submucous or interstitial fibroid.
Metropathia hemorrhagica.
Adenomyosis uteri.
Carcinoma or sarcoma of the uterus.
Pyo, hemato, or physometra.
Subserous fibroid.
Localized adenomyosis.
Ovarian, tubal, or broad ligamentary swelling.
Pregnancy in a rudimentary horn.
Management
Conservative Management
small asymptomatic fibroid,
fibroid in pregnancy or puerperium.
Medical Treatment:
Pre-operative till the time of surgery.
Patient near the menopause, or newly married
with minimal symptoms.
Red degeneration with pregnancy.
Lines of treatment:
Symptomatic:
Correction of anemia,
haemostatics,
analgesics, and anti-spasmodics (anti-PG).
Anti-estrogens:
large dose of progesterone,
Tamoxifen, Danazol,
LH-RH analogues
useful in decreasing the size and vascularity of the tumor by 50%
which is beneficial before myomectomy
Surgical Management
Indications:
Symptomatic cases or uterus larger than 12
Myomectomy
vs. Hysterectomy
weeks
size.
Suspected malignancy
??!! (rapidly enlarging or
post-menopausal growth).
Multiple huge fibroids liable to complications.
Infertility.
Myomectomy
Abdominal Myomectomy
Vaginal Myomectomy
Endoscopic Myomectomy
Hysteroscopic
Laparoscopic
Principle
Myomectomy aims at
removal of all the myomas,
with conservation of a functioning uterus to
preserve the reproductive function.
Principle
The patient must be prepared for the possible need for an
emergency hysterectomy.
Precautions to minimize blood loss during myomectomy:
The timing of operation is post-menstrual (minimal pelvic congestion).
Pre-operative LH-RH analogues: may be given for 3 months before
surgery to reduce the size and vascularity of the myomas.
Intraoperative hemostasis
Vaginal Procedures
Vaginal myomectomy:
Indicated when a fibroid
polyp is not larger than 8
weeks pregnancy size.
The polyp is grasped and
twisted until the pedicle
tears.
If the pedicle is too thick it
is cut with scissors.
A large polyp could be cut
as piece-meal fashion
(morcellation).
Laparoscopic Myomectomy
Hysteroscopic Myomectomy
Hysterectomy
Patient around 40 years, and completed her
family.
The number or site contraindicate myomectomy
Severe bleeding during myomectomy.
Major damage of the uterus by myomectomy
which affects its function for pregnancy.
Recurrent fibroids.
Suspicious of malignancy
Embolization
Degenerative
Vascular
Inflammatory
Malignant Changes
Degenerative Changes
Hyaline degeneration:
Commonest secondary change.
Usually starts around the menopause, and in
the center of the fibroid.
Macroscopically, fibroid looks homogenous,
waxy, soft, with loss of whorly appearance.
Fatty changes:
Likely to start around the age of menopause.
Lipids reach the fibroid through the blood, so
fatty change starts at the periphery of the
fibroid, resulting in a yellow soft fibroid.
Calcification:
Atrophic changes:
Myxomatous change:
Pseudo-cystic changes:
Vascular Changes
Telangeactasis:
Likely to occur with pregnancy, malignant change, and cervical fibroid due to
increased vascularity.
There are numerous dilated blood vessels on the surface of the fibroid which
may rupture leading to acute abdomen and internal hemorrhage.
Lymphangeactasis:
Likely to occur around the age of menopause as the fibroid is full of lymphatics.
Dilated lymphatic vessels on the surface may rupture leading to lymphatic
exudates and strong adhesions.
Inflammatory changes
Ways of infection:
Trauma of submucous fibroid e.g. D & C or
labor.
Near by inflammation e.g. appendicitis.
Blood-borne (very rare).
Result of infection:
The fibroid becomes congested, tender, and
even abscess formation; it becomes soft and
heals by adhesions to the surrounding
Malignant changes
Rare (0.5%) into leiomyosarcoma (round,
spindle, mixed or giant cell histopathology
types).
Symptoms suggestive:
The fibroid becomes more painful.
Post-menopausal bleeding or growth of the tumor.
Signs suggestive:
The fibroid become softer, tender, or fixed.
Rapid growth of the tumor.
Complications of fibroid
Degenerative changes.
Vascular changes.
Inflammatory changes.
Malignant changes.
Pregnancy complications e.g. abortion, and preterm labor.
Pressure complications on the urethra, bladder, ureters,
rectum, and pelvic veins.
Rarely, chronic inversion of the uterus.
Polycythemia and hypertension due to the release of
erythropoietic agent.
Infertility.
Secondary parasitic attachment of fibromyomas to other
abdominal structures gaining another blood supply.