Benign lesions of uterus

1. BENIGN LESIONS
of

2. BODY OF UTERUSAND
ENDOMETRIUM
The uterus has two major components:
Myometrium - composed of tightly
interwoven bundles of smooth muscle that
form the wall of the uterus
Endometrium - composed of glands
embedded in a cellular stroma

4. BODY OF UTERUSAND
ENDOMETRIUM
Diseases of uterus result from
 endocrine imbalances
 complications of pregnancy
 neoplastic proliferation

6. Benign disease of the uterus is an important
problem for many women and their gynaecologists.
• The commonest condition in this category is fibroids but
adenomyosis and uterine polyps are also important.
• Both fibroids and endometrial polyps are very common
and although asymptomatic in many women, they can
cause considerable morbidity for others.

8. Uterine polyps are benign polyps
comprising endometrial, fibroid,
cervical and placental polyp

10. Number
• Single or multiple
Types
• Pedunculated
• Sessile
• Mucous
• Fibroid
• Placental
Age
• All age group
• Peak (40-49 years)
Size
• Few mm – several cm

11. Endometrial polyps
Endometrial polyps are discrete outgrowths of the
endometrium that contain a variable amount of glands,
stroma and blood vessels. They are attached to the
endometrium by a pedicle and they may be
pedunculated or sessile.

13. Endometrial polyp
• Localized overgrowths of the endometrial glands and stroma projecting
beyond the endometrial surface
• Mostly arises from hyperplasia of endometrium
• Some of the endometrial lining protruding into the uterine cavity as
polyps
• Composed of endometrial glands and stroma covered with a single
layer of columnar epithelium
• Secondary malignant change may occur

14. Epidemiology
 The presence of endometrial polyps is being increasingly recognized since the widespread
adoption of transvaginal ultrasound and outpatient's hysteroscopy.
 It is mostly seen in 25% of women with abnormal vaginal bleeding
 Peak age incidence is at 40-49 years
 At least 10% of asymptomatic women are also likely to have polyps
 They are particularly common in women taking preparations- such as tamoxifen for ca breast.
 Cause is unknown; - but in menopause, common in women with HRT
 Mostly are asymptomatic, mostly are detected bysonography.
 Common manifestation is intermenstrual bleeding in perimenopausal or postmenopausal
bleeding.

15. RISK FACTORS
HRT
Tamoxifen
therapy
Diabetes
Hypertension
Obesity
Increased
patient age

16. PATHOLOGY
• a part of thick endometrium project
into the cavity and ultimately
attained pedicle/sessile
•CUT SECTION: grey or reddish brown
GROSS
APPEARANCE:
•Core : contain stromal cells, glands and large
thick walled vascular channel.
•Surface : lined by proliferative endometrial
lining with cystic hyperplasia or squamous
metaplasia
•Pedicle : contain thin fibrous tissue with thin
bloodvessel
MICROSCOPIC

17. ENDOMETRIAL POLYP

18. PREDICTOR OF MALIGNANCY
Size >10 mm
Postmenopa
usal status
Abnormal
uterine
bleeding
• Malignant transformation is estimated at
0.5%

19. CLINICAL FEATURES
Maybe
asymptomatic
Menorrhagia
Intermenstrual
bleeding
Contact bleeding
(polyps situated
outside cervix)
Infertility and
miscarriage
(multiple polyps)
Unscheduled vaginal bleeding or spotting is the commonest
presentation for endometrial polyps

20. - Single/multiple
- Pink swellings
- 1-2cm in diameter
- With a pedicle

21. Site:
within the
endocervical canal
Size:
small and sessile to
large
(5-cm masses that
protrude through the
cervical os)
Consistency:
soft& mucoid
CERVICAL
POLYP

22. Differential diagnosis:
 Submucous leiomyoma
 Adenomyoma
 Retained products of
conception
 Endometrial hyperplasia
 Endometrial carcinoma
 Uterine sarcoma

23. ON EXAMINATION
• Uterus is in normal size/uniformly enlarged
• Cervix appears soft, slippery and small in size
(outside the cervix)
• PER SPECULUM : Reddish in color attached
with small pedicle.

24. INVESTIGATIONS
• Must be ruled out in women with abnormal
uterine bleeding who do not respond to regular
treatment.

25. 1. Transvaginal ultrasound
2. Intrauterine injection of saline can markedly increase the diagnostic
performance of transvaginal ultrasound.
3. Hysteroscopy – The best method for diagnosing polyps is hysteroscopy;
so it is a possibility that they might then be treated at the same time.
• They can be distinguished from pedunculated fibroids since they have
fewer vessels over the surface.

