Undergraduate course lectures in Obstetrics&Gynecology prepared by DR Manal Behery .Professor of OB&Gyne .Faculty of medicine ,Zagazig University

3. Bengin tumors arising from the smooth muscle
cells of the myometrium
They are the most common pelvic tumor in
women.
20% of women >of 35 years .

4. PathologyPathology
Well circumscribed
white firm mass with a
whorled appearance
- surrounded by false
capsul formed by
compressed by
uterine muscle

5. PathologyPathology MicroscopicallyMicroscopically
Smooth muscle
& Connective
tissues
.

6. Pathology Of FibroidPathology Of Fibroid
SizeSize
Varies from very small fibroidsVaries from very small fibroids
(seedlings) to huge tumours(seedlings) to huge tumours
ShapeShape
Starts as a small spherical tumourStarts as a small spherical tumour
but as it enlarges its shape may bebut as it enlarges its shape may be
changed by compression.changed by compression.
ConsistencyConsistency
Firm unless affected by degenerationFirm unless affected by degeneration

7. Secondary pathological
degenerative changes and
complications of fibroids

8. 1)1) Atrophy.Atrophy.
2)2) Necrosis.Necrosis.
3)3) Degeneration.Degeneration.
4)4) Malignancy.Malignancy.
5)5) Infection.Infection.
6)6) Torsion.Torsion.
7)7) Incarceration.Incarceration.
8)8) Inversion of the uterusInversion of the uterus..

9. Loss of worled appearance ifLoss of worled appearance if
degenration occurreddegenration occurred

10. Risk of MalignancyRisk of Malignancy
Incidence of leiomyosarcoma in
hysterectomy specimens of women
receiving surgical treatment for
fibroid
0.1% in reproductive age group
1.7% after age of 60 years

12. Early menarche (<10 years old) is associated with an increased risk of
developing fibroids.
Early menarche (<10 years old) is associated with an increased risk of
developing fibroids.
 Parity (having one or more pregnancies extending
beyond 20 weeks) decreases the chance of fibroid
formation.
 Early age at first birth decreases risk and a longer
interval since last birth increases risk
 Parity (having one or more pregnancies extending
beyond 20 weeks) decreases the chance of fibroid
formation.
 Early age at first birth decreases risk and a longer
interval since last birth increases risk
No definit risk with oral contraception
No association of fibroid growth with agents for ovulation
induction
No definit risk with oral contraception
No association of fibroid growth with agents for ovulation
induction
A relationship between fibroids and increasing body mass.
The relationship is complex and is likely modified by other
factors
A relationship between fibroids and increasing body mass.
The relationship is complex and is likely modified by other
factors

14. Site of originSite of origin
Corporeal
fibroid
(97% )
Cervical
fibroid
(3%)

15. Fibroids are often described accordingFibroids are often described according
to their location in the uterusto their location in the uterus

17. Anatomic LocationsAnatomic Locations

19. SymptomsSymptoms

21.  It is the most common symptom.
 Menorrhagia is the typical bleeding pattern with myomas
.
 Intermenstrual bleeding and
 postmenopausal bleeding
 are NOT characteristic of myomas
 EXCEPT IF

23. Bulk-related symptoms —
urinary frequency, difficulty emptying the bladder,urinary obstruction
Piles &constipation
Hydrourter &hydronephrosis
.

24. Dysmenorrhea —
Dysmenorrhea is also reported by many women with fibroids.
Leiomyoma degeneration or torsion —
fibroids cause acute pain from degeneration (eg, red degeneration)
or torsion of a pedunculated tumor.

25. submucosal or intramural with an intracavitary
component) result in:
 difficulty conceiving a pregnancy
Increase risk of abortion
leiomyomas have been associated with adverse
pregnancy outcomes eg,
placental abruption,
 fetal growth restriction,
and preterm labor and birth

26. Signs of cervical fibroidSigns of cervical fibroid
A firm fixed pelvic massA firm fixed pelvic mass with thewith the
uterus lying on its top.uterus lying on its top.
Barrel-shapedBarrel-shaped enlargement of theenlargement of the
cervix.cervix.
A cervical polyp.A cervical polyp.

29. Pelvic ExamPelvic Exam
AA pelvi-abdominal Or pelvic mass.pelvi-abdominal Or pelvic mass.
symmetrical enlargement of the uterus.symmetrical enlargement of the uterus.
A symmetrical enlargement of the uterus.A symmetrical enlargement of the uterus.
- A pedunculated subserous- A pedunculated subserous
- A broad ligament fibroid.- A broad ligament fibroid.

