1. Uterine Fibroid
Gaya 

2. ‘Benign tumours (myoma /leiomyoma) arising from
the uterus’
Etiology unknown but they are estrogen dependent
and undergo atropy after menopause
More common in nulliparous women

3. Types
• Subserosal –grow in outer surface of uterus
• Pedunculate – when they grow out of the
uterus on pedicles
• Intramural / interstitial – grow inside the
myometrium will enlarge the entire body of
the uterus

4. • Submucosal – grow beneath the
endometrium .they can distort the cavity.
These fibroid can grow in to the uterine cavity
and known as fibroid polyps
• Broad ligament fibroids - grow in to broad lig.
• Cervical – arise from the cervix

6. Symptoms
• Majority od fibroid are asymptomatic ,detect
during USS or laparoscopy
1)Menorrhagia –
Usually with submucosal and interstitial fibroid
Due to increase of endometrial surface and
impaired contractility and increasing vasularity
and pelvic congestion.

7. 2)Intermenstrual bleeding –
due to ulceration of a submucosal or fibroid
polyps
3)Dysmenorrhoes –
Cause by submucosal fibroid or fibroid polyps.
Those are interfere with the uterine contractility
during menses in attemp to expel it through the
cervical canal

8. 4)Subfertility –
Due to impaired of uterine and tubal mortility
due to heaviness of uterus ,defective
implantation ,mechanical obstruction of tubal
and problem in migrating of the sperm occur
5) Acute pain can occur –due to red
degeneration of torsion of pudunculate fibroid

9. Complications
• If can affect POD and acute retention of urine
can be happen
• Pedunculated fibroid can undergo twisting and
necrosis
• Infection can occur in submucus fibroid following
delivery or miscarriage same can happen in
interstitial fibroid following caesarian section if
the uterine incision extend inti myoma
• Malignant changes are rare

10. Types of degeneration occur in fibroid
• Hyaline degeneration – commonest type and
more common in larger fibroid. degenration
occur in the central part and tumour become
soft in consistency .common in menopause
• Cystic degeneration – following hyaline d. and
cavitation formation occur at the central part

11. • Red degeneration – commonly occurs during
pregnancy and puerperium, increased
vascularity of the uterus and tumour become
painful and tender
• Calcification - occur in postmenopausal
women and is due to deposition of Calcium
carbonate and phosphate .also called womb
stones

12. Complication in pregnancy
• Early stage –repeat miscarriage (in submucus
fibroid specially)
• Late stage –premature labour ,pain due to red
degeneration ,abnormal lies and presentation ,
fetal growth restriction
• During labour –obstructed labour and increased
incidence of caesarian delivery .lower segment
fibroid incision need to do in upper segment in c-
section
• Post partum period- higher incidence of post
partum haemorrage

13. Examination
• General examination always look foe anemia
• Abdominal examination –
When the uterus is larger than a pregnant
uterus of 12-14 week size it become palpable
abdominally in the suprapubic region
DD s are :
Full bladder , pregnancy , ovarian tumours
,adenomyosis ,tubo-ovarian masses

14. Investigation
• FBC –to exclude anemia
• USS - main stay of diagnosis
• 3D vaginal sonography – used in evaluating the
uterine cavity specially with regard to submucus
fibroid and fibroid polyps
• CT and MRI
• Laparoscopy –to detect small fibroid and exact
location
• Hysteroscopy –to diagnosis submucosal and
fibroid polyps

15. Management
• Conservatively
• Surgical
• Medical
• Uterine artery embolization

16. Conservative (expectant)
• Asymptomatic fibroid that detect during routine
examination are managed conservatively
• Risk of sarcomatous 1 in 1000
• Conservative management indicate in pregnancy and
puerperium.
• Regular follow up (with 6-12 month) with USS in necessary
to detect any sudden enlargement or change in the
echogenicity
• Spontaneous regression of the fibroid is expected after
menopause

17. Surgical management
The choice of surgical treatment is determined by
the presenting complaint and the patient’s aspirations
for menstrual function and fertility
Indicate to:
 Symptomatic fibroid
 When fibroid become palpable abdominally (large enough
12 week gestation size or 5-6cm on USS measurement )
 Subfertility when other method fail

18. Surgical procedures are
o Myomectomy
o Hysterectomy
Indication for myomectomy over hysterrectomy
are :

19. • Woman has not complete family
• Fibroid causing subfertility
• Desire to retain uterus
Advantages of hysterectomy :
• Recurrence of myoma does not exist
• It is easier to achieve hemostasis during surgery
• Risk of post operative adhesion formation low

20. • Menorrhagia associated with a submucous
fibroid or fibroid polyp should be treated by
hysteroscopic removal
• Where a bulky fibroid uterus causes pressure
symptoms, the options are myomectomy with
uterine conservation, or hysterectomy.
• Myomectomy will be the preferred option
where preservation of fertility is required.