26. MANAGEMENT
Curettage of
Hysteroscopic endometrium
polypectomy (to rule out
hyperplasia)

27. Diagnosis of Malignant polyps:
 Malignant polyps are more likely to be irregular, vascular or friable.
 Biopsy should be carried out to confirm the diagnosis, since appearance is not
sufficient.
Treatment
Optimal management is removal by Hysteroscopy with D and C
In the symptomatic women, treatment will normally be performed under
general anaesthesia.
However, they can also be treated in the outpatients setting either by removal
under direct vision or by treatment with specially developed diathermy instrumentation.

28. Placental polyp
• Formed from retained placental tissue
• May cause:
– Secondary postpartum hemorrhage
– Intermittent vaginal bleeding following an
abortion or normal term delivery

29. Clinical features
• Menorrhagia
• Metrorrhagia
• Postmenopausal bleeding
• Postcoital bleeding (if it protrudes through the os)

30. Diagnosis
• Clinically, uterine polyp may not be evident and uterus may or
may not be enlarged.
• It is easy to diagnose when the polypus protrudes through
the cervical canal.
• Ulrasound can detect the uterine polyp
• Saline sonosalphingogram/hysterosalphingogram

31. Management
• D&C can scrape the polyp
• Hysteroscopic removal of multiple polyps may be
desirable to ensure their complete removal.

34. Commonest benign tumor of the uterus
Commonest benign tumor in female

35. fibromyoma
Tumor is composed of fibrous connective tissue
and smooth muscle

37. LEIOMYOMA
• These are the benign tumors of muscle cell origin.
• These are the most frequent pelvic tumors and the most common
tumors in women.
• Highest prevalence is above the 3thdecade of woman’s life
• Found in 30-50% of perimenopausal women
• Symptomatic leiomyomas are the primary indication for approximately
30% of all hysterectomies
• Risks factors:
Increasing
age Low
parity
Obesity
- Early menarche
-Tamoxifen use
- High fat diet
- African racial
• A fibroid is a benign tumour of uterine smooth muscle,
termed as a leiomyoma.

38. • Incidence:
– At least 20% of women at the age of 30 have got
fibroid in their wombs
–50% remains asymptomatic
– Incidence higher in black women
– More common in nulliparous/one child infertility

39. Prevalence:
• highest between 35-45 years
(childbearing age group)
• Rarely before 20 years
• Although leiomyomas have the potential to grow to impressive
sizes, their malignant potential is minimal.
• Sarcomatous changes occur in less than 1 per 1000 uteri with
fibroids

40. Risk factors for developing leiomyomas include:
1 – Increasing age during the reproductive years,
2 – Ethnicity: African-American women have at least 2- to 3 fold increased risk
compared to Caucasian women,
3 – Nulliparity,
4 – Family history.
5 – Higher body mass index is associated with a greater risk of leiomyomata.

41. Risk/Modifying factors for fibroid
Increase
–Nulliparity
–Obesity
–Hyperestrogenic
state
–Black women
Decrease
– Multiparity
– Oral contraceptive pills
and (depot
medroxyprogesterone
acetate ) DMPA injections
may be associated with
reduced risk.
– Athletic women

42. Predominantly an estrogen-dependant tumor
• Evidenced by:
– Potentially limited during child-bearing period
– Increased growth during pregnancy
– Rarely occur before menarche
– Cessation of growth and there is no new growth at all following
menopause
– Contain more estrogen receptors than the adjacent myometrium
– Frequent association of anovulation

43. Pathogenesis
• Factors that initiate leiomyomata are not known, but ovarian sex steroids are important for their
growth.
• Leiomyomas rarely develop before menarche and seldom develop or enlarge after menopause,
unless stimulated by exogenous hormones.
Leiomyomas can also enlarge dramatically during pregnancy.
• Leiomyomas have increased levels of estrogen and progesterone receptors compared to other
smooth muscle cells.
• Estrogen stimulates the proliferation of smooth muscle cell, whereas progesterone increases the
production of proteins that interfere with programmed cell death or apoptosis.
• Leiomyomas also have higher levels of growth factors that stimulate the production of fibronectin
and collagen, major components of the extracellular matrix that characterizes these lesions.

