UTERINE FIBROIDS

Question 1

Where do Uterine fibroids arise from?

Answer 1

Uterine fibroids are the commonest tumours in the female genital tract and in the body as a whole.
•They are benign neoplasms arising from smooth muscle of the uterus.

Question 2

PATHOGENENESIS

Answer 2

There is evidence that each individual leiomyoma is unicellular in origin (unique clonal neoplasm).

Leiomyoma contain estrogen receptors in higher concentration than surrounding myometrium but in lower concentration than endometrium.
•The hormone sensitivity of leiomyomas is indicated by the fact they develop during the reproductive years and regress after menopause and also by the fact that treatment with GnRH antagonist induce a hypogonadal or hypoestrogenic state that often cause shrinkage of myomas.

Under the influence of circulating E2, tumour may enlarge & weigh >10kg. Atrophy usually occurs after menopause. HRT, OCP ->rapid increase in size.

Progesterone increases the mitotic activity of myomas in young women and by down – regulating apoptosis in the tumor.

Question 3

Which chromosomal abnormalities leads to having a large myeloma and smaller myeloma.

Answer 3

T(12,14)– larger myeloma. Del (7)long arm– small myeloma.

Question 4

Pathology of uterine fibroids

Answer 4

Fibroids are usually multiple, discrete and either spherical or irregularly lobulated.
•They are falsely encapsulated and clearly demarcated from the surrounding myometrium.
•They therefore pout above surrounding myometrium when cut.
•Between tumor and normal myometrium, is a thin layer of areolar tissue which forms a pseudo-capsule through which blood vessels enter the myoma.
•Because entire blood supply is derived from these few vessels, growth of tumor often outstrips the blood supply, leading to degenerative changes.

Question 5

Types of degeneration?(5)

Answer 5

•a. Hyaline degeneration
•b. Cystic
•c. Calcification over time.
•d. Red degeneration:
In pregnancy, extravasation of blood through the tumor (venous infarction) gives a raw beef appearance.
•e. Sarcomatous change: Less than 0.1%

Question 6

Macroscopic and microscopically ?

Answer 6

•Macroscopically, fibroids are greyish in colour, rounded, smooth, and usually firm.
•Lighter than surrounding endometrium.
•Cut section shows the characteristic whorled appearance of smooth muscle bundles
•Microscopically, the individual muscle cells are usually uniform in size and have the characteristic oval nucleus and long, slender bipolar cytoplasmic processes.
•Mitotic figures are scarce

Question 7

RISK FACTORS?

Answer 7

➢ Race:3-9x commoner in black women than whites
➢ Obesity
➢Nulliparity; At least 2 full term pregnancies reduces risk by half
➢Diet and environmental factors
➢Onset of menstruation before the age of 12yrs
➢Sedentary women with higher risk
➢Smoking decreases risk
➢HRT does not increase risk

Question 8

Classification?

Answer 8

➢Submucous
➢Intramural
➢Subserous

➢Others
➢Intraligamentary
➢Parasitic
➢Cervical

Question 9

CLINICAL PRESENTATION

Answer 9

Asymptomatic: Small (and some large ones) – detected on routine examination
•Symptomatic ones may present as:-
–Menorrhagia. May lead to anaemia, with symptoms.
–Abdominal mass
–Crampy pains may result from contraction of the uterus.
–Pressure symptoms from large fibroids
–Dysuria
–Constipation or backache
–Pelvic pain and sometimes, impossible intercourse from cervical myoma
–Subfertility and Recurrent miscarriage from submucous fibroids

Question 10

INVESTIGATIONS

Answer 10

Full blood count
-Haemoglobin estimation
-white blood count- leucocytosis may indicate presence of infection.
•Grouping and cross matching of compatible blood
•Midstream urine for microscopy, culture and sensitivity
•Abdominopelvic ultrasound scan
-localize the fibroid and to differentiate from other pelvic masses. Also, KUB evaluation

Hysterosalpingography
•May pick up submucous fibroids and to predetermine the patency of the tubes especially when dealing with an infertile woman.
Laparoscopy
•Subserous fibroid and associated investigation of tubal patency
Hysteroscopy
EUA & Endometrial biopsy
Magnetic resonance imaging
Computerized axial tomography

Question 11

DIFFERENTIALS

Answer 11

Adenomyosis
•Endometriosis
•Pregnancy
•Abortion
•Tubo Ovarian mass
•Ovarian tumour
•Endometrial Carcinoma
•Leiomyosarcoma
•Pelvic Kidney
•Congenital Abnormalities

Question 12

MANAGEMENT

Modalities of Treatment include(?)

