FIBROID

Dr.Shashikant
Raghuwanshi
 MC benign uterine tumor
 They arise from uterine smooth muscle with variable
amount of fibrous connective tissue.
 MC tumor of genital tract
 True incidence is difficult to determine.
80% black
70% white (Am J Obs Gynecol 2003; 188: 100-107.)
 40-50% of > 35 yrs of age.
 MC indication far hysterectomy
 77% of hysterectomy specimen have leomyoma
 1-2% of pregnancies
 Responsible for about 1/3rd all hospital admissions to
gynaecological services.
 Monoclonal
 Somatic mutation in myometrial cell  progressive loss of
growth regulation.
 Genetic predisposition  positive family history ,
1st degree relatives,
monozygotic twins
 Chromosomal abn  50%, t(12 , 14) del 7 ,trisomy 12
 ↑ oestrogen exposure  Continuous uninturrupted
estrogen exposure -- the most important risk factor in
myoma development

2 FT pregnancy - ↓ risk to ½
 ↑ parity – low risk
 ↑ during reproductive age grp and ↓ after menopause
 Gn RH agonist – shrinks myomas
 High dose oc pills
 Progesterones –
 Stimulates mitotic activity in myoma
 Receptors more on myoma (Brandon et all 1993)

 Oncogenes - ↓ mac 25 (tumor suppressor gene)

↑ BCl-2 (ant–apototic proto-oncoegne)
↑ c fos, c-jun ---- leomyosarcoma
Disruption of HMGIC and HMGIY gene
 Polypeptide growth factors –
 EGF

VEGF, FGF

IGF I, II
 PTH – rP
 Prolactins
 Age –
 Rare before 20

20% of 20 yrs &
 40% of 40 yrs has single tiny tumor
 Symptomatic 35 to 45 yrs
 Parity -
 Nullipara
 Infertile -: Uterus deprined of preg consoles
itself with Myoma
 Racial/genetic factors –
 80% black,

70% white
 Associate conditions –
 Endo hyperplasia –
 Endo carcinoma
 Endo metriosis
 Risk Factors for Fibroid
 Increased risk
 Reduced risk
 Nulliparity

 Obesity
 Multiparity

 Hyperoestrogenic state
 Smoking
 Black women
 Classification and
Pathophysiology

A typical moyama is well circumscribed round to oval,

firm,white whorled variable sizes and sites with

pseudocapsule, single or multiple , Vessel (nutrient

art) lie in Pseudocapule sends radial br to tumor

centre least perfused  degeneration and

calcifications at periphery.
 SITES
 Acc to their relationship to endometrium and
peritoneal coat Myomas are being described as
 Submucous 15%

Interstitial 75%
 Subserous 10%
 Most situated in body of uterus

 1-2% in cervix – Supravaginal portion.

 Because they arise Myometrum they all are

intramural in beginning.
 Intramural Fibroids –
75%
 Myoma arise in
myometrium, they all are
interstitial in beginning
after extend in an internal
or external direction
subserous or submucous
in location.
 Intramural myomas are
separated from
surrounding myometrium
by a thin layer of
connective tissue – so
called pseudocapsule
(false capsule) provides
plane of cleavage for
enucleation.
 Subserous Fibroid 15%
 Intramural fibroid is pushed
outward toward peritoneal
cavity. Partialy or completely
covered with peritoneum.
 When completely covered
with peritoneum usually
attains pedicle –
Pedunculated subserous
fibroid  adherent to
Omentum with and develop
alternative blood supply –
Parasitic fibroid
 Sub serosal fibroids from lat
ut wall may lie between layers
of broad lig. may need to
distinguish from broad lig
fibroid which has no
attachment to uterus.
Submucous Fibroid –
10%
 Intramural fibroid pushed inward – covered with
endometrium
 Distorts ut cavity
 Pedunculated submucous fibroid come out through
cervix – Pseudocervical Myoma
 Least common variety with max symptoms
 Fate
surface necrosis – ulceration
Polypoid change
Infection
degeneration with sarcomatous change
 Leiomyomatosis
 Extension of Polypoid intravascular projections into
veins of Parametrium and broad ligaments.
 Origin – vascular invasion Myoma

denovo from walls of veins of myometrium

behaves benign –extensions – uterine veins in
broad lig (MC) vaginal, ovarian and Illiac veins ,vena
cava – Rt atrium.
 Total surgical excision