44. GROWTH
Not squarely distributed amongst the
fibroids which are usually multiple
Some grow faster than the others

45. On the whole, rate of growth is
SLOW
Takes about 3-5 years for the fibroid to grow
sufficiently to be felt per abdomen

46. grows RAPIDLY
 During pregnancy
 Amongst pill users (high dose pills)
 Due to malignant change
*The newer low dose OCP are not associated with increase in the growth of a
fibroid

47. Types
Body
(Corporeal)
Intramural
(75%)
Subserosal
(15%)
Submucosal
(5%)
Cervical
• Fibroids consist of varying proportions of
smooth muscle and fibroblasts.
• They may be single or multiple and can
occur anywhere in the uterus

50. Fibroids are
usually located in
the body and are
usually multiple

51. Morphology
Site – Leiomyoma can occur within the
myometrium – intramural
- just beneath endometrium -
submucosal
- beneath the serosa - subserosal
 Size - varying in size from small to massive tumors
that fill the pelvis.
 Number – single or most often multiple

52.  Shape - sharply circumscribed, discrete,
round
 Color & Consistency - firm, gray-white
tumors
 on cut section – characterised by the
pattern of smooth muscle bundles
 red degeneration- areas of yellow-brown to
red softening in large tumors

53. Morphology
On histologic examination
leiomyoma is composed of,
whorled bundles of smooth muscle cells that
resemble the uninvolved myometrium
The individual muscle cells are,
- uniform in size and shape
- have the characteristic of oval nucleus
- long cytoplasmic processes

54. Initially, fibroids are
intramural in position
but subsequently,
some are pushed
outward or inward
about 70%
persist in that position
INTERSTITIAL/INTRAMURAL

55. Intramural fibroid is
pushed outwards
towards the
peritoneal cavity
SUBSEROSAL/SUBPERITONEAL

56. When it completely
covered by peritoneum,
it usually attains a
pedicle –
“pedunculated
subserosal fibroid”
SUBSEROSAL/SUBPERITONEAL

57. On rare occasion, the
pedicle may be torn; the
fibroid gets its
nourishment from the
omental or mesenteric
adhesions –
“wandering/parasitic
fibroid”
SUBSEROSAL/SUBPERITONEAL

58. SUBMUCOSAL
Intramural fibroid, when
pushed toward the
uterine cavity and is lying
under the endometrium
Can make the uterine
cavity IRREGULAR &
DISTORTED

59. SUBMUCOSAL
Least common
but
MAXIMUM
symptoms

60. SUBMUCOSAL
Pedunculated
submucosal fibroid may
come out through the
cervix
May be
infected/ulcerated to
cause METRORRHAGIA

61. CERVICAL
Rare (1-2%)
May be anterior, posterior,
lateral or central
May displace the cervix or
expand it so much that the
external os is difficult to
recognize

62. SECONDARY CHANGES IN FIBROIDS
• Degenerations
• Atrophy
• Necrosis
• Infection
• Vascular changes
• Sarcomatous changes
DANIVaS

63. • Degenerations:
– Hyaline degeneration
– Cystic degeneration
– Fatty degeneration
– Calcific degeneration
– Red degeneration

64. • Atrophy: due to loss of support from estrogen
– following menopause
– Following pregnancy enlargement
• Necrosis: due to circulatory inadequacy (central
necrosis of the tumor )
– Pedunculated subserous fibroid

65. • Infection: access through the thinned and
sloughed surface epithelium of the
submucous fibroid.
– Following delivery or abortion
– Intramural fibroid may also be infected following
delivery.

66. • Vascular changes: Telangiectasis (dilatation of the vessels)
or lymphangiectasis (dilatation of the lymphatic channels)
inside the myoma may occur. Cause is not known.
• Sarcomatous changes: may occur in <0.1% cases.
The usual type is leiomyosarcoma.

67. Other Complications
• Hemorrhage
– Intracapsular
– Ruptured surface vein of
subserous fibroid 
intraperitoneal
• Polycythemia
– Erythropoietic function by the
tumor
– Altered erythropoietic
function of the kidney
through ureteric pressure
• Torsion of subserous
pedunculated fibroid
• Inversion of uterus
• Endometrial carcinoma
associated with fibromyoma
• Endometrial and
myohyperplasia
• Accompanying
adenomyosis
• Parasitic fibroid

68. Symptoms
Menstrual disturbances
Infertility, recurrent abortions
Pain
Pressure symptoms
Abdominal lump
Vaginal discharge

69. Symptoms
Menstrual disturbances
• Menorrhagia
• Conspicuous in IM & SM fibroid
• due to increased vascularity,
endometrial
hyperplasia & enlarged uterine cavity
• Metrorrhagia/irregular bleeding
• Ulceration of SM fibroid or fibroid
polyp
• Torn vessels from the sloughing base of
polyp
• Associated endometrial carcinoma

