fibroids, newer techniques in fibroid, fibroid in pregnancy, types of fibroid, HIFU, myomectomy, fertility conservation surgery,

1. FIBROIDS
DR. PREKSHA JAIN
DR. PRACHI DIXIT

2. Contents
• Introduction
• Incidence
• Etiology
• Risk factors
• Symptoms
• Natural history
• Secondary changes &
complications
• Diagnosis & Types
• Fibroids in Pregnancy
• Treatment (Medical & surgical)
• Recent advances

3. Introduction
• Definition
• Myoma, leiomyoma, fibromyoma
• Derived from smooth muscle cell rests from vessel wall
or uterine musculature

4. Incidence
• M/c benign tumors of myometrium
• 77% of hysterectomy specimen
• 60% in 35-49 yrs
• 80% in >50 yrs
• 40% in 35 yrs
• 70% in 50 yrs
Afro american
White women

5. Etiology
• Genetic (40%)
• Hormonal
• Growth factors

6. Genetics
• Cellular, atypical & large fibroids
• Translocations 12 & 14 chrm
• Deletion of 7 chrm
• Trisomy of 12 chrm
• Leiomyosarcoma have different origin

7. Hormones
• E & P increase in receptors no. & responsiveness.
• Hyperestrogenic states- Obesity, Ca endometrium,
early menarche, anovulatory infertility.
• Highest mitotic counts encountered in peak
progesterone production.
• Before puberty & after menopause – less incidence

8. Growth Factors
• TGF-β, bFGF, EGF, PDGF, IGF, VEGF, PRL

9. Risk Factors
INCREASE DECREASE NO EFFECT
Age Green veg OCP
Endogenous hormone Exercise IUCD
Family history (2.5 times) Parity STI, CMV, HSV, EBV
Afro American Smoking
Weight

10. Classification

11. UTERINE FIBROIDS
BODY CERVIX
INTERSTITIAL SUBSEROUS SUBMUCOUS
SUBSEROUS
BROAD
LIGAMENT
PARASITIC
• ANTERIOR
• POSTERIOR
• CENTRAL
• LATERAL
• SESSILE
• PEDUNCULATED
75%
15%
10%
OTHERS-
• Intravenous leiomyomatosis
• Leiomyomatosis peritonalis disseminata
• Bizzare leiomyoma

14. Symptoms
Asymptomatic 50% (<5cm size & uterus <12cm)
Abnormal uterine bleeding – 30%
 Menorrhagia (intramural & submucous)
 Metrorrhagia (submucous & endometrial cancer)
 Polymenorrhea (cystic ovaries & PID)
 Purulent discharge (infected fibroid polyp)

15. Symptoms
Pain-
• Congestive & spasmodic dysmenorrhea
• Acute pain - torsion, hemorrhage & red degeneration.
• Chronic Pelvic pain
• Rapidly growing sarcoma

16. Symptoms
Pressure symptoms –
• Retention of urine premenstrual
• Hydroureter & hydronephrosis
• Constipation
• Intestinal obstruction

17. Symptoms
Infertility – 30%
• >4cm
• Distortion of cavity
• PID, endometriosis, anovulation
• Fertility rate –
Submucous type
Subserosal type- No effect
Intramural type - slightly decrease

18. Symptoms
Abdominal lump –
• Rapid growth
• Pseudo Meig’s syndrome
Others –
• Secondary to anemia
• Vaginal discharge

19. Natural History
• Grow slowly 9% over 1 year
• Regress after menopause
• Rapid growth in Premenopausal- indicates pregnancy
not sarcoma
• Postmenopausal with pain & bleeding- Sarcoma
• Secondary or degenerative changes

20. Secondary changes & complications
• Hyaline 65%, cystic, fatty, calcareous 10% & red
degeneration, necrosis
• Atrophy
• Sarcomatous change
• Torsion, Inversion, Hemorrhage, Infection
• Association with endometrial cancer(3%), adenomyosis/
endometriosis 30%, salpingoophoritis 15%, Anovulation

