Fibroid is a benign tumor of uterine smooth muscle termed leiomyoma
It is the most common tumor of the uterus affecting 20-30% of women.
Classification: according to its location
1-Submucous fibroid :The tumor is protruding through the uterine cavity.
2-Intramural fibroid :The tumor is located within the myometrium.
3-Subserosal fibroid :The tumor is located at the outer border of the myometrium.
4-Pedunculated fibroid :The tumor is attached to the outer border of the uterus
by a narrow pedicle containing blood vessels.
5-Fibroids can arise as a separate entity away from the uterus in the broad
ligament mainly from the embryonic remnant
Pathology
Macroscopic appearance
Fibroids present as single or multiple circular or irregular masses. They have
a false capsule consisting of compressed myometrial tissue by the tumor.
On cross section, the tumor has characteristic whorled arrangement of tissue
bundles and its centre may show different types of degeneration.
Microscopic appearance
Fibroids consist of smooth muscle fibers and fibrous connective tissue.
Types of fibroid degeneration
1-Red degeneration
It follows an acute loss of blood supply to the fibroid during its active growth
mainly seen during pregnancy.
Patients present with sudden onset of abdominal pain and tenderness localized
to the uterus associated with mild pyrexia and leukocytosis.
The symptoms and signs resolve over a few days and surgical intervention is
rarely required.
2-Hyaline degeneration
This type of degeneration is caused by gradual decrease in the blood supply
to the fibroid.
It is asymptomatic and can cause central necrosis leaving cystic spaces at the
center termed cystic degeneration.
Calcification of fibroid
This type of change in the fibroid is caused by deposition of calcium in the
fibroid and can be detected on the abdominal x-ray in postmenopausal women.
Malignant changes
Occurs in 0.1 -0 .5 % of fibroids termed as sarcoma, and is characterized by
rapidly increasing tumor size.
Clinical features
The symptoms of this disease depend on the location and size of the fibroid
1- Menstrual disturbance
Fibroid is an important cause of uterine bleeding mainly menorrhagia or intermenstrual
bleeding mainly in sub mucous type and as thus can present with symptoms of
anemia.
2-Pressure symptoms, especially urinary frequency or constipation due to
pressure of the growing fibroid on the adjacent structures like the urinary
bladder and the rectum.
3-Pain is unusual except in red degeneration of fibroid
4-Sub- fertility;
Due to mechanical distortion or occlusion of the fallopian tubes and distortion
of the endometrial cavity by a sub mucous fibroid which can prevent implantation of
the fertilized ova.
5-Obstetric complications
In late pregnancy if the fibroid is located in the cervix or the lower uterine segment
it can cause fetal abnormal lie or presentation and obstructed labor.
After delivery, there is a risk of postpartum hemorrhage due to inefficient
uterine contractions.
Signs of fibroid
Abdominal examination may indicate the presence of a firm mass arising from
pelvis.
On bimanual examination, the mass is felt to be a part of the uterus with some
limited mobility.
Predisposing factors
1-Nulliparity
2-Obesity
3-Family history
4-African racial origin
Differential diagnosis
1- Ovarian tumor whether benign or malignant.
2- Adenomyosis.
3- Leiomyosarcoma; patient presents with a history of rapidly enlarging abdominal-pelvic
mass and decreased mobility of the uterus. In addition to general signs of cachexia.
Diagnosis
.1-U/S mainly vaginal U/S gives accurate information to distinguish a uterine
fibroid from an ovarian mass.
Fibroids appear as circular, well-demarcated lesions.
2-Hysteroscopy for diagnosing and treating sub mucous fibroids.
Treatment
The choice of treatment depends on the age, parity, general health and the desire
to have more children in addition to the size and location of the fibroid.
Medical treatment
Small and asymptomatic fibroids need follow up by u/s every 6 months. When symptoms
appear and treatment is required, medical therapy is ovarian suppression using GNRH agonist.
This type of treatment is effective in shrinking the tumor. When treatment is
stopped, ovarian function resumes and fibroids grow back to their previous size.
Surgical treatment
Cases of sub mucous and intrauterine fibroids can be removed by hysteroscopy.
Other types of fibroid are removed by abdominal myomectomy or hysterectomy.
1-Myomectomy
Usually done for young women who want to preserve their reproductive function.
It is done by Laparotomy especially for large size fibroids
2-Hysterectomy; reserved for patients above 40 years who completed their families
either by total or subtotal abdominal or vaginal hysterectomy.
GNRH agonist pretreatment over a two month period can facilitate hysterectomy
or myomectomy to reduce the bulk and vascularity of fibroid prior to surgery.
Indications for surgery
1-Heavy or prolonged blood loss through the menses.
2-Large size fibroid
3-Pressure symptoms like urine retention
4-Possible malignant changes
Fibroid destruction
1-Myolysis; the idea of this treatment is to cut the blood supply to the fibroid
laparoscopically and use laser to cauterize the blood vessels feeding the
fibroid.
Disadvantages of this method are that it may be associated with intra abdominal
adhesions especially between uterus and the intestines.
2-Embolization of the uterine artery
This type includes selective block to the uterine artery.
This is the most modern type of treatment done by percutaneous selective catheterization.
It is associated with substantial reduction in fibroid size and improvement
of menstrual symptoms over the following 6 months.
