Transcript الشريحة 1

( also called uterine Leiomyoma,
Myoma, Myomata uteri, fibromyoma).
objective
* There is many benign lesion of the uterus the most
important is fibriod
 *In spit that fibriod is benign tumor it cause many
structural and functional disturbance in reproductive life of
women's.

 *50% asymptomatic and the other group has one or


more
of important symptoms.
*Secondary changes in fibroids makes the tumor more
difficult in diagnosis and management .
*There is different ways in treatment the most curative
is
myomectomy which is bloody surgery needs preparation
and a
written consent for hysterectomy.
. Definition:
Circumscribed , benign tumor composed of muscle with
fibrous connective tissue elements.
. most common masses of uterine origin.
. may occur singly but usually multiple ( as many as 100
or more have been found in a single uterus).
. in 20 - 40% of women of reproductive age.
. more often found in nulliparous women or in women who
have not been pregnant for sometime.
. 3 - 9 times more common in blacks.
.may be found in organs outside uterus such as fallopian
tube, vagina, round ligament, uterosacral lig.,
vulva, and GIT
A etiology: localized proliferation of smooth
ms.Cells and there is gradual addition of fibrous
material .
. fibroids arise from immature ms. Cells & cell
nests. Contraction of uterine muscles  points
of
stress within the myometrium  act as
growth
stimuli to immature muscle cells  fibroids.
. dependent on estrogen for growth :
increase in pregnancy.
Rarely found before puberty, and stop growing after
menopause.
New myomas rarely appear after menopause
Types of myomas:
1.Intramural myoma
( interstitial ) :
most common,
pseudo
encapsulated ,
isolated nodules
of varying sizes,
occurring within
the wall of the
uterus.
2.Sub mucous myoma : beneath the
endometrium, grow into the uterine
cavity, maintaining attachment to the
uterus by a pedicle, may associated
with disturbed bleeding pattern
:
3.Sub serous myoma :
beneath the serosa,
usually asymptomatic
, grow out toward the
peritoneal cavity, may
reach a large size ,
and also may develop
a pedicle (
pedunculated ), it may
be mobile and may
attach to the
surrounding
structures.
Symptoms:
1.Abnormal menstrual bleeding : most common symptoms,
it's typically Menorrhagia.
2.Pain : acute pain associated with either torsion of a
pedunculated myoma or infarction of myoma.
3.Pressure : as myomas enlarge , they may cause a feeling
of pelvic heaviness or produce pressure symptoms on
the surrounding structures:
a. Urinary frequency : a common symptoms.
b.Urinary retention : when myoma creates a fixed
retroverted uterus.
c.May cause unilateral urethral obstruction and
hydronephrosis.
d.Constipation and difficult defecation : by large posterior
myoma.
4.Reproductive disorders :
a. infertility.
b.Increase incidence of abortion and premature labour.
•Signs :
1.Abdominal examination: may be
palpated as irregular, nodular tumours
protruding against the ant. Abdo. Wall,
usually firm upon palpation. Softness
and tenderness suggest the presence
of edema, sarcoma, pregnancy, or
degenerative changes.
2.Pelvic examination: the most common
finding is uterine enlargement. The
shape of the uterus is usually irregular
in outline.
Secondary changes in Fibroids
1.Atrophy.
2.Necrosis.
3.Degeneration (Hyaline degeneration,
Cystic degeneration, Fatty degeneration,
Calcification, Red degeneration or
necrobiosis).
4.Infection.
5.Vascular changes.
6.Malignancy (Sarcoma).
Differential diagnosis:
1.Dysfunctional uterine bleeding: irregular
bleeding with slight enlargement of the uterus.
2.Adenomyoma: heavy menstrual bleeding
accompanied by pain.
3.Ovarian tumours: rate of growth is rapid, u.s.
4.Inflammatory swellings: 2ry dysmenorrhea,
tenderness, uterus not enlarged.
5.Abdominal & pelvic carcinomas: laparatomy is
often justified.
6.Cervical & endometrial carcinomas: cytological
exam. And biopsy.
7.Pregnancy : amenorrhea, soft elastic uterus
enlargement. U.S., immunological tests for
preg
Malignancy :
