MANAGEMENT OF UTERINE FIBROIDS

BY
Dr Bennett Ariweriokuma
Department of O & G
UPTH
Port Harcourt
INTRODUCTION

CLINICAL PRESENTATION

DEFFRENTIALS

INVESTIGATIONS

TREATMENT MODALITIES

COMPLICATIONS

SPECIAL CONDITIONS
 –INTRODUCTION
Uterine leiomyomas are benign neoplasia
of the uterus commonly refered to as
myomas, fibromyomas or fibroids because
of their fibrous character and high
collagen content.
Uterine fibroids are the most common
pathologic abnormalities of the female
reproductive system.
Not seen before puberty
20-25% of reproductive age group of
women
3-9x more in blacks than whites.
In Nigeria 80% of women above 25yrs
have fibroids
The cause of fibroid remains unknown.
It can arise from a single cell- monoclonal
Fibroids can be single or multiple
The transformation from a normal cell to fibroid
may be genetic.
Paternal genetic up-regulation
Somatic genetic mutation, deletion or
translocation in chromosome 12q14 -15 and
7q22. Such mutations predispose the
leiomyocyte more sensitive to estrogens and
insulin like growth hormones .
This means that there is familial
inheritance
Common in nulliparity but reduces with
pregnancies.
Women weighing >70kg have x3 risk.
Smoking, COC and progestogens protect
occurrence of the condition.
The management of fibroid is very important
because there is a growing social trend in
delayed childbearing in developed and
developing countries.
Many women in search of education may
delay pregnancy until the age of 25 – 30yrs
and that is the period when the incidence of
fibroid rises.
Although women want gynaecological solutions
to fibroids they dislike the traditional
myomectomy or hysterectomy.
They prefer minimal access surgery or medical
treatment to cure the fibroid and also preserve
their fertility.
It was against this barground that the 3rd world
congress on controversies in obstetrics,
gynaecology and infertility meeting held in W-DC
June 2002 challenged the traditional surgery and
encourage minimal access surgery for the
future.
 CLINICAL FEATURES

Most are asymptomatic

Symptomatic present as:-
abdominal mass
menstrual abnormalities
infertility, recurrent abortions
lower abdominal pains
dysmenorrhoea
Pressure symptoms on urinary, GIT. Lower limb
vascular and lymphatic vessels.
 CLINICAL SIGNS

Depends on the size, shape and number.

Palpable firm single or multiple fibroid
nodules.
Vaginal exam :-Cx fibroid polyp. Cx fibroid
Uterine fibroids
DIFFERENTIAL DIAGNOSIS

Adenomyosis
Pregnancy
Abortion
Tubo ovarian mass
Ovarian tumour
Pelvic kidney
Genetic carcinomas
 INVESTIGATIONS:-

FBC
URINALYSIS
ULTRASOUND SCAN
HSG for submucous fibroid and the state
of the tubes.
Hysteroscopy, laparoscopy
EUA & Endometrial biopsy
CT SCAN, MRI rarely used.
 TREATMENT
EXPECTANT
NON SURGICAL
- medical
-radiological intervention
-MINIMAL ACCESS SURGERY
Laparoscopic-myolysis, myomectomy with
endoscopic knotting.
hysterospic –myomectomy, endometrial
resection or ablation
 SURGERY
Myomectomy-abdominal
- vaginal
Hysterectomy –abdominal
- vaginal
Low tech uterine artery ligation
- abdominal
- vaginal
-coagulation of uterine artery
PRINCIPLES OF TREATMENT
Age of the patient
Size of the fibroid
Severity of the symptoms
The reproductive desires of the patient
 GENERAL TREATMENT

Correct anaemia with – haematinics; tablets or

parenterally
Continuous COC therapy

EXPECTANT MANAGEMENT
Indications:-
Small fibroid 6-8cm in diameter
Fibroid outside endometrium
Asymtomatic fibroid
Myoma co existing with pregnancy
Post menopuasal woman
FOLLOWUP
Review patient quarterly
Patient should complete her family
Postmenopausal should be regularly seen

MEDICAL MANAGEMENT
Indications:-
A young woman who has symptomatic fibroid but does
not want surgery
For elderly women- diagnostic curettage and ablation
Drugs to shrink the fibroid
 DRUGS IN USE

Danazol (danacrine )-400mg-800mg daily in

divided doses for 6-9 months.
Suppresses –FSH/LH secretion by the ovaries
leading to low estrogen and progesterone
Causes endometrial atrophy.
May reduce tumour size.
Side effects:-Increase LDL, decrease HDL,
weight gain, oedema, reduced breast size, oily
skin and hirsutism
GnRH Agonists – peptides synthesized by substituting the
6th and 10th amino acid in the native GnRH molecule to
achieve longer action and better binding to receptor site.
It causes flare effect and after the 2nd week it down
regulates the pituitary leading to low FSH, LH and
oestrogen.
When used for 6months tumuor size reduces by 57%
with the hope to do surgery
Side effects:- tumour size returns after use.
Pseudomenopause, osteoporosis and fracture.
Mifepristone:-competively interferes with progesterone and oetrogen
sites in the nucleus thereby reducing their effect.
Given 25mg daily for 3 months.
It may reduce the fibroid size.
PROGESTOGENS:-
Gestrinone, depomedroxy progesterone acetate all cause atrophy of
the endometrium and reduce uterine bleeding.

LNG-IUCD atrophies the endometrium and inhibits the insulin like

growth hormones thereby reduces the fibroid.