70. Symptoms
Infertility, recurrent abortions
• Infertility:
• Distortion / elongation of uterine cavity 
difficult sperm accent
• Poor rhythmic uterine contraction during
intercourse  impaired sperm transport
• Menorrhagia and dyspareunia
• Recurrent abortions:
• Defective implantation
• Poorly developed endometrium
• Reduced space for the fetal growth

71. Symptoms
Pain
• Usually painless
• Pain may be due to some complications of the
tumor / associated pelvic pathology
• Due to tumor:
• Degeneration
• Torsion
• Extrusion of polyp
• Associated pathology:
• Endometriosis
• PID

72. Symptoms
Pressure symptoms
• Bladder  frequency and retention of urine
• Ureter  hydroureter & hydronephrosis
(in broad ligament fibroids)
• Rectum  constipation(rare)

73. Symptoms
Vaginal discharge
Abdominal lump
• Heaviness in the lower abdomen
• A pedunculated fibroid feels separate from
the uterus and gives impression of ovarian
tumor

74. Symptoms
Vaginal discharge
Vaginal discharge
• Rare
• Often blood-stained

75. Physical signs
• Anemia
• Abdominal lump
– Arising from pelvis
– Well-defined margins
– Firm in consistency
– Smooth/bossy surface
– Mobile from side to side unless fixed by large size or
adhesions

76. • Bimanual examination:
– Enlarged uterus
– Cervix moves with the swelling
which is not felt separate from
uterus unless it is pedunculated
– In cervical fibroid, the normal
uterus is perched on top of the
tumor
– Broad ligament fibroid displaces
the uterus to the opposite side

77. Differential diagnosis ?
Pregnancy Full bladder
Haematometra/
pyometra
Adenomyosis
Bicornuate
uterus
Ectopic
pregnancy
Chronic PID
Benign/malignant
ovarian tumor

78. Investigations
• Haemoglobin, blood grouping
• Ultrasound abdomen & pelvis
• Hysterosalphingography (to identify submucous myoma)
• Hysteroscopy
• D&C (to rule out endometrial cancer)
• Laparoscopy
• MRI (to identify adenomyosis and myoma)
In majority cases, the clinical features are clear cut. Elaborate
investigations are not required.

79. TREATMEN
T
There's no single best
approach to uterine fibroid
treatment

80. Type of fibroid
MANAGEMENT PROTOCOL OF UTERINE FIBROIDS
BODY
SYMPTOMATIC
MEDICAL SURGERY
MYOMECTOMY,
HYSTERECTOMY,
MYOLYSIS,
EMBOLOTHERAPY
ASYMPTOMATIC
REGULAR
SUPERVISION
(6 MONTHS
INTERVAL)
IF SIZEINCREASE
& SYMPTOMS
APPEAR 
SURGERY
SURGERY
IF SIZE >12
WEEKS, DX
UNCERTAIN,
UNEXPLAINED
ABORTION/INFE
RTILITY,
PEDUNCULATED
CERVIX
SUPRAVAGINAL
MYOMECTOMY HYSTERECTOMY
VAGINAL
MYOMECTOMY POLYPECTOMY

81. MEDICAL MANAGEMENT
 To improve menorrhagia
and to correct anemia
before surgery
 To minimize the size and
vascularity of the tumor
in order to facilitate
surgery
 As an alternative to
surgery in
postmenopausal women
or women with high-risk
for surgery
 Where postponement of
surgery is planned
temporarily

82. • Antiprogesterones
– Mifepristone (daily dose of 25-30mg for 3mo)
• Danazol
– 200-400mg divided dose for 3mo
• GnRH analogs
– Agonists (luporelin, goserelin, buserelin, nafarelin)
– Antagonists (cetrorelix, ganirelix)
• PG synthetase inhibitor - to relieve pain
Tominimize blood loss

83. Levonogestrel-releasing
intrauterine system
(LNG-IUS)
 Reduce the size and
vascularity of the fibroid

84. SURGICAL MANAGEMENT
• Factors affecting the type of surgical approach:
• Age of the patient
• Parity
• Future reproductive plans
• Classic indications for Myomectomy:
• Persistent abnormal bleeding
• Pain or pressure
• Enlargement of an asymptomatic myoma to more than 8 cm in a woman who has not
completed chilbearing

85. • Contraindications to Myomectomy:
•
•
•
•
Pregnancy
Advanced
adnexal disease
Malignancy
• Myomectomy maybe performed through:
•
•
•
•
Laparoscopy
Hysteroscopy
Laparotomy
Vaginally