30. speculum examspeculum exam
cervical polypcervical polyp

31. CERVICAL POLYPCERVICAL POLYP

33. TAS&TVSTAS&TVS
size, sitesize, site andand numbernumber of fibroidsof fibroids
differentiatesdifferentiates the tumour from otherthe tumour from other
swellings asswellings as ovarian tumourovarian tumour

34. 2-Saline infusion sonogRaphy2-Saline infusion sonogRaphy

35. (3) Hysteroscopy(3) Hysteroscopy
To visulize a sub
mucous fibroid or a
small fibroid polyp.

36. (4) Intra venous pyelogram (IVP)(4) Intra venous pyelogram (IVP)
InIn cervicalcervical andand broad ligament fibroidbroad ligament fibroid
- Course of ureter.Course of ureter.
- Hydroureter & hydroneprosisHydroureter & hydroneprosis
- Kidney function.- Kidney function.

39.  AsymptomaticAsymptomatic
 Fibroid small (<12 wk gestational size)Fibroid small (<12 wk gestational size)
 Near menopauseNear menopause
Treatment is not necessary if….Treatment is not necessary if….
(follow up every 6 months )(follow up every 6 months )

40. Hormonal tttHormonal ttt
COCPsCOCPs
DanazolDanazol
Gonadotrophin releasing hormone analogueGonadotrophin releasing hormone analogue
(agonist)(agonist)
Mifepristone:Mifepristone: a progesterone receptora progesterone receptor
antagonist It reduces the size of myomas byantagonist It reduces the size of myomas by
50%.50%.

41. MirenaMirena coil treats menorrhagia, and reducescoil treats menorrhagia, and reduces
the size of fibroids + contraception)the size of fibroids + contraception)

43. MyomectomyMyomectomy
Removal of fibroids from the uterusRemoval of fibroids from the uterus
Indications:Indications:
Young age below 40 yearsYoung age below 40 years
Single myomaSingle myoma

44. Contraindication of MyomectomyContraindication of Myomectomy
AgeAge > 40.> 40.
Multiple fibroids (leaveMultiple fibroids (leave behind a uselessbehind a useless
organ).organ).
Cervical fibroidCervical fibroid
IfIf malignancymalignancy is suspected.is suspected.
 presence of other lesions in the uterus aspresence of other lesions in the uterus as
adenomyosis.adenomyosis.

45. Open myomectomyOpen myomectomy

46. LaparoscopicLaparoscopic MyomectomyMyomectomy

47. HysteroscopicHysteroscopic MyomectomyMyomectomy

48. How to decrease blood lossHow to decrease blood loss
during myomectomy ?during myomectomy ?

49.  Pre operative correction of anemia:Pre operative correction of anemia:
– Iron supplementation,Blood transfusionIron supplementation,Blood transfusion
Pre operative GnRH agonists treatmentPre operative GnRH agonists treatment
Vasopressin(20U in 20 ml NS)Vasopressin(20U in 20 ml NS) -- as effective asas effective as
vascular occlusion for controlling blood lossvascular occlusion for controlling blood loss
Tourniquets :Tourniquets :
Bonney’s myomectomy clampBonney’s myomectomy clamp
Ring forcepsRing forceps
Elastic rubber catheter(around cervix)Elastic rubber catheter(around cervix)

50. HysterectomyHysterectomy
Indication:Indication:
1)1)Multiple myomaMultiple myoma
2)2)Cervical fibroidCervical fibroid
3)3)Uncontrollable bleedingUncontrollable bleeding
during myomectomyduring myomectomy

51. Cervical fibroidCervical fibroid

52. Smooth muscle tumors of the uterus are often multiple. Seen hereSmooth muscle tumors of the uterus are often multiple. Seen here
are submucosal, intramural, and subserosal leiomyomata of theare submucosal, intramural, and subserosal leiomyomata of the
uterusuterus

53. Embolization of both uterine arteriesEmbolization of both uterine arteries
Indicated when patient is unfit or refuseIndicated when patient is unfit or refuse
hysterectomy .hysterectomy .
< tumour size about< tumour size about 50%.50%.
endometritis and pyometraendometritis and pyometra
infection of the necrotic fibroids.infection of the necrotic fibroids.

56. MRI-guided Focused UltrasoundMRI-guided Focused Ultrasound
(MRI-FUS(MRI-FUS))

58. Management Clinical effect Method of
Treatment
Observation Most
Serial Pelvic Exams
Pre-surgical Shrinkage Size by 50%
GnRH analog 3-6months;
regrowth after stopping
Myomectomy Preserves fertility
Laparotomy, laparoscopy
Embolization Preserves the uterus
Invasive radiotherapy
Hysterectomy Fertility completed
TAH,TVH
Definitive tx