Fadrosole which is an an aromatase inhibitor blocks the conversion of

testosterone to oestrogen.

GENE therapy:- Still exprimental.

RADIOLOGICAL INTERVENTION THERAPY
(uterine artery embolizattion)
It uses poly vinyl particles via a catheter through
the femoral artrery to selectively occlude the
uterine artery in order to cause ischaemic
necrosis of the fibroid.
Can be used for fibroid size <24wks and those
who reject hysterectomy.
Not used for pedunculated or infected fibroid.
Menorrhagia is rapidly reduced.
 Complications
Allergy to contrast medium
Haematoma and trauma to femoral artery
Ischaemia and ovarian failure
Infection
Damage to endometrial vasculature &
synaechia
Maybe larger and more spherical particles
may reduce the complications.
IMPACT ON FERTILITY OF NON
SURGICAL PROCEDURES
Literature review from Dec 2002 -2004 on current
opinion in obstetrics and gynaecology states that:-
A large randomised trial showed that pre operative
treatment with GnRH agonist did not improve surgical
result or blood loss.
In general non surgical therapy do not enhance
fertility as they cause anovulatory cycles.
Few data exist as regards the course of pregnancy
and outcome following embolization
Therefore non surgical therapy is experimental for
those who need pregnancy but beneficial to those who
do not desire pregnancy
 TYPES OF SURGERY

Myomectomy:- this involves the

enucleation of myomas from the uterus .
Indications:-
Fibroid polyp
Symptomatic fibroid in a patient who
desires to conserve her reproductive and
menstrual function
 A Fibroid polyp that prolapses through
the cervix with a thin pedicle can be twisted
and avulsed in theatre.
Vaginal myomectomy
A Fibroid polyp with a wide base: the
cervico vaginal mucosa can be reflected
for the myomectomy to be done. The
wound is closed in two layers.
 ABDOMINAL MYOMECTOMY

This is full laparatomy

Double consent should be obtained from the patient
Techniques to reduce blood loss
Pre operation:-
Surgery done in the proliferative phase of menstruation
period.
Haemodilution with normal saline, autologous blood
transfusion, use of 200ug misoprostol intravaginally 1
hour before surgery
Intraoperatively:-
Hypotensive anaesthesia
Application of rubber tourniquet at the anterior posterior
lower uterine isthmus occluding the uterine vessels for
40 – 45mins
Smaller rubber tourniquet is applied lateral to each
ovary to occlude the vessels. Bonneys clamp can be
used
Diluted vasopressin into the superficial myometrium and
the overlying serosa
Use of laser for the incision
Fast surgery
Few incisions preferably at the anterior midline
Use one incision to remove as many fibroid nodules as
possible
PREVENTION OF ADHESIONS

Application of bonney’s hood

Reduce number incisions
Cover uterine surface with cellulose material
Wash off all blood clots
instill into peritoneal cavity some normal saline
or dextran 70
Insert a drain
 POST OPERATIVE TREATMENT
Nil orally , I.V. fliuds until bowel sounds are
established
Analgesics
Antibiotics
Urethral catheter for 24 hours
Blood transfusion where necessary
Stitches out on the 7th or 8th post op day’
Follow up in two weeks
 Complications
Haemorrhage
Trauma to bladder, GIT, Ureters
Infections
Adhesions
Infertility
Recurrence
Rupture scar during labour if the uterine
cavity was bridged during the myomectomy
 ABDOMINAL HYSTERECTOMY

Indications:-
Huge uterine fibroid > 24wks
Patient who has completed her family with
symptomatic fibroid
Recurrent symptomatic fibroids
Rapidly growing fibroid in the menopausal
period
Fibroids with recurrent PID
PRE OPERATIVE PREPARATION

Counsel patient and obtain consent

FBC
URINALYSIS
E/U
PAP SMEAR
ECG FOR THOSE > 50yrs
ENDOMETRIAL BIOPSY
OBESE PATIENT TO REDUCE WEIGHT
ANAESTHESIA :- Could be spinal or general
Clean vagina and cervix with antiseptic solution, then paint
with methylene blue
Pass self retaining urethral catheter
Clean anterior abdominal wall with antiseptic
Surgery
POST OP RX
Adequate fluids
Analgesic
Urethral catheter out >24 hours
Oral sips when bowel sounds return
Open wound 5th day, stitches out on 7th -9th day post op
 COMPLICATIONS

Anaesthetic complications
Haemorrhage intra-operatively, post – operatively,
reactionary and secondary
Cuff haematoma
INJURIES
Bladder- VVF
Ureters –transection ,ligation, crushing and kinking.
Uretero-vaginal fistula
Infection
Wound dehiscence
Pelvic adhesion and intestinal obstruction
Deep vein thrombosis
 VAGINAL HYSTERCTOMY
Indications:
same as for abdominal hysterectomy but the
size of the fibroid should be < 12wks

CAESAREAN MYOMECTOMY
Should be avoided as much as possible
However may be done if leiomyoma is along the
line of incision
Bleeding is more but not statistically significant
There should be some pints of blood available
 MYOMECTOMY AND IVF

For submucuos fibroid, myomectomy should

be done first.
For others, IVF first.
 CONCLUSION
The treatment of uterine fibroid has been
very dynamic in recent times in order to
cope with the trend of social needs of
women in the reproductive age group.
The non surgical procedures are
experimental in women that have not
completed their families but may be useful
for those that have completed their
families and are scared of any major
surgery.