RUFAIDA COLLEGE OF NURSING

SEMINAR ON
UTERINE FIBROIDS

SUBMITTED TO SUBMITTED BY
MS. SOMIBALA THOKCHOM MS. NARGIS KHATOON
ASSISTANT PROFESSOR M.Sc. NURSING 2nd YEAR
RCON RCON
JAMIA HAMDARD JAMIA HAMDARD
 IDENTIFICATION DATA

SUBJECT: Obstetrics and gynecology

NAME OF THE TOPIC: Uterine fibroids

NAME OF STUDENT TEACHER: Ms. Nargis Khatoon

NAME OF SUPERVISOR: Ms. Somibala Thokchom

GROUP: M.Sc. Nursing 2nd year

SIZE OF GROUP 5 students

METHODS OF TEACHING: lecture cum discussion method

DURATION: 1 hour

AV AIDS: PPT, Lesson Plan

DATE OF TEACHING:

TIME OF TEACHING

VENUE: Rufaida College of Nursing

PREVIOUS KNOWLEDGE: The group has some knowledge about Uterine fibroids

GENERAL OBJECTIVES: At the end of discussion the group will gain knowledge
about Uterine fibroids

.
TIME SPECIFIC CONTENT TEACHING EVALUATION
OBJECTIVES LEARNING
ACTIVITY

2min To introduce INTRODUCTION

the topic.
Uterine fibroid is
composed of smooth
muscle and fibrous
connective tissue, so
named as uterine
leiomyoma, myoma or
fibromyoma.
It has been estimated
that at least 20 % of
women at the age of 30
have got fibroid in
their wombs, mostly
remain asymptomatic
The incidence of
symptomatic fibroid in
hospital outpatient is
about 3 %, 10 %
prevails in England. In
colored races (black
women), the incidence
is even higher, more
common in nulliparous
or in those having one
child infertility,
highest prevalence
between 35-45 years.

2min At the end of ANNOUNCEMENT

the session
the group Myself Nargis
will be able Khatoon student of
to: M.Sc. nursing 2nd year
presenting my seminar
on uterine fibroid.

2min To define DEFINITION Student teacher will Define uterine

uterine define uterine fibroid fibroid.
Uterine fibroids are noncancerous growths of
the uterus that often appear during childbearing by lecture cum
 fibroid. years also called leiomyomas or myomas, aren't discussion method.
associated with an increased risk of uterine
cancer.

These are benign smooth muscle tumors that

occurs within the uterus and is the most
common tumor of the female genital tract.

Fibroids range in size from seedlings,

undetectable by the human eye, to bulky masses
that can distort and enlarge the uterus, single
fibroid or multiple ones. Uterine fibroids often
cause no symptoms and can be incidentally
detected during a pelvic exam or prenatal
ultrasound.

2min To discuss HISTOGENESIS Student teacher will Discuss

histogenesis discuss histogenesis of histogenesis of
of uterine Origin uterine fibroid by uterine fibroid.
fibroid. lecture cum discussion
The aetiology still remains unclear. The
prevailing hypothesis is that, it arises from the method.
neoplastic single smooth muscle cell of the
myometrium. The stimulus for initial neoplastic
transformation is not known. The following are
implicated:

Chromosomal abnormality - In about 40 per

cent of cases there is a varying type of
chromosomal abnormality particularly the
 chromosome six or seven (rearrangements,
deletions). Abnormal cellular proliferation may
be due to this genetic potential.

Role of polypeptide growth factors -

Epidermal growth factor (EGF), insulin-like
growth factor-1 (IGF-1), transforming growth
factor (TGF), stimulate the growth of
leiomyoma either directly or via oestrogen. A
positive family history is often present.

Growth
It is predominantly an oestrogen-dependent
tumour. Oestrogen and progesterone is
incriminated as the cause. Oestrogen
dependency is evidenced by: -

▪ Growth potentiality is limited during

child bearing period.
▪ Increased growth during pregnancy.
▪ They do not occur before menarche.
▪ Following menopause, there is cessation
of growth and there is no new growth at
all.
▪ It seems to contain more oestrogen
receptors than the adjacent
myometrium.
▪ Frequent association of anovulation.

The growth potentiality is not squarely

distributed amongst the fibroids which are
usually multiple, some grow faster than the
others. On the whole, the rate of growth is slow
and it takes about 35 years for the fibroid to
grow sufficiently to be felt per abdomen (c.f. -
ovarian tumour grows in months).
However, the fibroid grows rapidly during
pregnancy or amongst pill users (high dose
pills). Rapid growth may also be due to
degeneration or due to malignant change.