86. • Indications for Hysterectomy:
•
•
• All indications for myomectomy,
plus:
Asymptomatic myomas when the uterus that has
reached the size of 14-16 weeks gestation
Rapid growth of myoma after menopause

87. Fibroids complicating
pregnancy
Pregnancy generally cause an
increase in the size of the
fibroids
– Increase vascularity
– High tendency to undergo
degenerative changes

88. Red degeneration
result of the
softening of
the
surrounding
supportive
tissue
capillaries
tend to
rupture
blood effuses
out into the
myoma
(diffuse reddish
discolouration)
severe acute
abdominal
pain
(restricted to
the site of
fibroiduterus)

89. EFFECT OF PREGNANCY ON FIBROID
A. Subinvolution
B. Ascending infection
C. Torsion

90. EFFECTS OF FIBROID ON PREGNANCY
1- Infertility
2- Abortion
3- preterm labor
4- Abruptio placentae
5- abnormal Lie & position
6- Increase rate of operative delivery
7- PPH (uterine atony) .

92. Common condition in which islands of
endometrium are found in the wall of the
uterus
“ADENOMYOSIS”

94. ADENOMYOSIS
• Presence of endometrial tissue in
myometrium >2.5mm from the basal layer of
endometrium
• Endometrial gland and stroma must present

96. • Observed frequently in elderly women
• Women are usually parous
• Around the age of 40 years
• The disease often coexists with uterine
fibromyomas, pelvic endometriosis (15%) and
endometrial carcinoma

97. PATHOGENESIS
• Oestrogen recepter mutation
• Gene polymorphism
• Basal layer of endometrium including stroma
and gland infiltrating myometrium.
• Surrounding myometrial tissue hypertrophied
and hyperplasia
• Uterine enlargement

99. PATHOLOGY
• DIFFUSE
– Involve anterior an
– Causes uniform ute
– Thickened myomet
osterior uterine walls
e enlargement
m and hemorrhagic foci of
d p
rin
riu
adenomyosis
•
ma (no capsule or distinct
LOCALIZED
– Grossly mimic leiomyo
plane of dissection)

100. CLINICAL FEATURES
• Common in multiparous age 40-50
• Does not occur before menarche and regress
after menopause
• Uterus uniformly enlarged
• Palpable abdominally (<14
week’s size)
• May co-exist with other
pelvic pathology
– Leiomyoma
– endometrial hyperplasia
– endometriosis
– endometrial carcinoma
• Dysmenorrhea
(increased with
duration of disease
and depth of
infiltration
• Menorrhagia

101. Gross examination
• Uterus appears symmetrically enlarged to not more
than 14-weeks size
• Cut section may show only a localized nodular
enlargement
• Affected area reveals a peculiar, diffuse, striated and
non-capsulated involvement of the myometrium, with
tiny dark hemorrhagic areas.

103. INVESTIGATIONS
Transvaginal ultrasonography
• Asymmetrical thickening of uterine walls
Doppler sonography
• Todifferentiate from fibroid
MRI
• Conservative surgical or medical management preferred
• Young lady with infertility
Image directed needle biopsy

104. Differential diagnosis
• A localised adenomyosis  asymmetrical
enlargement of uterus – resembles myoma
• But, myoma of this size is rarely painful.
• Therefore, menorrhagia, with painful,
assymmetrical enlargement of the uterus
suggests adenomyosis

105. MEDICAL MANAGEMENT
NSAID
COMBINED OCP
DANAZOL
•Reduce in size, menorrhagia reduce
•Temporary effect
GnRH ANALOGUE
•Prior to surgery to reduce size and vascularity
LEVONOGESTREL INTRAUTERINE SYSTEM (LNG-IUS)
DANAZOL LOADED INTRAUTERINE DEVICE
•Reduce pain and bleeding

106. SURGICAL MANAGEMENT
• Definitive surgery • Perimenopausal age
• Poor response to medical
therapy
• Associated pelvic pathology

107. CONSERVATIVE SURGERY
• Localized adenomyoma by
adenomyomectomy
Resection of
adenomyoma
• Diffuse adenomyosis
• Partial resection of uterine walls
Myometrial
reduction
• Submucosal adenomyosis/ polypoidal lesion
Hysteroscopic
reduction

108. NEWER INTERVENTIONAL TECHNIQUE
Endometrial
ablation
Uterine
artery
embolisation
MRI guided
focused
ultrasound
surgery

109. That’s
all!