Fibroids in Ultrasound

1. FIBROIDS
P
Presented by Khumbulani Dzinamarira

2. MEANING:
Fibroids are the tumours composed
of smooth muscle and fibrous
connective tissue of uterus. These
are commonly benign tumours.
- D C. Dutta

3. ALTERNATIVE NAMES :
Myoma
Leiomyoma
Fibromyoma
Uterine tumour
Myomata
Fibromyomata

4. TUMOURS OF THE BODY OF
UTERUS
I. BENIGN :
1. Adenoma
2. Myoma
II. MALIGNANT :
1. Carcinoma
2. Sarcoma
3. Chorio-
carcinoma
4. Mesodermal
mixed tumour
5. Secondaries

5. INCIDENCE:
 20% of women at 30 years of age (asymptomatic)
 3% of women in OPD (symptomatic)
 10% more prevalence in England
 Higher rate in black race
 More common in nulliparous or in women having
infertility after 1 child
 Highest prevalence between 35-45years

6. SITES OF FIBROIDS:

7. HISTOGENESIS :
Risk factors for fibroids:
Increased risk Reduced risk
 Nulliparity
 Obesity
 Hyperestrogenic
state
 Black women
 Age between 35-45
F/h/o tumour
 Multiparity
 Smoking

8. ETIOLOGY :
1. Unknown
2. Immature muscle cells present in
myometrium
3. Excessive Oestrogens
- myomas grow during child
bearing age only.
- after menopause the growth of
tumour stops or regression in size

9. Causes of Neoplastic
transformation :
ORIGIN:
1. Chromosomal abnormality:
- About 30% the chromosome abnormality is seen in 6th or 7th
chromosome( rearrangement or deletion)
2. Role of polypeptide growth factors:
- Epidermal growth factors (EGF), Insulin like growth factor-1( IGF-1),
Transforming growth factor (TGF), stimulate the growth of leiomyoma
directly or via estrogen

10. GROWTH:
 Predominantly estrogen-dependent tumuor.Oestrogen dependency evidenced by:
 Growth potentiality is limited to during child bearing period
 Increased growth during pregnancy
 They don’t occur before menarche
 Following menopause, decrease in size of tumour or cessation of growth.
 Frequent association of anovulation
 More of oestrogen receptors than adjacent myometrium

11. Contd…
 Growth rate is slow & takes about 3-5 years to be felt
per abdomen
 Grows rapidly during pregnancy or pill users
 Rapid growth can be due to degeneration or malignant
change

12. FEATURES OF TUMOURS:
 Arise from muscles not from fibres
 Single or multiple ( upto 200)
 Size variable from millimeters to the size of foot ball (filling whole
abdomen)
 Spherical in shape & firm consistency
 Surrounded by pseudo-capsule
 Cut surface of the tumour becomes convex & has white whorled appearance
 Nuclei rod shaped, uniform in size & shape

13. TYPES OF FIBROIDS:
I. Body (Corporeal)
II. Cervical
1. Interstitial or Intramural
2. Sub-peritoneal or subserous
3. Submucous
4. Pseudo-cervical fibroids

14. TYPES OF FIBROIDS :

15. TYPES OF FIBROIDS :

16. INTERSTITIAL or INTRAMURAL:
- In this case the myomas grow & stay in the wall of the
uterus
- Surrounded by myometrial tissue
- Initially fibroids are intramural subsequently pushed
outward or inward
- 70% persist in position.

17. SUBSEROUS:
- Fibroid are partitially or completely covered by
peritoneum
- When completely covered it attains a pedicle called as
‘Pedunculated subserous fibroid’
- If the pedicle is torn then it gets nourishment from
omental or mesenteric adhesions called as ‘Wandering’
or ‘Parasitic fibroid’.