The newer low dose oral contraceptives are not

associated with increase in the growth of a
fibroid.

2min To enlist risk RISK FACTORS Student teacher will enlist risk
 factors of enlist risk factors of factors of
uterine Increased risk uterine fibroid by uterine fibroid.
fibroid. lecture cum discussion
▪ Age 35- 45 years
method.
▪ Nulliparity
▪ Obesity
▪ Early menarche
▪ Hyperoestrogenic state
▪ Black women
▪ Family H/O DM, HTN

Reduced risk

▪ Multiparity
▪ Smoking

2min To discuss TYPES Student teacher will discuss the

the types of discuss the types of types of uterine
uterine A. BODY: uterine fibroid by fibroid.
The fibroids are mostly located in the body of
fibroid. lecture cum discussion
the uterus and are usually multiple
method.
Interstitial or intramural (75%)
Initially, the fibroids are intramural in position
but subsequently, some are pushed outwards or
inwards. Eventually, in about 70 per cent they
persist in that position.

Subperitoneal or subserous (15%)

In this condition, the intramural fibroid is
pushed outwards towards the peritoneal cavity.
The fibroids are either partially or completely
covered by peritoneum. When completely
covered by peritoneum, it usually attains a
pedicle -called pedunculated subserous fibroid.
On rare occasion, the pedicle may be torn
through; the fibroid gets its nourishment from
the omental or mesenteric adhesions and is
called 'wandering' or 'parasitic' fibroid.
Sometimes, the intramural fibroid may be
pushed out in between the layers of broad
ligament and is called broad
Ligament fibroid (false or pseudo)

Submucous (5%)
 The intramural fibroid when pushed towards the
uterine cavity, and is lying underneath the
endometrium, it is called submucous fibroid.
Submucous fibroid can make the uterine cavity
irregular and distorted. Pedunculated
submucous fibroid may come out through the
cervix. It may be infected or ulcerated to cause
metrorrhagia. Although, this variety is least
common (about 5%) but it produces maximum
symptoms

B. CERVICAL
Cervical fibroid is rare (1-2 %). In the
supravaginal part of the cervix it may be
interstitial or sub peritoneal variety and rarely
polypoidal. Depending upon the position, it
may be anterior, posterior, lateral or central.
Interstitial growths may displace the cervix or
expand it so much that the external os is difficult
to recognize. All these disturb the pelvic
anatomy, especially the ureter.
In the vaginal cervix, the fibroid is usually
pedunculated and rarely sessile.

Pseudocervical fibroid: A fibroid polyp arising

from the uterine body when occupies and
distends the cervical canal, it is called
pseudocervical. fibroid.

2min To explain PATHOLOGY Student teacher will explain

pathology of explain pathology of pathology of
uterine Naked eye appearance: uterine fibroid by uterine fibroid.
fibroid. lecture cum discussion
The uterus is enlarged; the shape is distorted by
multiple nodular growth of varying sizes. method.
Occasionally, there may be uniform
enlargement of the uterus by a single fibroid.
The feel is firm.

Cut surface of the tumour is smooth and whitish

The cut section, in the absence of degenerative
changes, shows features of whorled appearance
and trabeculation. These are due to the
intermingling of fibrous tissues with the muscle
bundles.
 The false capsule is formed by the compressed
adjacent myometrium. They have more parallel
arrangement and are pinkish in colour in
contrast to whitish appearance of the tumour.
The capsule is separated from the growth by a
thin loose areolar tissue. The blood vessels run
supply the tumour. It is through this plane that
the through this plane to tumour is shelled out
during myomectomy operation. The periphery
of the tumour is more vascular and have more
growth potentiality. centre of the tumour is least
vascular and likely to degenerate. It is due to
contraction of the false capsule that makes the
cut surface of the tumour to bulge out.

Microscopic appearance:

The tumour consists of smooth muscles and

fibrous connective tissues of varying
proportion. Originally, it consists of only
muscle element but later on, fibrous tissues
intermingle with the muscle bundles. As such,
the nomenclature of 'fibroids' although
commonly used, is inappropriate and should
better be called either 'myomata' or
fibromyomata

2min To discuss SECONDARY CHANGES IN FIBROIDS Student teacher will discuss

secondary discuss secondary secondary
changes in DEGENERATIONS changes in uterine changes in
uterine fibroid by lecture cum uterine fibroid.
▪ Hyaline degeneration
fibroid. discussion method.
It is the most common (65%) type of
degeneration affecting all sizes of fibroids
except the tiny one. It is common specially in
tu- mours having more connective tissues. The
central part of the tumour which is least
vascular is the common site. The feel becomes
soft elastic in contrast to firm feel of the tumour.
Naked eye examination on the cut surface
shows irregular homogenous areas with loss of
whorl-like appearance.
Microscopic examination reveals hyaline
changes of both the muscles and fibrous tissues.
 ▪ Cystic degeneration

It usually occurs following menopause and is

common in interstitial fibroids. It is formed by
liquefaction of the areas with hyaline changes.
The cystic spaces are lined by irregular tagged
walls. The cystic changes of an isolated big
fibroid may be confused with an ovarian cyst or
pregnancy.