Answer 12

Modalities of Treatment include:
➢Expectant

➢Non-Surgical
●Medical;
●Radiological Intervention

➢Surgical
Laparotomy
●Myomectomy
●Hysterectomy
Hysteroscopy
●Myomectomy
●Endometrial ablation or resection
Laparoscopic
●Myolysis
●Myomectomy

Question 13

PRINCIPLES OF TREATMENT

Answer 13

•Patient’s Age
•Size of the fibroid
•Severity of the symptoms
•The reproductive desires of the patient

Question 14

EXPECTANT MANAGEMENT
Indications and follow up by?

Answer 14

Indications:
Small fibroid 6-8cm in diameter
Fibroid outside endometrium
Asymtomatic fibroid
Myoma co-existing with pregnancy
Post menopausal woman
Follow up by;
•Reviewing patient quarterly
•Postmenopausal women should be seen regularly.

Question 15

NON SURGICAL;
1) MEDICAL…indications?

Answer 15

•For elderly women- after diagnostic curettage and ablation
•For patients who are unsuitable for surgery:
Drugs are used to shrink the fibroids and control symptoms.

Question 16

DRUGS USED Include:

Answer 16

Danazol
Fadrozole

Question 17

Danazol;
Dosage, MOA, effects and side effects

Answer 17

(Synthetic androgen) 400mg-800mg daily in divided doses for 6-9 months.
•Suppresses –FSH/LH secretion ovaries leading to low estrogen and progesterone
•Causes endometrial atrophy.
•May reduce tumour size.
Side effects:-Increase LDL, decrease HDL, weight gain, oedema, reduced breast size, oily skin and hirsutism.

Question 18

Fadrozole……MOA?

Answer 18

Fadrozole : A non steroidal aromatase inhibitor, blocks the conversion of testosterone to oestrogen.

Question 19

Hormones used; (5)

Answer 19

•Levonorgestrel Intrauterine System (LNG IUS)
•Mifepristone
•Gestrinone
•Depomedroxy progesterone acetate
•GnRH agonists

Question 20

LNG-IUCD…MOA

Answer 20

LNG-IUCD atrophies the endometrium and inhibits the insulin like growth hormones thereby reduces the fibroid

Question 21

Mifepristone (RU-486):

Answer 21

Causes a significant decrease in size of myomas and often stops abnormal uterine bleeding.
• Its use is promising but it is not currently widely marketed

Question 22

Depomedroxy progesterone acetate…MOA?

Answer 22

All cause atrophy of the endometrium and reduce uterine bleeding.

Question 23

GnRH agonists
MOA,

Answer 23

Peptides synthesized by substituting the 6th and 10th amino acid in the native GnRH molecule to achieve longer action and better binding to receptor site.
•Used for decades
•Decreases symptoms and size by 30-60% within 3 months of use
•The agent acts by down regulating pituitary GnRH receptors leading to induction of pseudomenopause.

Question 24

Specific indications for GnRH agonists…?

Answer 24

Perimenopausal women who are not willing to have surgical intervention.
•Pre-operative short-term measure to regress the fibroid and reduce its vascularity.
•Its use in shrinking fibroids in grossly obese women with a view of performing a vaginal hysterectomy could be advantageous.
•A more cosmetic incision (eg Pfannenstiel) is more feasible following fibroid shrinkage.

Question 25

DRAWBACKS ofGnRH agonist?