 Open heart surg for intracardiac thrombosis

 Tamoxifen.
 Leiomyomatosis
Peritonali’s Disseminata
 Can be confused with i.v. leiomyomatosis
 Only subperitoneal surf of uterus and other pelvic
and abd viscera ale involved however invasion of
lumen of blood vs does not occur
 Benign
 Reproductive yrs
 Large ut leiomyoma
 Are usually pregnant or taking are o.e.pills
 Prolong and continuous stimulation and
subperitoneal dicidua by estrogen and
progesterone.
 t/t – TAHBSO
 Omentectomy if omentum involved.
 Secondary Changes in
Microscopically fibroids are Myoma
composed of sm ms. cell admixed --- connective
tissue.
 vasculature of myoma --- vs in pseudocapsule -- send redial branches
in tumor.
 Centre - least blood supply -- degenerates
 calcification at periphery and spread inward along the vs.
Hyaline degeneration – 63%
 MC change in leiomyoma
 Common specially in tumor with more connective tissue
 Almost all myoma except tiny
 Cut surface smooth and homogenous and may become cystic.
Cystic degeneration
 Sometime cystic change are so great leiomyoma become mere shell and
is truly cystic tumor may confused with preg or ovaria cyst.
 Usually occur following menopause common in interstitial fibroid.
Fatty degeneration
 Usually at or after menopause and at globules in ms cells.
Calcereous degeneration
secondary to vascular impairment and ischaemic necrosis calcium phosphate
and carbonates are deposited in periphery along the course of vs – calcified
cyst
 Advanced degenerative change – leiomyoma solidly calcified – wombstones.
 Old black women with long standing leiomyoma who have pedunculated
subserous tumor.
 Radiography – easily identified.
Reg degeneration (Carneous degeneration)
 Is an aseptic condition this complication develop most frequently during
pregnances (1/2 half and puerperium)
 abd pain, fever and constitutional upset
 Myoma become tense and tender
 Cut surface – raw beef appearance with fishy odour
 Thrombosis of large veins in capsule and small vs in substance.
 Discolouration – diffusion of blood pigments from thrombosed vessels.
 Mod leucocytosis, ↑ ESR
Infection
 Submucous leiomyoma MC ---- peduculated submucous
leiomyoma thing out endometrium evetually surface
ulcerates and infects
 Streptococcal, Bact fragilis
 Parametritis, peritonitis – septicaemia
 Inf is also common is peuerperium causing delayed PPH &
sepsis.
Sarcomatous Change –
 Most imp but rare < 0. 1%
 variation in incidence
histological misinterpretation with cellular leiomyoma
.
 larger leiomyoma --- centre ---- poor blood supply.
 Soft and homogenous with necrosis---- friable and
haemorrhagic.
 Post-menopausal - sudden growth
pain
post menopausal bleeding
highly malignant with spread via blood stream.
Torsion –
Subserous pedunculated myoma
Axial rotn of whole of uterus –
neighbourhood of int os at level of mackendro lig
 MC during pregnancy and after menopause
Inversion – chronic inversion
Atrophy – following menopause – loss of estrogen support and
decreased vascularity – firmer, fibrotic small size – also after
delivery
Hemorrhage
Intracapsular
Intraperitoneal – one of the large vein of subserous
Polycythemia
 Erythropoietic function by tumor
 Altered erythropoietic function of kidney through ureteric
pressure.
 Clinical Features
 Most leiomyomata are asymptomatic (>50%) accidentally
detected during gynecological checkup & USG done for
some unrelated reason.
 Symptoms are related to anatomic type and size of
tumor, site is more important than size, small submucous
is more symptomatic than large intramural or subserous.
 Menstrual abnormalities – are the most common initial
symptoms and most frequently leads to surgical
intervention.
Menorrhagia - 30%
 Gradual and progress blood loss at regular interval.
 Loss is heaviest on 2nd and 3rd day.
 Never amenorrhea unless pregnant
 Any disruption of normal cyclicity – exclude other causes
than fibroid.
Causes
 Increased SA of endometrium 15cm2 – 200 cm2
 Increased bleeding surface
 Severity parallel surface area
 Interference with myometrial contraction and contractility of
spiral arterioles,obstruction and proximal congestion of
veins in Myoma
 Associated hyperplasia and endo polyps
 prostanoids – relative def of TXA2 (↑ PG F1α)
Metrorrhagia / Meno Metrorrhagia and discharge
 Ulceration of submucous fibroid or fibroid polyp
 Torn vs from sloughing base of polyp

Associated endo carcinoma
 Sarcomatous change is fibroid
 > 40 yrs of D & C for to ---- endo carcinoma

Spasmodic dysmenorrhoea
 Submucous tumor – expulsive uterine contraction

Fibroma at uterotubal junction – severe one sided
dysmenorrhoea.
 Pressure symptoms
 Urinary bladder -suffers most often

Tumor weight – urgency and frequency

Acute retention and overflow in continence

Compression of urethra and bladder neck against symphysis

12 wk tumor incarcerated in culde-sac wedge cervix forward
against urethra – obstruction.