▪ Fatty degeneration
It is usually found at or after menopause. Fat
globules are deposited mainly in the muscle
cells.

▪ Calcific degeneration (10%)

It usually involves the subserous fibroids with
small pedicle or myomas of postmenopausal
women. It is usually preceded by fatty
degeneration. There is precipitation of calcium
carbonate or phosphate within the tumour.
When whole of the tumour is converted into a
calcified mass, it is called "womb stone".

▪ Red degeneration (carneous

degeneration )
It occurs in a large fibroid mainly during second
half of pregnancy and puerperium. Partial
recovery is possible and as such called
necrobiosis. The cause is not known but is
probably vascular in origin. Infection does not
play any part.

Naked eye appearance of the tumour shows

dark areas with cut section revealing raw-beef
appearance often containing cystic spaces. The
odour is often fishy due to fatty acids. Colour is
due to the presence of haemolysed red cells and
haemoglobin.

Microscopically, evidences of necrosis are

present. Vessels are thrombosed but
extravasation of blood is unlikely.
 a. Atrophy: Atrophic changes occur
following menopause due to loss of
support from oestrogen. There is
reduction in the size of the tumour.
Similar reduction also occurs following
pregnancy enlargement.

b. Necrosis: Circulatory inadequacy may

lead to central necrosis of the tumour.
This is present in sub- mucous polyp or
pedunculated subserous fibroid.

c. Infection: The infection gains access to

the tumour core through the thinned and
sloughed surface epithelium of the
submucous fibroid. This usually
happens following delivery or abortion.
Intramural fibroid may also be infected
following delivery.

d. Vascular changes: Dilatation of the

vessels (telangiectasis) or dilatation of
the lymphatic channels
(lymphangiectasis) inside the myoma
may occur. The cause is not known.

e. Sarcomatous changes: Sarcomatous

change may occur in less than 0.1%
cases. The usual type is
leiomyosarcoma. Recurrence of fibroid
polyp, sudden enlargement of fibroid or
fibroid along with postmenopausal
bleeding raises the suspicion.

2min To discuss ASSOCIATED CHANGES IN THE Student teacher will discuss

associated PELVIC ORGANS discuss associated associated
changes in changes in pelvic changes in
Uterus: The shape is distorted; usually pelvic organs.
pelvic organs by lecture cum
asymmetrical but at times, uniform.
organs. Myohyperplasia is almost a constant finding. It discussion method.
may be due to hyperoestrinism or work
hypertrophy in an attempt to expel the fibroid.

The endometrium may be of normal type. In

others, there are features of anovulation with
 evidences of hyperplasia. There is dilatation and
congestion of the myometrial and endometrial
venous plexuses. The endometrium as a result
be- comes thick, congested and oedematous.
The endometrium overlying the submucous
fibroid may be thin and necrotic with evidences
of infection.

The uterine cavity may be elongated and distor-

ted in intramural and submucous varieties.

Uterine tubes: The frequent tubal infection

(about 15%) detected in association with fibroid
seems coincidental.

Ovaries: The ovaries may be enlarged,

congested and studded with multiple cysts. The
cause may be due to hyperoestrinism.

Ureter: There may be displacement of the

anatomy of the ureter in broad ligament fibroid.
The compression effect results in hydroureter
and or hydronephrosis.

Endometriosis: There is increased association

of pelvic endometriosis and adenomyosis
(30%).

Endometrial carcinoma: The incidence

remains unaffected.

2min To enlist COMPLICATIONS OF FIBROIDS Student teacher will enlist

complication enlist complications of complications
s of uterine A. Effect of fibroid on pregnancy: uterine fibroid by of uterine
fibroid. lecture cum discussion fibroid.
a. Pregnancy
▪ Abortion method.
▪ Pressure symptoms
▪ Malpresentation
▪ Retro- displacement of uterus
▪ Non engagement of presenting part

b. Labor
▪ Malpresentation
▪ Uterine inertia
▪ Premature labor
 ▪ Dystocia
▪ PPH
▪ Manual removal of placenta if adherent
on fibroid

c. Puerperium
▪ Subinvolution
▪ Secondary PPH
▪ Puerperial sepsis
▪ Inversion of uterus with fundal
submucous fibroid

B. EFFECT OF PREGNANCY AND

LABOUR ON FIBROID
As the fibroid is estrogen dependent tumor,
during pregnancy there is increased secretion of
estrogen which leads to increased size of
fibroid.

