Uterine fibroids

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.

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Size:

• From microscopic to very huge size filling the whole abdominal cavity (up to 40 kg was recorded).

Shape:

• Spherical, flattened, or pointed according to the type.

Cut section:

• 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, and vascular, inflammatory, and malignant changes.
• Hard fibroid occurs in calcification.

Capsule:

• It is a pseudo-capsule formed by compressed normal surrounding muscle fibers.
• 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?

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.

For small asymptomatic fibroid.

Also for fibroid in pregnancy or puerperium.

Just keep in observation every 6 months.

Beware of underlying and/or associated pathology.

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
• Hemostatics
• 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.

Indications:

Symptomatic cases or uterus larger than 12 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

Embolization techniques (Interventional Radiology)

Principle

Myomectomy aims at-

• Removal of all the myomas
• With conservation of a functioning uterus to preserve the reproductive function.

Generally the morbidity is higher than those with hysterectomy.

• It is associated with much blood loss
• Liability of recurrence of fibroid.

Myomectomy is better reserved only for those keen to preserve the reproductive function.

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
• Vertical midline incision is the least vascular
• Application of Bonney’s myomectomy clamp or a rubber tourniquet
• Use ring forceps to occlude the ovarian vessels
• Careful dissection to enucleate all the masses is needed to avoid recurrence.
• Avoid anesthetic agents that induce uterine relaxation (e.g. halothane).
• Vasopressin (pitressin) 20 IU in 20 ml in normal saline are injected in the uterine wall at the site of incision.
• Obliteration of the tumour cavities.
• Buried sutures to the tumor bed after shelling out of the masses.
• Use absorbable sutures.

Blood need to be prepared for possible transfusion.

Technique of abdominal myomectomy:

Preliminary diagnostic curettage to exclude endometrial carcinoma.

The uterine incision:

• Avoid incisions on the posterior uterine wall, for the risk of adhesions to the bowel.
• The smallest incision is designed to enable removal of as many lesions as possible.
• Tunneling in the uterine wall is utilized to minimize many incisions and peritoneal trauma.
• Try to avoid opening the endometrial cavity.

To keep the uterus anteverted

• Ventrosuspension or plication of the round ligaments and uterosacral ligaments.

Dextran solution, Ringer lactate solution or dexamethazone could be instilled in the peritoneal cavity to minimize postoperative adhesions.

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).

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

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:

• Step following fatty change when fatty acids undergo saponification with Ca salts giving Ca stearate and palmitate, forming layers of calcifications.
• Clinically, the fibroid become hard like bone (Womb stone).
• Radiologically, show a radio-opaque shadow with typical onion skin appearance.

Red degeneration (Necrobiosis):

• Usually occurs in the middle trimester of pregnancy, due to increased vascularity and venous stasis, the tumor enlarges with hemorrhage inside the tumor.
• It is called necrobiosis because it shows dead parts (central) and living parts (peripheral).

Atrophic changes:

• Atrophy occurs due to estrogen withdrawal as after menopause, puerperium, or anti-estrogen use.
• All myomas decrease in size after the menopause except in calcification it remains stationary, or with malignant change or HRT it increases in size.

Myxomatous change:

• Occurs near the menopause, in the center of the myoma, forming a gelatinous mucoid material which may undergo pseudo-cystic changes.

Pseudo-cystic changes:

• A step following hyaline or myxomatous changes, when it liquefies & becomes soft in consistency.

Torsion (Axial rotation):

• Occurs in moderate-sized, pedunculated, subserous fibroid with no adhesions.
• The precipitating factor is sudden twisting movement as trauma, intestinal movement, or fetal kick, leading to axial rotation which is prevented from re-twisting by the lashing effect of the pulsating pedicle.
• The clinical effects depend on the onset of torsion:
• Sudden torsion leads to acute abdomen and necrosis of the tumor.
• Gradual torsion leads to gradual decrease of the blood supply from the pedicle which ends in the development of parasitic tumor.

Telangiectasis:

• 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.

Congestion and edema:

• A result of impaction, incarceration, torsion, infection, or pregnancy

Ways of infection:

• Trauma of submucous fibroid e.g. D & C or labor.
• Nearby 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.

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.