Pedunculated submucous tumor distend vagina press urethra
against pubis.

Ureteral compression at pelvic brim more or right.

Alimentary tract

Constipation

Intermittent int. obstn – small int entwined with subserous
pedunculated tumor.

Veins and lymphatics – oedema and vericosities of legs with large
tumor
 Nerves
 Pressure on sacral plexus or on obturator nerve – extremely rare
 malignant involvement of nerves
 Pain

Fibroid are usually painless
 Pelvic abdominal pain / discomfort – 1/3rd symptomatic
fibroma
 Acute abdomen – Torsion of pedunculated or
degeneration
 Confusion with sp. abortion
 Associate Pathology

PID
 Endometriosis

Tubal pregnancy
 Appendicitis
 Abdominal distortion
 Patient may have sense of heaviness or she may feel lump without any
symptoms one may recommend removal of tumor if abdominal distortion
of such magnitude as to be embarrasing patient.


Rapid growth – arbitory defined ≥ 6 wk gestation size/yr
Premenopauses
Pregnancy
High dose estrogen OC pills
 Sarcoma rarely
Postmenopausal
Malignancy
Sarcoma of myoma
Sarcoma of endometrium
Endometrial carcinoma
Ovarian neoplasm
D & C with removal of growth.

 USG is much more objective way for establishing the size of myoma
and evaluating rate of growth.
Miscelleneous
Iron def anemia – palpitation, lassitude
Ascites – pseudo meig syndrome
Polycythemia – risk of thromboembolism
Hypoglycaemia – retroperitoneal with high cellular activity.
Hypokalaemia

Signs
Pallor
≥14 wks – firm to hard – cystic on degeration,
margins well defined  pelvic origin, nodular to smooth
mobile side to side ,dull percusion.

Pelvic examination
Bimanual examination – irregularly enlarged uterus
Cervix moves with movement of tumor felt per abdomen
Investigations
 To confirm diagnosis
 Pre-op assessment.

USG – confirm diagnosis

 well defined recorded, hypoechoic
– hyperechoic , peripheral
vascularisation.
 Differentiats from pregnancy and
ovarian mass
 Rate of growth,
 Ectopic or adnexal mass
 No and location and size of fibroid
 examination of ovaries difficult –
peducubted subserosal fibroid
with solid overian mass
 TVS -- small lesion and
submucous fibroids TV vg
 Sonohysterography – enhanced
visualization of uterus.
 MRI
 No place in routine

investigation in fibroids-- cost

and accessability

Most accurate technique

Visualization and localization ≥
0.3 cm

US inconclusive 20% cases
and did not yield a definitive
diagnosis in 59% cases – MRI
was more definitive in all .
 Adenomyosis and

sarcomatous changes not ----

recognized by USG
 HYSTEROSCOPY
 Submucous fibroid with

unexplained infertility and

repeated preg loss
 Direct visualization and

localisation of submucous
fibroid.
 Laparoscopy
 >12 wk ut with infertility or pelvic pain

Detect coincidental endometriosis

Pelvic adhesions or tubal pathology
 Differentiate peduculated tumor from ovarian neoplasm.
D & C -- postmenopausal
 With irregular bleeding
 Scraping off small endo polyps
 Detect any coexisting pathology -malignancy

X ray abdo n pelvis

IV Pyelography
 PAP smear
 CA125
 Management Protocol

Body Cervix

Symptomati Asymptomati
c c
Medical Surgery

Endoscopic Myomectomy Hysterectom

resection y

Regular Supervision <12 weeks >12 weeks, uncertain

Conform diagnosis Require follow Unexplained infertility or abortion
up 6 MONTHLY Pediculated fibroid

Supra vaginal Vaginal

Size, Size stationary

symptomatic Asymptomatic Myomectomy Hysterectom
y

surgery Follow up Myomectomy Polypectomy

Management of Fibroids
 Asymptomatic (expectant -----) > 50%
 To treat or not to treat -- malignant chance < 0.1%; <
operative mortality
 H/o rapid growth in post menopausal, indicates removal
 Small asymptomatic myoma can be observed.