Complications of fibroids are:

▪ Degenerations
▪ Necrosis
▪ Infection
▪ Sarcomatous change
▪ Torsion of subserous pedunculated
fibroid
▪ Haemorrhage –
(Intracapsular, Rupture surface vein of
subserous fibroid, intraperitoneal)
▪ Polycythemia due to
Erythropoietic function by the tumour,
▪ Altered erythropoietic function of the
kidney through ureteric pressure

LIFE-THREATENING COMPLICATIONS
OF FIBROIDS

▪ Persistent menorrhagia, metrorrhagia or

continued vaginal bleeding leads to
severe anemia.
▪ Severe intraperitoneal haemorrhage due
to rupture of veins over subserous
fibroid.
▪ Severe infection leading to peritonitis or
septicaemia.
▪ Sarcoma.
2min To discuss CLINICAL FEATURES Student teacher will discuss clinical
clinical discuss clinical features of
features of SYMPTOMS OF FIBROID UTERUS features of uterine uterine fibroid.
uterine fibroid by lecture cum
▪ Asymptomatic - majority (75%)
fibroid. ▪ Menstrual abnormality: Menorrhagia, discussion method.
metrorrhagia.
▪ Dysmenorrhoea
▪ Dyspareunia
▪ Infertility
▪ Pressure symptoms
▪ Recurrent pregnancy loss (miscarriage,
preterm labour)
▪ Lower abdominal or pelvic pain
▪ Abdominal enlargement.

a. Patient profile

The patients are usually nulliparous or having

long period of secondary infertility. However,
early marriage and frequent childbirth make its
frequency high even amongst the multiparous
women. The incidence is at its peak between 35-
45 years. There is a tendency of delayed
menopause.

Symptoms: The majority of fibroids remain

asymptomatic (75%). They are accidentally
discovered by the physician during routine
examination or at laparotomy or laparoscopy.

The symptoms are related to anatomic type and

size of the tumour. The site is more important
than the size. A small submucous fibroid may
produce more symptoms than a big subserous
fibroid.

MENSTRUAL ABNORMALITIES

(a) Menorrhagia (30%) is the classic

symptom of symptomatic fibroid.
The menstrual loss is progressively increased
with successive cycles. It is conspicuous in sub-
mucous or interstitial fibroids. The causes are:
 ▪ Increased surface area of the
endometrium (Normal is about 15 sq
cm).
▪ Interference with normal uterine
contractility due to interposition of
fibroid.
▪ Congestion and dilatation of the
subjacent endometrial venous plexuses
caused by the obstruction of the tumour.
▪ Endometrial hyperplasia due to
hyperoestrinism (anovulation). Pelvic
congestion.
▪ Role of prostanoids - imbalance of
throm- boxane (TXA2) and prostacyclin
(PGI2) with relative deficiency of
TXA2.

b) Metrorrhagia or irregular bleeding may be

due to:
▪ Ulceration of submucous fibroid or
fibroid polyp
▪ Torn vessels from the sloughing base of
a polyp
▪ Associated endometrial carcinoma.

c) Dysmenorrhoea: The congestive variety

may be due to associated pelvic congestion or
endometriosis. Spasmodic type is associated
with extrusion of polyp and its expulsion from
the uterine cavity. Subserous, broad ligament or
cervical fibroids are usually unassociated with
menstrual abnormalities.

d) Infertility: Infertility (30%) may be a major

complaint. The probable known attributing
factors are:

Uterine

▪ Distortion and or elongation of the

uterine cavity → difficult sperm ascent.
▪ Preventing rhythmic uterine contraction
due to fibroids during intercourse →
impaired sperm transport.
 ▪ Congestion and dilatation of the
endometrial venous plexuses→
defective nidation.
▪ Atrophy and ulceration of the
endometrium over the submucous
fibroids → defective nidation.
▪ Menorrhagia and dyspareunia.

Tubal

▪ Cornual block due to position of the

fibroid.
▪ Marked elongation of the tube over a big
fibroid.
▪ Associated salpingitis with tubal block.

