FIBROID UTERUS (LEIOMYOMA)

It is a benign tumor of uterine smooth muscle.

It is the most common tumor of uterus.

Incidence is 20% of women in reproductive age group.

Risk factors

·        Overweight women (increased Body Mass Index)

·        Advancing age

·        Hyperestrogenic states or Estrogen agonist use(     Enlarge in pregnancy and regress                                                                                           after Menopause)

·        Black women

·        Comorbid Hypertension

·        Family History of Uterine Fibroids

·        Nulliparity

Reduced risk in,

·        Five pregnancies or more

·        Menopause (fibroids typically regress)

·        Oral Contraceptive or Depo Provera use

·        Tobacco Abuse

Types of fibroid based on the location,  

·        subserous,

·        intramural

·        submucous fibroids.

·        Cervical fibroids

·        Broadligament fibroids

DIFFERENTIAL DIAGNOSIS

·        Adenomyosis

·        Bicornuate uterus

·        Ovarian tumor

·        Retroperitoneal connective tissue tumor

·        Calcified tuberous pyosalpinx

Complications:

·        Torsion of pedunculated subserous fibroid

·        Infection of submucous myoma

·        Malignant change in 0.2% of uterine fibroids

·        Degeneration (Hyaline/Cystic/Fatty/Red degeneration)

·        Pregnancy complications like spontaneous abortion, preterm delivery, abruption-                                                                                   placentae

·        Labor complications: Inertia, Dystocia, PPH

 Symptoms

Most leiomyomas are asymptomatic and are diagnosed incidentally

1. Bleeding-heavy menstrual bleeding

2. Pressure symptoms-Pelvic discomfort or feeling of heaviness in pelvis

-Acute urinary retention

-Urgency or frequency of micturition

-Rarely dyspepsia or constipation

3. Pain

-Lower abdominal and pelvic pain: Not a common symptom but may occur in cases of fibroid polyp/ torsion of pedicle of subserous pedunculated fibroid/ degeneration of fibroid/ sarcomatous change in fibroid

4. Infertility

5. Pregnancy complications-Increase in size with red degeneration, abortions, preterm labor, malpresentations

6. Labor complications-Inertia, Dystocia, PPH

Signs

General examination-Pallor may be present in cases of anemia due to heavy menstrual bleeding.

Abdominal examination may reveal a firm, non-tender, rounded/lobulated mass with side to side mobility and which is dull to percuss.

Speculum exam- usually normal.  Submucosal fibroid polyp may be seen coming out of the cervix into the vagina.

Bimanual pelvic examination reveals an enlarged irregular firm uterus, but it may be symmetrically enlarged in cases of intramural and submucous fibroid. Subserous fibroid may be felt attached to the uterus or it may be felt as irregularity on one side or as an adnexal mass in case it is pedunculated or broad ligament fibroid.

Investigations

FBC

Ultrasonography- TVS              

Endometrial biopsy when diagnosis is in doubt

Treatment

Treatment modality should be individualized to each patient after considering patient’s age, severity of symptoms, need for fertility preservation, presence of other gynecological diseases and any other co-morbidity.

Small Leiomyomas discovered incidentally and not associated with any complications usually do not require any treatment.

Asymptomatic fibroid may warrant treatment in following situations:

·        The size of fibroid uterus is more than 12-14 weeks pregnant uterus

·        Rapidly growing fibroid

·        Evidence of hydroureter / hydronephrosis resulting because of compression of ureters                                                           by the tumor.

·        Subserous pedunculated fibroids are liable to undergo torsion of pedicle and hence may be treated even if asymptomatic.

General measures: Correction of anemia with hematinics (iron & folic acid). Severe anemics with ongoing blood loss may require packed cell transfusion. Reducing blood loss during periods.

Medical management(conservative):

When patient present with heavy menstrual bleeding with fibroids < 3cm in diameter following treatment can be attempted,

·        NSAIDS

·        Tranexamic acid

·        OCP

·        Progestogens

·        Antiprogesterone

·        Levonorgestrel releasing intrauterine system(mirena)

·        GnRH analogues

Surgical management

1.Myomectomy – removal of fibroid with preservation of uterus

                            Offered to patient whose family is not completed or if patient wish to preserve her uterus.

Trained staff can do myomectomy via laparascopy .

2.Hysterectomy – removal of uterus with fibroid.

3.Hysterescopic resection of fibroid – ideal for small submucosal fibroid.

4.Uterine artery embolization

5.MRI- guided focused ultrasound