 Larger tumors can be watched safely

 If nature of tumor is certain (ut vs overian)
 No compromise of renal function
 No medical complication (renal failure)
 Some advocate removal
 ut ≥ 12 wks
 Inability to asses ovaries
 Pissibility of malignancy
 Compromised adjacent organ function
 Potential for better fertility if myomectomy on small uterus.
 Medical management
 Permanent cure not yet available

 Adjunct to surg treatment or as a temporary

substitute
 Relief of symptoms avoids surgery--uterus

conservation
 NSAID’s

Pain relief

↓ in menorrhagia

May not adress underlying problem
 OC pills

Significant ↓ in duration of bleeding (5.5 – 4.4)
 ↑ Hct

 Progestins
 Inhibiting gonadotrophin secretion

 Confilcting results

 Levonorgestred ---- significant ↓ bleeding and ↑

HCT
 GnRH Analogue Medical
Oopherectomy/ Medical
Menopause
 Most effective in ↓ myoma size & menorhegia
 ↑ Gonadotrophins→ desensitization → down
regulation →hypogonadotrophic hypogonadal state
 35 – 60% ↓ myoma size in 3-6 months
 Amenorhea in 2/3
 Preop ↑Hct, ↓Ut size, allows vaginal and laproscopic
hysterectomy, ↓blood loss
 Caesation of treatment– re growth of tumor
 Vasomotor symptoms reversible after stoppage of
therapy
 Add back therapy with estrogen & progesteron if t/t >
6 months.
 Preparation Dose Route

Buserelin 300-600 µg S.C.

Naferelin 400-800 µg Intra nasally

Goserelin 3-6 Mg every S.C

28 days
Leuprorelin 3.75 Mg every S.C./ I.M
28 days
Triptorelin 30 Mg every I.M
28 days

Therapy commenced in mid luteal phase with no intercourse

Mifepristone RU 486 DANAZOL
 Synthetic steroid  19 Nor testosterone
progesterone derivative, androgenic
 ↓ Vol by 49% (0-87%) & progestinic activity
( Murphy 1993)
 Inhibits gonadotrophin
 Induce amenorrhea
secretion & ovarian
( most common) 25-30
mg for 3 Months
enzyme
Recent review support the  Induce amenorrhea &
usage but has been no effect on uterine
associated with volume
 Hot flushes  200 – 400 mg for 3
 Endometrial hyperplastic months
 Without trabecular bone  Androgenic side effects
loss
Ref: Obste Gynea 2004 June
103(G)-1331-6
GESTRINONE RALOXIFENE
 Synthetic derivative of  Selective estrogen
ethinyl nor receptor modulator
testosterone, Anti
 Antagonist on uterus,
estrogen, Anti
progestin breast and agonist on
 ↓ Ut volume by 40%, bone
Amenorrhea (76-96%)  ↓Ut size in post
 Advantage – Carry menopausal
over its effects
 Data conflicts in
 Side effect- Androgenic
premenopausal
 Further studies
 Side effects DVT, VMS
required
 GnRH Antagonist
 Pituitary suppression without flare up stage
 Advantages- Improved Menorhegia
 ↑ Hct
 Relief of press symptoms
 ↓ size 50% when used for 6 months
 ↓ Vascularity of tumor, ↓ blood loss during
myomectomy
 Facilitates laparoscopic/ hysteroscopic surgery
 Treatment for 3-6 months 50% reduction in uterine
volume
 Citrorelix S.C Inj
 Ganirelix S.C Inj.
 Surgical Management
 Minimal Invasive Technique
 UAE

Mylosis
 Myoma coagulation
 Myomectomy
 Abdominal
 Vaginal

Hysteroscopic
 Laparoscopic
 Hysterectomy
 Abdominal
 Vaginal

Laproscopic
 HYSTERECTOMY
INDICATIONS:

• Symptomatic myomas

• Failed medical management

• High suspicion for malignancy

• Other factors: pelvic floor relaxation, abnormal

endometrial/cervical cytology
• Abdominal Hysterectomy (75%)
• 30% due to fibroids
• 9.1% complication rate
• Vaginal Hysterectomy (20%)
• 4% due to fibroids
• 7.8% complication rate
• Benefits:
– ↓ complication rates, convalescence, hospital $$$
• factors affecting choice of vaginal hysterectomy
– surgeon’s experience
– uterus size
– concomitant pathology-
Endometriosis, adnexal disease,
Adhesions, previous pelvic surgery, chronic PID,
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
§ advantages: smaller incision, ↓ hospital stay, pain &
recovery
Disadvantage: longer operating time
– avg 102 mins (81 mins for vaginal hyst; 68 mins abd
hyst)
(Ottosen et al., 2000)
Laparoscopic Hysterectomy (LH)
• Upper limit of the uterus depends on surgeon’s
expertise
• Disadvantages: ↑ operating time & complication rate
• Evaluate study: ↑complication rate 11% vs 6% in abd
hyst; longer to perform; less painful; shorter stay (Gary
et al., 2004)
Total vs. Supracervical Hysterectomy
? associated TAH w/ sexual dysfunction, ↓ pelvic support,
&
urinary problems in comparison w/ SCH

TOSH (Total Or Supracervical Hysterectomy) –

DUB, or both.

• 135 patients randomly assigned TAH or SCH

• Both techniques statistically significant ↓ in symptoms
• No statistically significant differences in complications,
Degree of symptom improvement, or activity limitation
 Myomectomy
 Enucleation of myoma from the uterus leaving behind the
potentially functioning area capable of future function
 1st performed by Washington & John Atlec 1844
 considerations for myomectomy are mainly to preserve
reproductive function and menstruation.
 Is more risky operation when fibroid is too big or too many.
 Chances of persistent menorrhegia (1-5%)
 Relaparatomy (20-25%)
 Pregnancy rate 40-60%
 Mandatory hospital delivery after myomectomy although scar
rapture rare
 Recurrence -- 5-10%
 Avoid during pregnacy- Vascular Uterus
 10% myomectomied patients require mysterectun within 5-10
yrs
 INDICATIONS

Patient of reproductive age group

Cases of RPL due to fibroid
Prerequisites prior to Myomectomy

Be certain about diagnosis

Rule out other causes of infertility
 Hysteroscopy or HSG to rule out fibroid encroaching uterine
cavity or a polyp or tubal block
 D&C- Poplyp or exclude endometrial carcinoma
 Restore Hb -11gm/dl
Contraindications

Infertile husband

Associated infective T-O mass

Infected fibroid

Big broad ligament fibroid

Too many fibroids

Myomectomy to be tried, may end in hysterectomy

Abdominal Myomectomy
 Atlee brothers 1844
 .Measures to control blood loss during
myomectomy
 Preop treatment with GnRH analogue reduces the
vascularity of tumor & thereby reduces operative
blood loss.
 Use of Victor Bonners clamp to reduce uterine
arterial blood flow, clamp placed around ut vs &
round lig

Bonney-1920’s –uterine artery clamp

Use of tourniquets around

ut art & IP lig, --important

to arrest arterial blood flow

and not venous

Use of Vasoconstructive agent—
Vasopressin
20 units in 20 ml N --saline
72% ↓ need of bld. Transfusion
S/E -- direct vascular inj
angina.MI
water intoxication
delayed bleeding

Controlled hypotensive anesthesia with NTG or sod.

Nitropruside
mean - 60mmHg
c/I – PVD,MI,CVE,renal & hepatic dis
Essential basic principles of myomectomy
 Incision on uterus should be as few as possible
 Incision should be vertical and middle in least vascular
area
 Incision on peritonial surface avoided
 Bonney’s hood – large fundal myoma
Lateral fibroid are removed by tunneling
Avoid injury or occlusion of intramural portion of tubes
All tumor cavities obliterated avoid dead space – heamatoma
formation .
Modified Baseball Suture Technique
Round lig shortening, Restoration
Adhesion, prevention- Interceed , Gore-Tex
Perioperative antibiotic prophylaxis

COMPLICATIONS
 Hemorrhage

Injury to bladder & ureter
 Injury to fallopion tubes
 Bowel injury
 Febrile morbidity
 Vaginal Myomectomy
 Most appropriate initial treatment for -

Pedncuclated submucous myoma

1845 Atlee

Morcellation- Very large tumor

Avoid too much rachotraction - inversion
 Identify pedicle clamp ligate as high as possile
 Small sub mucous myoma removed by twisting it free & its
attachment.
 Duhrseen incision- higher sub mucus pedineucleated myoma