Ovarian: Anovulation

Peritoneal: Endometriosis

Unknown: (majority)

Pregnancy related problems like abortion,

preterm labour and intrauterine growth
restriction are high. The reasons are defective
implantation of the placenta, poorly developed
endometrium, reduced space for the growing
fetus and placenta. Red degeneration and
torsion of subserous pedun- culated fibroid is
common in pregnancy. Post- partum
haemorrhage is also more.

Pain lower abdomen

The fibroids are usually painless. Pain may be

due to some complications of the tumour or due
to associated pelvic pathology.

a. Due to tumour
▪ Degeneration
▪ Torsion subserous pedunculated fibroid
▪ Extrusion of polyp.

b. Associated pathology
▪ Endometriosis
▪ PID.
Abdominal swellings (lump)

The patient may have a sense of heaviness in

lower. abdomen. She may feel a lump in the
lower abdo- men even without any other
symptom.

Pressure symptoms

Pressure symptoms are rare in body fibroids.

The fibroids in the posterior wall may be
impacted in the pelvis producing constipation,
dysuria or even retention of urine. A broad
ligament fibroid may produce ureteric
compression → hydroureteric and
hydronephrotic changes infection → pyelitis.

Signs

General examination reveals varying degrees of

pallor depending upon the magnitude and
duration of menstrual loss.

Abdominal examination

The tumour may not be sufficiently enlarged to

be felt per abdomen. But if enlarged to 14 weeks
or more, the following features are noted.

Palpation

▪ Feel is firm, more towards hard; may be

cystic in cystic degeneration.
▪ Margins are well-defined except the
lower pole which cannot be reached
suggestive of pelvic in origin.
▪ Surface is nodular; may be uniformly
enlarged in a single fibroid.
▪ Mobility is restricted from above
downwards but can be moved from side
to side.

Percussion: The swelling is dull on percussion.

 Pelvic examination: Bimanual examination
reveals the uterus irregularly enlarged by the
swelling felt per abdomen. That the swelling is
uterine is evidenced by:

▪ Uterus is not felt separated from the

swelling and as such a groove is not felt
between the uterus and the mass.
▪ The cervix moves with the movement of
the tumour felt per abdomen.

The only exception of these two findings is a

subserous pedunculated fibroid. As such, such
type is too often confused with an ovarian
tumour. However, a submucous fibroid may
produce symmetrical enlargement of the uterus
and at times, it is difficult to diagnose
accurately.

2min To discuss CAUSES OF SYMMETRICAL Student teacher will discuss causes

causes of ENLARGEMENT OF UTERUS discuss causes of of symmetrical
symmetrical symmetrical enlargement of
▪ Pregnancy
enlargement enlargement of uterus uterus.
▪ Submucous or intramural (solitary
of uterus. fibroid by lecture cum
▪ Lochiometra discussion method.
▪ Malignancy
- Carcinoma body
- Choriocarcinoma
- Sarcoma

▪ Adenomyosis
▪ Myohyperplasia
▪ Pyometra

2min To explain INVESTIGATIONS Student teacher will explain

investigation explain investigations investigations
s of uterine The investigations aim at: of uterine fibroid by of uterine
fibroid. lecture cum discussion fibroid.
▪ To confirm the diagnosis
▪ Preoperative assessment. method.

To confirm the diagnosis

Although, the majority of uterine fibroids can
be diagnosed from the history and pelvic
examination but at times pose problems in
diagnosis.

Ultrasound and Colour Doppler (TVS)

findings are:
(i) Uterine contour is enlarged and distorted. (ii)
Depending on the amount of connective tissue
or smooth muscle proliferation, fibroids are of
different echogenicity-hypoechoic or
hyperechoic.
(iii) Vascularization is at the periphery of the
fibroid.
(iv) Central vascularization indicates
degenerative changes

Ultrasound is an useful diagnostic tool to

confirm the diagnosis of fibroid and to
differentiate it from ovarian mass or pregnancy.
However, in pedunculated subserous fibroid,
ultrasound cannot differentiate it from solid
ovarian tumour specially when the ovaries are
not visualised.
Transvaginal ultrasound can accurately assess
the myoma location, dimensions and also any
adnexal pathology. Hydroureter or
rhydronephrotic changes can be diagnosed.

3-Dimensional ultrasonography can locate

fibroids accurately. Serial ultrasound
examination is needed during medical or
conservative management.

Saline Infusion Sonography (SIS) is helpful to

detect any submucous fibroid or polyp.

Magnetic resonance imaging (MRI) — is

more - accurate compared to ultrasound (p.
625). It helps to differentiate adenomyosis from
fibroids. MRI is not used routinely for the
diagnosis. It is expensive and not widely
available.

