Fibroid 15 mark Answe with respect to shaw gynaecology book

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Uterine Fibroids (Leiomyomata Uteri) - 15 Marks

(As per Shaw's Textbook of Gynaecology; supplemented by Berek & Novak's Gynecology)

Definition

Uterine fibroids (leiomyomas, myomas) are benign, monoclonal tumors of the smooth muscle cells (myometrium). They contain large aggregations of extracellular matrix composed of collagen, elastin, fibronectin, and proteoglycan. They are the most common tumors of the female genital tract.

Incidence

Most common benign tumors of the uterus - found in 20-25% of women of reproductive age clinically; up to 77% on fine serial sectioning of hysterectomy specimens.
Rare before puberty; most common between 30-45 years.
More common in nulliparous and infertile women.
More common in Black women (incidence ~60% by age 35; >80% by age 50) compared to White women (~40% by 35; ~70% by 50).
They are the most frequent indication for hysterectomy (~240,000 procedures/year in the US).
They regress after menopause due to estrogen withdrawal.

Etiology / Pathogenesis

Each fibroid arises from a single smooth muscle cell (monoclonal origin).

Hormonal factors:

Estrogen and progesterone are the principal promoters of fibroid growth. Fibroids express more estrogen receptors and progesterone receptors than normal myometrium.
Growth is accelerated during pregnancy and with OCP use; regression occurs after menopause.
Fibroids rarely occur before menarche or after menopause.

Growth factors:

Epidermal growth factor (EGF), insulin-like growth factor (IGF-I and IGF-II), transforming growth factor-beta (TGF-β), and basic fibroblast growth factor (bFGF) contribute to fibroid growth.

Genetic factors:

About 40% show chromosomal abnormalities - trisomy 12, deletions of 7q, t(12;14)(q14-15;q23-24) are commonest. These rearrangements involve the HMGI-C gene (high-mobility group protein) on chromosome 12.

Pathology

Macroscopic:

Firm, well-circumscribed, encapsulated tumors.
Cut surface shows a whorled, trabeculated pattern of interlacing muscle bundles.
Size varies from a few millimeters ("seedling fibroids") to very large tumors filling the abdomen.
A pseudo-capsule of compressed myometrium surrounds each fibroid.

Microscopic:

Bundles of smooth muscle cells in whorled pattern.
Cells are spindle-shaped with cigar-shaped nuclei.
No mitoses (unlike sarcoma).

Classification / Types (by Location)

Type	Description
Intramural (interstitial)	Most common (~75%). Embedded within myometrial wall
Subserosal (subperitoneal)	Project outward from uterine surface toward peritoneum
Submucous	Project into uterine cavity; most symptomatic (cause AUB and infertility)
Cervical	Arise from cervix (~2-3%)
Broad ligament (intraligamentary)	Develop within leaves of broad ligament
Parasitic	Lose uterine connection and derive blood supply from omentum/bowel

Pedunculated fibroids: Subserosal or submucous fibroids attached by a pedicle. A pedunculated submucous fibroid may prolapse through the cervix.

FIGO Classification (PALM-COEIN): Submucous fibroids are classified:

Type 0: Pedunculated, entirely intracavitary
Type 1: <50% intramural
Type 2: ≥50% intramural

Degenerations (Secondary Changes)

Type	Description
Hyaline degeneration	Most common (>65%); replacement by hyaline tissue
Cystic degeneration	Further liquefaction of hyaline areas
Calcific (calcareous) degeneration	Calcification - commonest in post-menopausal women; "womb stone"
Red (carneous) degeneration	Aseptic degeneration with venous thrombosis; classically in pregnancy; causes acute pain and tenderness
Fatty degeneration	Rare; fatty infiltration following hyaline change
Necrosis	May follow torsion of pedicle or infection
Sarcomatous change (malignant)	Most feared; occurs in <1% (0.1-0.5%); usually leiomyosarcoma

Clinical Features

Symptoms

1. Abnormal Uterine Bleeding (most common)

Heavy menstrual bleeding (HMB) / menorrhagia is the cardinal symptom.
Most common with submucous fibroids (distort cavity, increase endometrial surface area).
Mechanisms: increased surface area, impaired uterine contractility, venous congestion, altered growth factors.
May lead to iron-deficiency anemia.