HPE to rule out malignancy.
 Complications

Cervicale incompetence

Bleeding
 Preop Criteria

Ut < 16 weeks
 Good uterine morbility
 Adequate vaginal access
 Absence of adnexal pathology
 Hysteroscopic Myomectomy
• Neuwirth & Amin first reported in 1976
• European Society for Human Reproduction and Embryology
• Type 0: Pedunculated Submucous Myoma
• Type 1: less than 50% Myometrium Penetration
• Type 2: more than 50% Myometrium Penetration
Contraindications:
• Endometrial hyperplasia or carcinoma
• Acute PID, cervicitis
• Pregnancy
• Size >3 cm, Type 2 (relative C/I)
Preoperative considerations:
• Classify Fibroids
• Endometrial preparation –
– done in follicular phase
– COC, progestins, GnRH agonists
• Cervical ripening –
– Misoprostol, laminaria
Hysteroscopic Myomectomy cont..

The resectoscope is a special type of

hysteroscope with a

built in wire loop that uses high-

frequency electrical

energy to cut or coagulate tissue.

Hysteroscopic Myomectomy cont..
Operative Considerations:
• Monopolar system:
1.5% glycine, 3% sorbitol,
5% mannitol
• Bipolar system – saline
• Fluid deficit >1000 ml ,
discontinue procedure
• Type 2 myomas –
transbdominal u/s guided;
second procedure after 1-2
courses of Lupron
Complications:
• Infection: Endomyometritis 0.5-2%
• Bleeding: 2%. Dilute intracervical vasopressin; 30ml foley balloon in uterus
& removed in 1-6 hrs.
• Diluitonal Hyponatremia – pulmonary edema, transient blindness, cerebral
edema, brainstem herniation, death.
• Uterine perforation: 1% – observation / laparoscopy / laparotomy
• Clinical Efficacy: Success rates 85-95% for abnormal uterine bleeding
Laproscopic Myomectomy
Indications:
• Removal of subserosal &
intramural myomas
Contraindications:
• To laparoscopy
• Diffuse leiomyomata
• >4 myomas 6 cm
• Uterine size > ? 16 wks
Laproscopic Myomectomy cont..
Advantages:
• Success equal to myomectomy for fertility
• ↓ morbidity
• Rapid recovery
• Short hospitalization
Disadvantages:
• Technically demanding
• High degree of skill
• Time consuming –↑ anesthesia time
• Costly
• Concerns regarding strength of uterine scar
Preoperative GnRH:
• ↑ risk of conversion to Laparotomy (5 fold), operative time,
recurrences
Procedure:
• Electrosurgical or laser techniques
• Multi-layer suturing
• Fibroid retrieved by morcellation, colpotomy, or abdominal incision
Laproscopic Assisted Myomectomy (LAM):
• Myoma > 10-12 cm, numerous & deep myomas
• requiring extensive morcellation & multi-layer
• suturing
• Place the corkscrew manipulator on the fibroid after the incision;
midline incision enlarged to 4-5cm; fibroid shelled out & repair in
layers.
• Advantages over conventional myomectomy or laparoscopic
myomectomy not well estab.
 LAPAROSCOPIC
MYOLYSIS
 Laparoscopic myoma coagulation was first
explored as an alternative to myomectomy or
hysterectomy in the late 1980s.

 The indications for myolysis include symptomatic

myomas requiring surgical treatment for:

3. Abnormal uterine bleeding and

4. Pelvic pain and

5. Pressure to adjacent organs.

 LAPAROSCOPIC MYOLYSIS
 In general, 3 months of GnRH agonist pretreatment reduces
the total uterine myoma volume by approximately 35% to
50%.

 Following myoma coagulation, the total uterine myoma

volume is reduced by an additional 30% for a total reduction

of approximately 80%, appearing to be permanent.

 Repeat diagnostic laparoscopy in a limited number

of women has demonstrated various degrees of
adhesion formation over the coagulated myomas.
 LAPAROSCOPIC MYOLYSIS
 The integrity and tensile strength of the uterine wall has not
been determined following laparoscopic myolysis.

 Although some women who underwent the procedure have

conceived and have uneventfully delivered by Caesarean
section,

 The fertility and pregnancy outcomes after laparoscopic

myolysis remain unknown.