18. Contd…
- If the fibroid is pushed out in between the layers of broad
ligament, called as ‘ Broad ligament fibroid’ ( false or
pseudo)

19. SUBMUCOUS:
- Fibroids grow towards the uterine cavity or cervical canal, may form a polyp
in the cavity & covered by the endometrium.
- They come out through the cervix, may be infected or ulcerated causing
metrorrhagia.
FATE –
 Surface necrosis
 Polypoid change
 Infection
 Degerations

20. SUBMUCOUS FIBROID:

21. CERVICAL
o Rare about 1-2%
o Seen in supravaginal part of cervix, may be any one
above type
o May be anterior, posterior, lateral or central depending
on position
o Disturb the pelvic anatomy, specially ureter

22. PSEUDOCERVICAL:
Fibroid polyp
arising from the
uterine body
when occupies &
distends the
cervical canal, it
is called as
Pseudocervical
fibroid.

23. CORPOREAL FIBROIDS

24. PATHOLOGY OF FIBROIDS:
Secondary changes in fibroids:
1. Degeneration
2. Atrophy
3. Necrosis
4. Infection
5. Vascular changes
6. Sarcomatous change

25. 1.DEGENERATION:
a. Hyaline degeneration- common type, firm feel of tumour becomes soft
elastic.
b. Cystic degeneration- after the menopause, in interstitial fibroids.
Liquefaction of areas with hyaline changes, if becomes big may be
confused with ovarian cyst or pregnancy
c. Fatty degeneration- at or after menopause, fat globules get deposited in
muscle cells

26. d. Red (carneous) degeneration- occur in 2nd half of
pregnancy or puerperium. Cut section revealing raw
beef appearance, cystic space & fishy odor
e. Calcareous degeneration- common in subserous type
followed by fatty degeneration. There is precipitation
of calcium carbonate or phosphate then whole
tumour is converted into calcified mass called ‘Womb
stone’

27. 2. ATROPHY
 Following menopause due to loss of oestrogen support
 Reduction in size of tumour ( as similar to that occurs
after pregnancy)
3.NECROSIS :
 Inadequacy of circulation leads to central necrosis of
tumour ( in submucous polyp or subserous)

28. 4. INFECTION:
 Gains way to tumour through the thinned & sloughed surface epithelium of
submucous fibroid, following abortion or delivery
5. VASCULAR CHANGES:
 Dilatation of the vessels (telangiectasis)
 Dilatation of lymphatic channels occur.
6. SARCOMATOUS CHANGES:
 Occur in less than 0.1%
 Usual type is lieomyosarcoma.

29. CHANGES IN THE PELVIC
ORGANS:
> Uterus- Shape distorted, asymmetrical
-Endometrium with features of anovulation with hyperplasia, as result
becomes thick, congested & edematous
> Uterine tubes- Frequent infection
> Ovaries- Enlarged, congested & filled
with multiple cysts.
> Ureter- Compressed leading to
hydroureter or hydronephrosis

30. CLINICAL FEATURES:
 PATIENT PROFILE:
 Usually nalliparous
 Chronic secondary infertility
 Early marriage
 Frequent child birth
 Age between 35-45 years
 Delayed menopause

31. Contd…
 SYMPTOMS:
 Asymptomatic (75%)
 Symptoms depend on anatomic type & size
 Symptoms depend on the site than the size
 Small submucous fibroid may produce more symptoms than big subserous
fibroid

32. I. Menstrual abnormalities:
1. Menorrhagia (30%)
CAUSES:
 Increased surface area of endometrium
 Interference with normal contractility
 Congestion & dilatation venous plexuses
 Endometrial hyperplasia due to hyperoestrinism
 Pelvic congestion
 Role of prostanoids

33. Contd…
2. Metrorrhagia:
CAUSES:
 Ulceration of submucous fibroid or fibroid polyp
 Torn vessels from the sloughing base of polyp
 Associated endometrial carcinoma

34. Contd…
3. Dysmenorrhoea:
 Congestive variety- may be associated with pelvic congestion or
endometriosis
 Spasmodic type- may be associated with extrusion of polyp & its
expulsion from the uterine cavity

35. Contd… II. INFERTILITY:
CAUSES:
1. Uterine –
> Distortion & or elongation of uterine cavity difficult sperm ascent
 Prevent rhythmic uterine contraction during intercourse impaired
sperm transport
 Congestion & dilatation of endometrial venous plexuses defctive
nidation
 Atrophy & ulceration of endometrium