Laparoscopy -Laparoscopy is helpful, if the

uterine size is less than 12 weeks and associated
 with pebric pain and infertility. Associated
pelvic endo- metriosis and tubal pathology can
be revealed. It can also differentiate a
pedunculated fibroid from ovarian tumour not
revealed by clinical examination and
ultrasound.

Hysteroscopy or HSG- The methods are of

help to detect submucous fibroid in unexplained
infertility and repeated pregnancy wastage
where myomectomy is contemplated. The
presence and site of submucous fibroid can be
diagnosed by direct visualization during
hysteroscopy or indirectly as a filling defect on
hysterosalpingography.

Uterine curettage- In the presence of irregular

bleeding, to detect any co-existing pathology
and to study the endometrial pattern, curettage
is helpful. It additionally helps to diagnose a
submucous fibroid by feeling a bump. However,
hysteroscopy and biopsy is a better alternative.

Preoperative assessment: Apart from routine

preoperative investigations, intravenous
pyelogra- phy to note the anatomic changes of
the ureter may be helpful.

Differential diagnosis: The fibroid of varying

sizes may be confused with:
(1) Pregnancy
(2) Full bladder
(3) Adenomyosis
(4) Myohyperplasia
(5) Ovarian tumour
(6) TO mass.

2min To discuss MANAGEMENT OF FIBROID UTERUS Student teacher will discuss

management discuss management of management of
of uterine a). Symptomatic fibroids uterine fibroid by uterine fibroid.
fibroid. lecture cum discussion
MEDICAL MANAGEMENT
method.
Drug therapy has established a firm place in the
management of symptomatic fibroids. The
drugs are used either as a temporary palliation
or may be used in rare cases, as an alternative to
surgery.
Prior to drug therapy, one must be certain about
the diagnosis. The objectives of medical
treatment are:

▪ To improve menorrhagia and to correct

anemia before surgery.
▪ To minimise the size and vascularity of
the tumour in order to facilitate surgery.
▪ In selected cases of infertility to
facilitate hysteroscopic or laparoscopic
surgery.
▪ As an alternative to surgery in
perimenopausal women or women with
high-risk factors for surgery.
▪ Where postponement of surgery is
planned temporarily.

DRUGS USED TO MINIMIZE BLOOD

LOSS

As a temporary palliation, various drugs are

used to minimize blood loss and to correct
anemia when a definite surgery cannot be
undertaken for certain periods.

▪ Antifibrinolytics
▪ Antiprogesterones
▪ Danazol
▪ GnRH analogues: Agonists, Antagonist
▪ Prostaglandin synthetase inhibitors
▪ Iron and vitamins
▪ NSAIDs
▪ Hormonal methods

Antiprogesterones - Mifepristone has been

found to be very effective in the treatment of
menorrhagia. It reduces the size of the fibroid
significantly. A daily dose of 25-30 mg is
recommended for 3 months. Long-term therapy
is avoided as it causes endometrial hyperplasia.

Danazol can reduce the volume of a fibroid

slightly. Because of androgenic side effects,
danazol is used only for a period of 3-6 months.
Danazol administered daily in divided doses
ranging from 200-400 mg for 3 months
minimizes blood loss or even produce
amenorrhea by its Antigonadotropin and
androgen agonist actions.

GnRH agonists: Drugs commonly used are

goserelin, luporelin, buserelin or nafarelin.
Mechanism of action is sustained pituitary
down regulation and suppression of ovarian
function. There is initial transient pituitary
stimulation.

GnRH antagonists- Cetrorelix or gani- relix

causes immediate suppression of pituitary and
the ovaries. They do not have the initial
stimulatory effect. Benefits are same as that of
agonists. Onset of amenorrhea is rapid.

BENEFITS OF GnRH ANALOGUE

THERAPY
▪ Improvement of menorrhagia and may
produce Amenorrhoea.
▪ Improvement of anemia.
▪ relief of pressure symptoms.
▪ Reduction in size (50%) when used for
a period 6 months.
▪ Reduction in vascularity of the tumour.
▪ Reduction in blood loss during
myomectomy
▪ May facilitate laparoscopic or
hysteroscopic surgery.

Antifibrinolytics have been found to reduce the

amount of blood loss significantly. Tranexamic
acid, 2-4 gm orally daily is useful for fibroid
related menorrhagia.