 As a same day procedure ,myoma coagulation appears to

be a extremely safe alternative to hysterectomy ,avoiding
major surg.& time,while providing an alternative solution for
pts. With symptomatic leiomyoma.
 Uterine Fibroid Embolization (UFE) or
Uterine Artery Embolliizatiion (UAE)
First reported by Ravina et. al. in 1990.
• Principle: limiting the blood supply to the myoma, their
volume can be reduced.

Indications:
• Symptomatic fibroids
• Desire to avoid surgery
• Poor surgical candidates
• Preop or primary treatment for very large fibroids
• Transfusion not acceptable
• Acute intractable hemorrhage from fibroids
Contraindications:
• Pregnancy
• Menopause
• Severe contrast allergy
• Renal failure
• A-V malformations
• Unknown pelvic mass
Relative Contraindications:
• Pedunculated fibroids w/ attachment < 1cm broad
• Acute PID
Pre-procedure Evaluation
• Interventional Radiologist consultation – review history,
imaging, investigate issue of infertility
• Endometrial biopsy, Gonorrhea, Chlamydia cultures
Procedure:
• Admitted the morning of the procedure
• Premedication- NSAIDS, Anti-emetics
• CBC, coags, BUN, creatinine, pregnancy test
 Uterine Fibroid Embolization (UFE) oUterine or
Uteriine Artery Embolliizatiion (UAE) cont..

• Femoral artery – U/L or B/L

approach

• Under fluoroscopic guidance,

catheter

• Introduced in abdominal

aorta.
 Uterine Fibroid Embolization (UFE) oUterine or
Uteriine Artery Embolliizatiion (UAE) cont..

Nonselective pelvic
angiogram
demonstrating the
tortuous and dilated
uterine arteries
supplying a
hyper vascular
uterine fibroid.
Uterine Fibroid Embolization (UFE) oUterine or
Uteriine Artery Embolliizatiion (UAE) cont..
Selective angiogram of uterine arteries prior to
catheterization & embolization.

Left Uterine Artery Right Uterine Artery

Uterine Fibroid Embolization (UFE) oUterine or
Uteriine Artery Embolliizatiion (UAE) cont..

Nonselective
angiogram of
the pelvis after
embolization
demonstrating
occlusion of
both the right and left
uterine arteries.
 Uterine Fibroid Embolization (UFE) oUterine or
Uteriine Artery Embolliizatiion (UAE) cont..

Embolization Particles:
§ Permanent:
– embolic particles
(PVA, Embospheres)
– thrombogenic coils
§ Temporary:
– gelfoam cellulose
particles
Pain Management:
• Pattern of pain: starts during/soon after the procedure,
• Peaks 6-12 hrs & subsides over 12 hrs to several days
• Conscious sedation during procedure; PCA pump, NSAIDS,
• Overnight observation, ambulate after 4-6 hrs
• Follow up:
• In first week
• Clinical eval in 6 wks & repeat imaging in 6 mths

Failure:
• Shrinkage > 10%
• Persistence /worsening of symptoms
• Subsequent hysterectomy 1-2% (infection, persistent pain or
bleeding, fibroid prolapse, uterine malignancy); myomectomy
Uterine Fibroid Embolization (UFE) Uterine or
Uteriine Artery Embolliizatiion (UAE) cont..

Pre Emb. 6mths Post Emb. Pre Emb. 6mths Post Emb.

Shrinkage*:
• Myoma – 15% at 6 wks; 27% at 6mths; 34% at 12 mths
• Total Uterine Volume – 31% at 6wks, 49% at 6mths,
50% at 12 mths, 73% at 5 yrs
*(Tulandi, ed., et al., Uterine Fibroids, 2003)
Procedural Complications:
• Puncture site complications: <1%
• Allergic/Anaphylactic reactions: 1%
• Incomplete UAE Catheterisation: 0.5-1%
• Misembolization: very rare.
• Radiation exposure

Post-Procedural Side Effects & Complications:

• Acute Post-Embolization Pain
• Post-Embolization Syndrome (40%):
o Diffuse abdominal pain, malaise, nausea, vomiting, fever,
leukocytosis
o Self-limiting; conservative management
Infection (1-1.8%):
• Endomyometritis, chronic salpingitis, TOA, infected myomas
• Persistent or Chronic Pain (5-10%)

Ovarian Dysfunction (5%):

• Transient & permanent menopausal symptoms

Menstrual Dysfunction:
• Amenorrhea – (transient 15%, permanent 3%)
• Transcervical Myoma Expulsion (5-7%)