Answer 25

•Induction of hypoestrogenic state leading to undesirable side effects:
–Amenorrhoea
–Nausea
–Vomiting
–Osteoporosis
•Rebound growth
•very expensive

Question 26

RADIOLOGICAL INTERVENTION

Answer 26

Done under conscious sedation & Fluoroscopic Guidance
•It uses micro particles (polyvinyl alcohol) via a catheter through the femoral artery to selectively occlude the uterine artery.
•Leads to ischaemic fibrosis of the fibroid: 40-70% at 3-12months
•Can be used for fibroid size < 24wks .
•Not used for pedunculated or infected fibroid.
•Menorrhagia is rapidly reduced.

Question 27

COMPLICATIONS of RADIOLOGICAL INTERVENTION

Answer 27

•Angiographic
•Pelvic infection
•Decrease ovarian function
•Treatment failure

Question 28

SURGERY;
OPEN MYOMECTOMY

Answer 28

•This involves the enucleation of myomas from the uterus .
Indications:
•Fibroid polyp
•Symptomatic fibroid in a patient who desires to conserve her reproductive and menstrual function

Question 29

Techniques to reduce blood loss
•Pre operation:-

Answer 29

–Optimize patients PCV
–Surgery done in the proliferative phase of menstrual cycle.
–Haemodilution with normal saline
–Autologous blood transfusion

Question 30

Techniques to reduce blood loss;
Intraoperatively

Answer 30

Hypotensive anaesthesia (spinal anaesthesia).
–Application of rubber tourniquet at the anterior posterior lower uterine isthmus occluding the uterine vessels for 40 – 45mins.
–Fast surgery
–Use one incision to remove as many fibroid nodules as possible
–Careful obliteration of all dead spaces

Question 31

PREVENTION OF ADHESIONS

Answer 31

Gentle/minimal handling of tissues
•Reducing number of incisions to one single anterior incision
•Covering uterine surface with cellulose material
•Washing off all blood clots
•Instilling into peritoneal cavity some normal saline or dextran 70 postop

Question 32

COMPLICATIONS of OPEN MYOMECTOMY

Answer 32

•Haemorrhage
•Trauma to bladder, GIT, Ureters
•Infections
•Adhesions (55-95% at 1yr follow up)
•Infertility-(38-65% pregnancy rates)
•Recurrence-27% at 10 years follow up.
•Rupture of scar during labour

Question 33

HYSTERECTOMY;

Indications?

Answer 33

:
•Huge uterine fibroid > 12wks
•Patient who has completed her family with symptomatic fibroid
•Recurrent symptomatic fibroids
•Rapidly growing fibroid in the menopausal period
•Fibroids with recurrent PID

Question 34

HYSTEROSCOPIC RESECTION

Answer 34

Submucous fibriods provided they are <10cm in diameter
•Give GnRH analogues by nasal inhalation or subcutaneous injection for 2-8 weeks
•Fibroids are resected using wire loop passed down an operating hysteroscope
•Diathermy/ laser can also be used to cut through fibroid base
•At higher power setting, can completely vaporize smaller fibroids

Question 35

OTHER MODALITIES

Answer 35

•LAPAROSCOPIC UTERINE MYOLYSIS
•COAGULATION OF UTERINE VESSELS
•BILATERAL UTERINE ARTERY LIGATION

Question 36

LAPAROSCOPIC UTERINE MYOLYSIS

Answer 36

•A laser fibre or more commonly an electrical device is placed into the fibroid through a laparoscope
•This is used to coagulate the myoma or the blood vessels feeding it
•The dead tissue is then gradually replaced by scar tissue
•Initial weakening of the myometrium and the formation of dense fibrous adhesions which might predispose to uterine rupture

Question 37

COAGULATION OF UTERINE VESSELS

Answer 37

•To treat symptomatic myoma

Question 38

BILATERAL UTERINE ARTERY LIGATION

Answer 38

•Low technology alternative to UAE
•Has a transvaginal approach
•Cheap
•The preliminary report suggests that it is effective in reduction of size and symptoms.