21. • An important point for the preoperative
discussion during the consent process is that
there is a small but significant risk of
uncontrolled life threatening bleeding during
myomectomy, which could lead to
hysterectomy performed as a life saving
measure.
• This has to be explain to the patient before
surgery and consent need to be taken

22. • Disadvantages of myomectomy
 Haemorrhage in to myoma cavity
 Sepsis
 Postoperative adhesion –can involve
omentum and bowel and leads to subacute
bowel obstruction
 Recurring

23. • Myomectomy can be done laparoscopy or
open surgery
• Open myomectomy –incision may become
suprapubic transverse but in large fibroid
extending above the umbilicus and midline
incision may become necessary
• Laparoscopic myomectomy will cause fewer
adhesion but become technically difficult in
removing large fibroid

24. • Morcellator need to take fibroid out from the
abdominal cavity once removed.

25. • Laparoscopic Myoma Screw
Used to stabilize and manipulate nondegenerating myomas,
fibroids, or other tissues intended for removal during
laparoscopic procedures.

26. Medical treatment
• medical treatment for heavy menstrual bleeding
(tranexemic acid, mefenamic acid, combined
oral contraceptive pill) tend to be ineffective.
• The only effective medical treatment is to use
gonadotrophin progressreleasing hormone
(GnRH) agonists and Danazol .
• While very effective in shrinking fibroids, when
ovarian function returns, the fibroids regrow to
their previous dimensions.

27. • Need prolong treatment at least 6-9 month
• Menopausal symptoms due to hypoestrogenic
state and osteoporosis are side effects .

28. Hysterectomy and myomectomy can be facilitated by
GnRH agonist pretreatment over a three-month period to
reduce the bulk and vascularity of the fibroids. Useful
benefits of this approach are to enable a suprapubic (low
transverse) rather than a midline abdominal incision, or
to facilitate vaginal rather than abdominal hysterectomy,
both of which are conducive to more rapid recovery and
fewer postoperative complications. GnRH agonist
pretreatment can obscure tissue planes around the
fibroid making surgery more difficult but, on the positive
side, blood loss and the likely need for transfusion are
reduced.

29. Uterine artery embolization
• Uterine artery embolization (UAE) is a newer technique
performed by interventional radiologists.
• It involves embolization of both uterine arteries under
radiological guidance with a small incision in the
femoral artery performed under local anesthesia.
• The current evidence indicates that the overall
shrinkage of fibroids and reduction in menstrual blood
loss is around 50 per cent, although long-term follow-
up data beyond 18–24 months are not available.

30. • patients usually require admission overnight
because of pain following arterial occlusion
• Requiring opiate analgesia.
• Complications include fever, infection, fibroid
expulsion and potential ovarian failure.
• Women wishing to retain their fertility should be
counselled carefully before undergoing UAE as
the effects are not known, although there have
been pregnancies reported in the literature.

32. Management
The management is by hysteroscopic (transcervical) resection of the fibroid (TCRF). This
can be performed as a day case under general anaesthetic (or even local anaesthetic if the
fibroid is small). The important points in counselling the patient are as follows.
• Description of the procedure: the procedure involves stretching (dilatation) of the
cervix and insertion of an endoscope into the uterus (hysteroscopy) to view the fibroid.
The fibroid is ‘shaved’ away with a hot wire loop (diathermy). Fluid is circulated
through the uterine cavity to enhance the view and allow cooling.
• What are the risks?
• bleeding: it is rare to bleed heavily but in the extreme situation blood transfusion
could be required, or even a hysterectomy to control the loss
• infection
• fluid overload: during the procedure, irrigation fluid is absorbed into the circulation.
Excessive absorption can cause breathing difficulties (pulmonary oedema) and
the need for hospital admission
• uterine perforation: rarely the hysteroscope perforates the wall of the uterus and if
this occurs or is suspected then laparoscopy is needed immediately to confirm it,
secure any bleeding and check for damage to surrounding bowel or bladder.
• What to expect afterwards: most women experience bleeding, discharge and passing
of ‘debris’ for up to 2 weeks after the procedure.