Mortality:
• 4 reported deaths in over 40,000 patients treated
• 1 in 10,000 vs 0.3 & 0.6 per 1000 for hysterectomy & myomectomy
 CERVICAL MYOMA
 Commonly single, Interstitial or subserous, rarely submucous
 Being extra peritoneal remain free in pelvis, displaces bladder and uterus.
 Ant – Bladder symptom
 Post - rectal pressure
 Lateral -ureter post laterally
 central
 During pregnancy- obstructed labour
 GnRH for 3 months
 Supravaginal fibroids
Myomectomy ----
 Anatomic difficulty
 Restoration to cervix can not be adequate for reproductive function.
Hysterectomy --------
 Enucleation followed by hysterectomy to avoid ureteric injury
Vaginal Fibroids—
 Myomectomy
 Polypectomy
Ant. Cervical Myoma - dissect bladder down – enucleation
Post Cervical Myoma – through pouch of douglas
Central Cervical Myoma – Dissect bladder down - Hemisection of
uterus – enucleation.
 Myoma with Pregnancy
1 in 1000
Effect of pregnancy on myoma
 Increase in size
 Degeneration
 Torsion
 Infection and polypoidal
changes
Effect on pregnancy
 None
 Retention of urine, constiaption
 Abortion
 Malpresentation, non
engagement
 Preterm delivery
Effect on labour
 Unaffected
 Dystocia
 Uterine inertia & PPH
Effect on Puerperium
Sub involution
Sepsis
Secondary PPH
Diagnosis
Difficult to diagnose without prior knowledge
Sonography confirms
Treatment
Don’t do anything to fibroid whenever possible
During pregnancy
Uncomplicated access at 38 weeks- method of delivery

myomectomy -- acute torsion,axial rotn of ut. Acute retn of urine.

Red degeneration - manage conservatively

During labor
•C.S. fibroid below presentation
No attempt for myomectmy during C.S.
•Elective Cesarean Section
Cervical or broad lig fibroid
Malpresentation
 Fibroid & Infertility
 This can be either cause or effect of myoma
 Deferement of preg encourage leiomyomas and

the leiomyoma then discourage pregnancy


A sole cause of in fertility in <3% cases
attributing factors :-
a) Uterus – distortion or elongation of cavity difficult
sperum ascent

Dysfunctional uterine contracticity – impaired
sperum, ovum transport and implantation.

Congest and dilatn of endo venous plexus –
defective nidation
 Atrophy and ulceration of endo

 Menorrhagia and dyspareunia.

B) Tubal
 Cornual block

 Marked elongation of tube over fibroid

 Ass salpingitis and tubal block

C)Ovarian – Anovulation
D) Peritoneal – Endometriosis

Best surgical and obstetric judgement is needed to make a proper
recommendation depends on her age, physical health, pelvic
findings, her own desires.

T/t
Hysteroscopic myomectomy 30-70% pregnancy rate
Large multiple myoma – poor results
ut ≥12 wks,& > 4myomas
Abdominal or laproscopic myomectomy
Intramural or sub serosal fibroids have little or no adverse
effects on fertility
Imp factors- age at time of procedure
duration of infertility
 LEIOMYOSARCOMA
 CAN IT BECOME CANCER, DOCTOR?
 Until proven otherwise, sarcomotus change in fibriod is a
myth.
 <0.1% , 43-53 years
 Suspect When –
 Rapid enlargment of fibroid
 Post menopausal bleeding
 Pain from myoma

Recurrence following myomectomy, polypectomy

H/O prior pelvic radiation (47%)

Diagnosis by histological examination
 >10 mitoses/ 10 hpf
 TAHBS0 with external pelvic radiation / chemotherapy
 Survival 20-30%
Broad Ligament Fibroids
TRUE

Arise from muscles fibers normally found in mesometrium

In round ligament

In ovario-uterian ligament
 In connective tissue surrounding ovarian/ uterine vessels
 True broad ligament tumors are entirely separate from uterus.
They displaces but don’t deform the uterus.
 Uterine artery lies beneath & inner side of tumor

Ureter is displaced inward and found running in posterior
peritonal layer of broad ligament & to courses under the tumor to
reach the bladder.
FALSE
 Tumor arises from lateral wall of uterine body or
cervix and bulge outward between the layers of
broad ligament, uterus is therefore integral part of
tumor.
 It displaces uterine artery outward and upward

 Ureter is displaced outward to pelvic wall & lies

under the tumor, exception rare lateral cervical
myoma.
 T/t -- Enucleation with/without Hysterectomy