36. Contd…
2. Tubal –
 Conual block due position of fibroid
 Marked elongation of tubes over big fibroid
 Association salpingitis with tubal block
3. Ovarian – Anovulation
4. Peritoneal – Endometriosis
5. Unknown

37. III. Pregnancy related
problems:
 Abortion
 Preterm labour
 IUGR
 PPH
Causes:
- Defective implantation of placenta
- Poorly developed endometrium
- Reduced space for the growing fetus

38. IV. Pain lower abdomen
 Usually painless
CAUSES:
- Due to tumour degeneration
- Torsion subserous pedunculated fibroid
- Extrusion of polyp
- Associated pathology like PID, endometriosis

39. V. Abdominal swelling
- Heaviness in lower abdomen
VI. Pressure symptoms:
- Constipation
- Dysuria
- Retention of urine
- Hydroureter
- Hydronephrosis
- Infection
- Pyelitis

40. SIGNS:
1. Pallor
2. Enlargement of abdomen
3. Firm feel on palpation
4. Restricted mobility
5. Dullness on percussion
6. bimanul findings
- Irregular uterus
- Cervix moves with movement of tumour

41. INVESTIGATIONS:
1. History
2. Pelvic examination
3. USG & Colour doppler (TVS)
- Uterine contour enlarged & distorted
- Echogenecity vary
- Vascularisation at periphery
- Central vascularisation indicate degeneration

44. DIFFERENTIAL DIAGNOSIS
Pregnancy
Full bladder
Adenomyosis
Myohyperplasia
Ovarian tumour
TO mass

45. COMPLICATIONS:
 Persistent menorrhagia, metrorrhagia or vaginal
bleeding leading to severe anaemia
 Severe intraperitoneal haemorrhage
 Severe infection leading to peritonitis or septicaemia
 Sarcoma

46. ASYMPTOMATIC FIBROID:
1. Observation:
 Perform diagnostic tests
 Begin expectant therapy
 Size < 12 wks of pregnancy
 Diagnosis certain
 Follow up
 Periodic examination at 6mth interval
 Observe the symptoms of fibroids

47. Contd…
2. Surgery:
Indications:
- Size >12 wks of pregnancy
- Diagnosis not certain
- Fibroid grows during follow up
- Subserous pedunculated fibroid
- Unexplained infertility with distortion of uterine cavity
- Unexpalined recurrent abortion
- Present in lower pole of uterus likely to complicate delivery

48. CERVICAL FIBROIDS

49. SYMPTOMS:
1. Anterior cervical:
- Frequency or retention of urine
2. Posterior cervical:
- Rectal symptoms (constipation)
3. Lateral cervical:
- Vascular obstruction
- Haemorrhoids
- Pedal oedema
- Ureters pushed laterally & below tumour

50. Contd…
4. Central cervical:
- Produce bladder symptoms
- Cervix expanded on all sides
- Asymptomatic during pregnancy
- Obstruction during labour.
- If pedunculated, sensation of something coming out, if infected a foul
smelling discharge per vagina

51. TREATMENT:
1. Supravaginal fibroids:
 Myomectomy – Its not only technically difficult but the anatomic &
functional restoration of cervix cannot be adequate to achieve the
future reproduction
 Hysterectomy
2. Vaginal part fibroids:
 Myomectomy
 If, pedunculated polypectomy

52. PREGNANCY AND MYOMAS
EFFECTS OF MYOMAS ON PREGNANCY:
1. During pregnancy
 Abortion: distortion pf uterine cavity, defective implantation,
interference with accomodation & increase in size, impaction of
myoma in pelvis
 Premature onset of labour
 Malpresentation

53. contd…
2. During labour:
 Abnormal uterine action
 Cervical dystcia
 Obstructed labour
 Retainned placenta
 Post partum haemorrhage
3. During puerperium:
 Puerperal sepsis
 Delayed involution of uterus

54. Contd…
EFFECTS OF PREGNANCY ON MYOMAS:
 Increase in size
 Change in consistency
 Red degeneration
 Torsion & infection