21. CYSTIC DEGENERATION

22. HEMORRHAGE & CALCIFICATION

23. RED DEGENERATION

24. SARCOMATOUS – 0.1-0.5%

25. ENDOMETRIAL CANCER

26. Diagnosis
• History
• Pelvic Examination – enlarged irregularly, firm, non
tender, mobile, arising from uterus.
• FIGO classification
• Imaging

27. Imaging
IMAGING SENSITIVITY SPECIFICITY
MRI 100% 91%
TVS 83% 90%
SIS 90% 90%
Hysteroscopy 82% 87%

28. MRI

29. TAS

30. TVS

31. SIS

32. Differential diagnosis
• Pregnancy
• Hematometra
• Adenomyosis
• Bicornuate uterus
• Ovarian cysts & tumors
• Ectopic pregnancy
• Pelvic kidney
• Chronic inversion

33. Management
 Routine investigations
 Others – IVP, Laparoscopy
 Treatment-
• Conservative-
1. Observation
2. Medical
3. Non-invasive- MRgFUS
4. Minimally invasive- UAE, Myolysis
5. Invasive- Thermal Ablation
• Surgical –Polypectomy, Myomectomy, Hysteroscopic
resection, Hysterectomy

34. • INDICATIONS for intervention:
1. Infertility
2. Recurrent pregnancy losses
3. Asymp >12wk/pedunculated
4. Pressure symptoms
5. Rapidly growing fibroid/ growth after menopause
6. Symptomatic- AUB

35. Medical Management
• Temporary palliation-
1. Menorrhagia
2. Before surgery-
Correction of anemia,
decrease size &
vascularity
3. Postpone surgery
• Alternative to surgery
1. Perimenopausal
2. Desiring fertility
3. Unfit for surgery

36. Drug Dose Advantage Disadvantage
ANTIFIBRINOLYTICS Tranexamic Acid
1-4gm/d
blood loss
Correct anemia
Size remain same
GnRH AGONIST Goserelin (Zoladex)
3.6mg every 28days
3-6mth s/c
30% size
35% ut vol
in 6mth
• Hypoestrogenic effect
• Rebound size
• Loss of plane
• Seedling fibroids missed
• Expensive
GnRH ANTAGONIST Cetorelix, Ganirelix 30% size in
3weeks
Under evaluation
ANTIANDROGEN Danazol 200-400mg
6-12mth
Gestrinone
Volume
No regrowth
Androgenic effect
PROGESTERONE
ANTAGONIST
Mifepristone
25-30mg 3-6mth
25-75% size
50% ut vol
Amenorrhea
Endometrial hyperplasia
Hot flushes, deranged LFT

37. • Antiestrogen- Faslox, Raloxifene, fadrozole (aromatase
inhibitor)
• MIRENA
• Others- chinese herbal medicine

38. SPRM
• Selective progesterone receptor modulator
ULIPRISTAL -
• Partial agonist & antagonist of Pg receptors
ASOPRISNIL –
• 10-25mg per day 3mth
• Inhibits growth
• Decreases uterine artery blood flow & menorrhagia
• No effect on endometrial proliferation

39. Magnetic Resonance guided Focused
Ultrasound
• FDA approved Oct 2004
• Selection criteria-
1. 4-10cm fibroids
2. Family completed
3. Perimenopausal
4. Subcut tissue to fibroid <12cm
5. Clearly visible on MRI
• Thermal ablation
• 31% reduction ut vol in 6mth

41. • US is focused either
1. Geometrically via Lens, Curved Transducer
2. Electronically via Phased Array
• Adv-
1. No scar
2. Short stay, early resuming of activities
3. Least chances of infection, complications
4. Repetition of procedure with low risk