Rare , about 1 - 3 / 1000, may be increased if:
Age >40 yrs, solitary fundal myoma , rapid
increase of size.
Treatment:
. if the tumour is not excessively large,
and there
are no symptoms, treatment may
not be necessary
1.Observation: in absence of pain ,
abnormal bleeding, pressure symptoms,
or large myomas, periodic examinations
are sufficient management especially if
the patient is nearing menopause ( the
myoma will atrophy as estrogen level
falls ).
a. Bimanual examination every 3-6 months.
b.Palpation of uterosacral lig. for evidence
of endometriosis ( often coexists with
fibroids ).
c.Regular blood counts, and oral iron may
be required.
d.Pelvic u.s.
◦
2.Gonadotropin - releasing hormone ( GnRH
) agonists:
Long acting GnRH agonists  suppress
gonadotropin secretion 
pseudomenopause, 55% reduction in
the size of the myomas, the myomas
usually regrow after the GnRh therapy is
discontinued. Gnrh therapy may cause
osteoporosis in prolonged therapy.
3.Surgery:
* Indications:
I. bleeding , usually with sub mucous or
intramural myomas.
II.Pain.
III.When the size of the uterus exceeds
that of a 12 week gestation.
IV.Sign & symptoms of pressure on the
bladder , bowel, or GIT.
* Surgical procedures:
a.Myomectomy: removal of single or
multiple myomas while preserving the
uterus. usually reserved for women who
desire pregnancy. 30% recurrence rate
within 10 years, higher in blacks. the
incidence of becoming pregnant is 40%
after myomectomy.preoperative GnRH
agonist can reduce size of myoma up to
55%. Pelvic pain , menorrhagia,
infection, and adhesion formation may
occur after myomectomy.
b.Hysterectomy : if the indications for
surgery are present & if the patient's
childbearing is complete , total removal
of the uterus is the procedure of the
choice.
With hysterectomy both leiomyoma and any
Associated disease are removed
permanently
And there is no risk of recurrence..
Ovaries should be retained in women less
than 40-50 years of age
Example: 25 years old woman with 4
children and symptomatic fibroid 
Hysterectomy.
*glandular proliferation with or without cytological
atypia.
*The aetiology may be attributed to the
unopposed secretion of estrogen by
progesterone.
*Unopposed estrogen is characteristic of chronic
anovulatory states such as polycystic ovary
disease; and estrogen-secreting tumours such as
granulosa-theca cell tumour.
*The risk of progression to endometrial carcinoma
is
1 - 14% in untreated cases, it is
greatest in postmenopausal women and in
women with atypical adenomatous hyperplasia.
Types:
1.Adenomatous hyperplasia:
The glands are hyperchromatic and
separated by strands of stroma, there is
no invasion or cytologic atypia.
2.Atypical adenomatous hyperplasia:
It is concedered carcinoma-in-situ of the
endometrium.
The glands are with intense
hyperchromatism and nuclear atypia,
there is little intervening stroma but no
invasion
Treatment:
I. Teenagers:
. cyclic estrogen with progestin for 6
months, and endometrial sampling
should be done regularly.
.if the patient continues to be anovulatory
after medical treatment, oral estrogen
and progestin or cyclic
medroxyprogesterone acetate ( 10mg
for 10 days every other month) should
be continued to induce stabilization of
the endometrium and to control
withdrawal bleeding
ii.Women of childbearing:
. 3 courses of cyclic estrogen with
progestin followed by a repeat of
endometrial sampling.
. if the pregnancy is desired ,
ovulation can be induced with
clomiphene citrate.
. If the pregnancy is not desired,
cyclic estrogen with progestin or cyclic
medroxyprogesterone acetate.
iii.Perimenopausal and postmenopausal
women:
3-6 months of cyclic medroxyprogesterone
acetate ( 10-20mg for 10-12 days every
month) or a depot of
medroxyprogesterone acetate ( 200mg
I.M. every 2 months for three courses),
repeat sampling at 3-6 months is
mandatory.
Hysterectomy: especially in persistent
hyperplasia following treatment with
progestational agents or in women with
severe atypical adenomatous
hyperplasia
Dr. Essam Abushwereb.
Consultant Gynae&obst.
Thank you