Prostaglandin synthetase inhibitors-These

are used to relieve pain due to associated
endometriosis or degeneration of the fibroid.
They cannot improve menorrhagia due to
fibroids.
Levonorgestrel- releasing Intrauterine
System LNG-IUS) reduces blood loss and
uterine size. However, this is not recommended
when the uterine size is >12 weeks or there is
distortion of uterine cavity.

Nonsteroidal anti-inflammatory drugs

(NSAIDs) — NSAIDs, such as ibuprofen and
naproxen can help reduce menstrual cramps and
decrease menstrual flow in some cases.

Hormonal method — Hormonal methods of

birth control include the pill, skin patch, vaginal
ring, DMPA, hormonal IUD, and implant.
These methods reduce bleeding, cramps, and
pain during your menstrual period and can
correct anemia. It might take three months for
bleeding to improve after you start taking
hormonal birth control.

Preoperative therapy: It is indeed

advantageous to reduce the size and vascularity
of fibroid prior to either myomectomy or
hysterectomy. While operation will be
technically easier in broad ligament or cervical
fibroid, in myomectomy, there may be little
difficulty in enucleation of the tumour from its
pseudocapsule. However, with the stoppage of
the therapy, the tumour will attain its previous
size slowly. Benefits are achieved when therapy
is given for a period of three months.

SURGICAL MANAGEMENT OF FIBROID

UTERUS

Indications of emergency surgery in a fibroid

▪ Torsion of subserous pedunculated
fibroid.
▪ Massive intraperitoneal haemorrhage
following rupture of veins over
subserous fibroid.
▪ Uncontrolled infected fibroid.
▪ Uncontrolled bleeding fibroid.

A. MYOMECTOMY
Myomectomy is the enucleation of myomata
from the uterus leaving behind a potentially
functioning uterus, tubes and ovaries capable of
future reproduction and also to avoid the future
hazards

▪ Mainly to preserve the reproductive

function and menstrual function in
parous women.
▪ more risky operation when the fibroid(s)
is too big and too many.
▪ Risk of recurrence and persistence of
fibroid is about 30-50%.
▪ Risk of persistence of menorrhagia is
about 1-5%.
▪ Risk of relaparotomy is about 20-25%.
▪ Pregnancy rate following myomectomy
is about 40-60%..
▪ Pregnancy following myomectomy
should have a mandatory hospital
delivery, although the chance of scar
rupture is rare (little more when the
cavity is open).

INDICATIONS OF MYOMECTOMY

▪ Persistent uterine bleeding despite

medical therapy.
▪ Excessive pain or pressure symptoms.
▪ Size >12 weeks, woman desirous to
have a baby.
▪ Unexplained infertility with distortion
of the uterine cavity.
▪ Recurrent pregnancy wastage due to
fibroid.
▪ Rapidly growing myoma during follow
up.
▪ Subserous pedunculated fibroid.

CONTRAINDICATIONS

▪ Infected fibroid.
▪ Growth of myoma after menopause.
▪ Suspected malignant change (sarcoma).
▪ Parous women where hysterectomy is
safer and is a definitive treatment.
 ▪ Function less fallopian tubes (bilateral
hydro- salpinx, tubo-ovarian mass) -
decision must be judicious with the
advent of microsurgery and ART.
▪ Pelvic or Endometrial tuberculosis.
▪ During pregnancy or during caesarean
section.

Myomectomy may be done by Laparotomy,

Laparoscopy, and Hysteroscopy

Vaginal myomectomy: Submucous

pedunculated myoma can be removed
vaginally.
▪ Morcellation (removal by piecemeal) is
needed if the tumour is large.
▪ A moderate size fibroid can be removed
by twisting.

Endoscopic surgery:

▪ Hysteroscopy:
Generally a fibroid of 3-4 cm diameter or a
polyp is resected with a hysteroscope Pedicle or
the base of the fibroid is coagulated using
electrocautery Nd: YAG laser can als be used.

Complications of hysteroscopic surgery are

uterine perforation, fluid overload,
haemorrhage and others.

▪ Laparoscopy:
Subserous and intramural fibroids could be
removed laparoscopically. Electrocautery laser
and extra corporeal sutures are used for
haemostasis.
Laparoscopic surgery is not suitable when the
fibroid is large, deep intramural, multiple or
technically inaccessible. Leiomyomas can be
desiccated (myolysis) using laser or bipolar
diathermy.

B. EMBOLOTHERAPY:

Embolization of uterine arteries s avascular

necrosis followed by shrinkage of fibroid.
Uterine arteries are occluded by injecting
causes polyvinyl alcohol particles through
percutaneous moral catheterization. This may
be an option to n with symptomatic fibroid
where surgery is women sot preferred.

