LEIOMYOMA - UTERINE FIBROID

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terine fibroid is the most common form of benign tumor to occur. It arises from the smooth muscle layer of the uterus; thus, it is called as “Leiomyoma”. It occurs in 20% of the women in reproductive age group.


It is dependent on estrogen predominantly. Other hormones such as growth hormone and human placental lactogen are also seen to play a role in the development of leiomyoma.

The conditions where estrogen is maximum are –

1.    Nulliparity

2.    Obesity

3.    Polycystic Ovarian Syndrome

4.    Endometrial hyperplasia

Anatomy and Pathology of fibroid – It is derived from the smooth muscle layer of the uterus. It is well circumcised, firm, round with a pseudo-capsule (fake covering). These may be single or occur multiple. They can turn soft if they become cystic or degenerative changes start to take place inside the tumor. Usually arises from the body of the uterus and less from cervix. Innermost part of the tumor is the first to undergo degeneration, where as the outermost part is the one to calcify. The blood supply to the tumor is radial at the center, i.e. radial branches are present. Cut surface of the tumor shows “whorled” appearance. Other names for this are –

1.    Leiomyoma

2.    Myoma

3.    Fibromyoma

Types of fibroids –

1.    Uterine fibroids –

i.                Subserous

ii.              Intramural (75%)

iii.            Submucous

2.    Extra-uterine fibroids –

i.                True (arising from the broad ligament)

ii.              False (arises into the uterus and then progresses outside the uterus to grow onto the broad ligament).

Parasitic Fibroid – Sometimes the original fibroid gets broken into pieces and one of it wanders and attaches to another tissue and grows there. This is called as Parasitic Fibroid. Usually it attaches to a vascular organ like Omentum or Bowel.


 Clinical Manifestation –

1.    Pain – Spasmodic Dysmenorrhea, back ache.

2.    Menorrhagia

3.    Vaginal discharge

4.    Abdominal lump or mass protruding into the introitus

5.    Infertility

6.    Recurrent abortions.

Fibroids can also lead to polycythemia. This happens because they may compress the renal vessels, which leads to hypoxia and release of erythropoietin and this increase in RBC/erythrocyte count.

When they are big enough the can obstruct the fallopian tubes or cervix or even the cavity of the uterus is obstructed and thus the sperm cannot pass into the fertilization area (ampullary isthmic junction) leading to infertility.

If the fibroid is under torsion and causes immense pain, it is an emergency and needs immediate attention.

Complications –

1.    Increased risk of abortions.

2.    Threatened pre-term labor.

3.    Premature delivery.

4.    IUGR (Intrauterine growth retardation).

5.    PPH (Postpartum Hemorrhage).

6.    Torsion

7.    Infection

8.    Inversion of Uterus.

Changes inside the Tumor –

1.    Atrophy

2.    Cystic degeneration

3.    Hyaline degeneration

4.    Fatty degeneration

5.    Calcification

6.    Sarcomatous degeneration

When the fibroid becomes tense, big and causes abdominal pain and fever; it becomes reddish and emits a foul fishy smell with thrombosed vessels and clinical examination shows elevated ESR and WBC counts. This is called as Red degeneration of the Fibroid.

Differential Diagnosis (DD) –

1.    Acute pyelonephritis

2.    Appendicitis

3.    Traumatic bleeding

4.    Torsion of cysts

It is self-limiting and gets resolved easily, but is becomes dangerous when it shows sarcomatous changes and turns malignant.

Management (both medically and surgically) –

Medical management –

1.    Iron therapy for anemia

2.    Low dose OCP’s (with low dose of estrogen)

3.    GnRH analogues like Leuprolide.

4.    Mifepristone

Surgical management –

Indications for surgical approach –

1.    Abnormal uterine bleeding resulting in anemia, not responsive to medications.

2.    Chronic pain with dysmenorrhea and lower abdominal pressure.

3.    Prolapsing submucosal fibroid.

4.    Infertility

5.    Marked enlarged size of uterus with compression or discomfort.

Surgeries done –

1.    Myomectomy (can be done by laparoscopic method)

2.    Hysterectomy (abdominal/vaginal/laparoscopic)

3.    Uterine artery embolization.

In myomectomy the fibroids are removed except the uterus. However there are some complications to myomectomy and they are –

1.    Trauma to other structures like ureter, bladder, etc.

2.    Hemorrhage.

3.    Infection.

4.    Intestinal obstruction.

If the size of the fibroid is less than 10 cm and is less than 4 in number, we can perform laparoscopic removal.

For hysterectomy subtotal hysterectomy is performed as compared to total hysterectomy because cervix is retained, less surgical morbidity and vault is preserved and there are low chances of prolapse.

When we remove uterus, cervix, and ovaries it is called as Panhysterectomy. Like myomectomy hysterectomy also has some complications -

1.    Trauma to surrounding structures

2.    Hemorrhage.

3.    Anesthetic complications.

4.    Post-operative infections.

5.    Thrombosis.

6.    Paralytic ileus, intestinal obstruction.

7.    Burst abdomen.

8.    Scars

 

This image shows the histology - 

NOTE THE SPIRAL PLACEMENT OF THE CELLS.

 

 


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