42. Uterine Artery Embolization
• Procedure
• Indication-Symptomatic fibroid, surgery not feasible
• Contraindications-
1. Immunocompromised
2. Genital tract infection or malignancy
3. Vascular disease
4. Contrast allergy/ impaired renal function
5. Infertility

44. • Adv-
1. 80% decrease in menorrhagia, 33% reduction of fibroid
in 3mth. Success rate 85-95%.
2. Short stay
3. No bleeding, adhesions
• Disadv-
1. Postembolization syndrome
2. Early ovarian failure & early menopause
3. Effect on fertility & pregnancy
4. May require hysterectomy
5. Death, sepsis, loss of organs

45. Myolysis
• Lap procedure
• Destroys by laser, cryotherapy, electrosurgical energy
• Indications-
1. Perimenopausal 3-10cm
2. Ut size < 14wk

46. Surgical Management
• I/c-
1. Severe anemia
2. Torsion
3. Pain, urinary symptoms compromising QOL
• Preoperative-
1. Correction of anemia
2. Control menorrhagia
3. Control medical problems

47. ACOG criteria for Hysterectomy
• Confirmation of indication:
1. Asymptomatic 12wk concern to patient
2. Excessive bleeding- Profuse bleeding >8days or
anemia
3. Pelvic discomfort- Acute & severe or chronic pain,
Pressure symptoms

48. Myomectomy
I/c : Unexplained infertility with cavity distortion
Unexplained RPL
Fertility conservation
Subserous pedunculated
• Prerequisities-
1. Correct Hb, oral iron, GnRH-a, Autotransfusion
2. Other causes of infertility should be ruled out
3. Consent for hysterectomy
4. Perform in preovulatory menstrual cycle
5. Endometrial cancer rule out by D&C

49. Myomectomy
• Types-
1. Vaginal
2. Hysteroscopic resection of submucous myomata
3. Laparoscopic
4. Abdominal

50. Abdominal Myomectomy
1. Examination rectovaginal abdominal bimannual examination under
anesthesia
2. Cervical dilatation
3. Maylard incision & retraction
4. Prevent adhesions
5. Prevent blood loss- Hypotensive anesthesia, temporary uterine artery
occlusion or vasoconstrictive agents, CO2 laser
6. Planning Uterine incision
7. Dissection & Enucleation
8. Repairing defects - Bonneys hood method, Complete obliteration of cavity
9. Serosal closure - Baseball sutures.
10. Confirm hemostasis.

52. Results of Myomectomy
• Complications-
1. Intraperitoneal bleeding
2. Infections
• 80% menorrhagia controlled
• 40-60% pregnancy rate
• 5% take home baby rate
• 30-50% recurrence
• 20-25% relaparotomy

53. VAGINAL
MYOMECTOMY

54. BONNEY’S HOOD
PROCEDURE

55. Radiofrequency Ablation
• Halt’s method
• Under Phase 3 clinical trials awaits approval
• 3 small incisions-
1. Laparoscopic camera
2. Intraabdominal ultrasound probe
3. Halt Device

56. Gene Therapy
• Recent evidence suggests that, fibroids develop as an
over expression of p14Arf Gene.
• This drives a negative feedback loop between, p53 &
MDM2 genes, which governs the fate of each individual
fibroid.
• NUTLIN -3, a known MDM2 antagonist, was thus used
to oppose the proliferative activity in cell cultures from
fibroids.
• It also stimulates Senescence Gene- p21 & Apoptosis
Gene- BAX, in vitro.

57. Fibroids in Pregnancy
• Incidence – 18%, 1 in 1000
• Effect of pregnancy –
1. Increase in vascularity & size
2. Torsion of subserous
3. Puerperal infection
4. Red degeneration – 5%
Presentation
Appearance
Cause
• Effect of fibroid on pregnancy –RPL, Ante, intra, postpartum

58. • Indication of removal during CS-
1. Pedunculated subserosal
2. Interfering with delivery or closure
3. Intractable pain
4. Incarcerated fibroid
5. Rapid growth with pressure symptoms