Result: Improvement of menorrhagia is

observed in 80-90 per cent with 60 per cent
reduction in size.
Contraindications: Active pelvic infection,
desire for future pregnancy, drug allergy.

Levonorgestrel-Releasing IUS can be used

control menorrhagia where the uterine size is <
12 weeks and there is no distortion of the cavity.

High-Intensity Focussed Ultrasound has been

used currently for its thermal and cavitational
effects on tissues. It is a non-invasive
procedure. Initial reports had shown it safety
and efficacy.

Magnetic Resonance guided percutaneous

laser ablation is found effective. Laser is used
for thermal ablation of the fibroid..

C. HYSTERECTOMY

Hysterectomy in fact, is the operation of choice

in symptomatic fibroid. As such, in the absence
of indication of myomectomy, hysterectomy is
done. The patients over the age of 40 years and
in those not desirous of further child are the
classic indications.

Total hysterectomy is performed. However, a

subtotal hysterectomy may have to be done in
conditions such as:

▪ Sudden deterioration of the general

condition of the patient during operation
specially when the operation is done in
anemic state.
▪ Associated endometriosis specially
involving rectovaginal septum.
Removal of the ovary: It is preferable to remove
the ovaries in postmenopausal women and to
preserve the same in earlier gif they are found
healthy.

Advantages

▪ There is no chance of recurrence.

▪ Adnexal pathology and the unhealthy
cervix if any are also removed.

Place of vaginal hysterectomy

Fibroids with size of 10-12 weeks of pregnancy

associated with uterine prolapse are better dealt
by the vaginal route. Vaginal hysterectomy with
repair of pelvic floor is the operation of choice.
Pre- treatment with GnRH analogue may
facilitate vaginal hysterectomy.

b. ASYMPTOMATIC FIBROID (75%)

Fibroids detected accidentally on routine

examination for complaints other than fibroids
are dealt with as follows:
▪ Observation
▪ Surgery

Observation:

A certain diagnosis of fibroid should be a must

prior to contemplating expectant management.
The risk of sarcomatous changes is so
insignificant (0.1%) that prophylactic removal
of fibroid is unjustified in asymptomatic cases.

The judicious observations may be instituted in

cases:
▪ Size < 12 weeks (of pregnancy size).
▪ Diagnosis certain
▪ Follow up possible.

Periodic examination at interval of 6 months is

needed. If the symptoms of fibroid appear and
or it grows and increases in size, surgery is
indicated.
2 To SUMMARY
min summarize
In this seminar
the topic. we have
discussed about
introduction of
uterine fibroid,
definition,
histology, types,
pathology,
clinical features,
investigation,
complication,
management
(medical,
surgical),
summary,
conclusion and
bibliography.

2 To conclude CONCLUSION
min the topic.
Fibroid is the
most common
pelvic tumour.
The incidence of
symptomatic
fibroid varies
from 3-10 per
ont It is common
in nulliparous
and the
prevalence is
highest between
35-45 years
Fibroid arises
from the smooth
muscle elements
of the
myometrium,
could be
genetically
determined and
the growth is
dependent on the
polypeptide
growth factors
(EGF, IGF-1,
 TGF) and
oestrogen.
Majority of
fibroids remain
asymptomatic
(75%)
Life-threatening
complications
include: -severe
anaemia,
intraperitoneal
haemorrhage
from ruptured
veins over the
subserous
fibroid, severe
infection and
sarcomatous
changes.

Medical
management
aims mostly as
palliative and the
drugs used are
progestogens,
antiprogesterone
s. danazol,
GnRH
analogues
(agonists and
antagonists).

The surgical
treatment of
fibroid
concentrates to
hysterectomy or
myomectomy
depending upon
the age of the
patient and need
for preservation
of reproductive
function.

BIBLIOGRAPHY

1. DC Dutta’s Textbook of Obstetrics :8TH

Edition: India JP Publication:2020; P-
 262- 273
2. Annamma Jacob textbook of midwifery
and gynecological nursing: 5th edition:
India JP Publication: 2019; P-281- 282
3. UpToDate [Internet]. Uptodate.com.
[cited 2023 Aug 16]. Available from:
https://www.uptodate.com/contents/ute
rine-fibroids-beyond-the-basics/print
4. Uterine fibroids [Internet]. WebMD.
[cited 2023 Aug 16]. Available from:
https://www.webmd.com/women/uterin
e-fibroids/uterine-fibroids
5. Uterine fibroids [Internet].
Medlineplus.gov. [cited 2023 Aug 16].
Available from:
https://medlineplus.gov/ency/article/00
0914.htm