2. Pain

Dysmenorrhea - due to uterine contractions against the fibroid.
Chronic pelvic pain - from pressure effect.
Acute pain - red degeneration (especially in pregnancy), torsion of pedicle.
Dyspareunia.

3. Pressure symptoms

Urinary frequency, urgency, or retention - anterior fibroids pressing on bladder.
Ureteric compression causing hydronephrosis (rare).
Constipation, tenesmus - posterior fibroids pressing on rectum.
Edema of lower limbs - rarely due to venous/lymphatic obstruction.

4. Reproductive effects

Infertility: submucous fibroids decrease fertility by ~70% (alter endometrial receptivity via HOXA10/HOXA11 pathways, impair implantation).
Recurrent miscarriage.
Complications in pregnancy.

5. Abdominal enlargement - large fibroids cause visible/palpable lower abdominal mass.

Signs

Abdominal examination: Firm, irregular, non-tender mass arising from the pelvis that moves with the uterus; dull to percussion.
Pelvic (bimanual) examination: Uterus enlarged, irregular, firm, non-tender; moves freely in all directions unless fixed by adhesions. The mass is felt continuous with the uterus (confirms uterine origin).
In cervical fibroids: cervix is displaced; fibroid felt below the level of internal os.

Diagnosis

1. Ultrasonography (USG pelvis) - Investigation of choice

Confirms diagnosis, localizes fibroid, measures size.
Transvaginal ultrasound (TVS) more accurate for small fibroids.
Appearances: well-defined hypoechoic/heterogeneous mass with acoustic shadowing.

2. Saline Infusion Sonography (SIS) / Sonohysterography

Best for delineating submucous fibroids and cavity distortion.

3. MRI Pelvis - Gold standard for fibroid mapping

Best for determining number, size, location; useful pre-operatively.
Differentiates fibroid from adenomyosis and from leiomyosarcoma (sarcoma shows enhancement on Gd-DTPA).
Used before UAE (uterine artery embolization) and HIFU.

4. Hysteroscopy

Directly visualizes submucous fibroids; allows simultaneous resection.

5. Hysterosalpingography (HSG)

Shows filling defect in uterine cavity.

6. Others: CBC (anemia), LFT, renal function (if urinary obstruction); LDH isoenzymes (elevated in sarcoma).

Fibroids and Pregnancy

Incidence of fibroids in pregnancy: ~0.5-5%.
Effect of pregnancy on fibroids: Most fibroids do not significantly grow; ~50-60% remain stable in size. Some enlarge in the 1st trimester.
Red degeneration: Classically occurs in 2nd trimester; causes acute pain, localized tenderness, low-grade fever, vomiting. Managed conservatively (analgesia, hydration).
Obstetric complications:
- Malpresentation (breech, transverse lie)
- Placenta praevia (if lower segment)
- Preterm labour
- Obstructed labour (cervical fibroid)
- PPH (impaired uterine contraction)
- Increased Caesarean section rate
- Retained placenta

Treatment

Indications for Treatment

Menorrhagia causing anemia not responding to medical treatment
Pressure symptoms
Infertility due to fibroid
Rapid growth or suspicion of sarcoma
Pedunculated fibroid with risk of torsion
Fibroid complicating pregnancy

1. Expectant (Watchful Waiting)

Asymptomatic fibroids, small, near menopause - can be observed.
Serial USG every 6-12 months.

2. Medical Treatment

Drug	Mechanism	Use
GnRH agonists (leuprolide, goserelin)	Hypo-estrogenic state → fibroid shrinkage by 30-60%	Pre-operative to reduce size, treat anemia; max 3-6 months (bone loss)
Ulipristal acetate (selective progesterone receptor modulator)	Reduces fibroid size and bleeding	Medical management in Europe
Tranexamic acid	Antifibrinolytic	Controls HMB
NSAIDs	Reduce prostaglandins	Dysmenorrhea, mild HMB
Levonorgestrel IUS (Mirena)	Local progestogenic effect	Controls HMB in intramural fibroids (not submucous)
Combined OCP / Progestogens	Hormonal	Limited long-term benefit
Mifepristone	Anti-progestogen	Reduces fibroid size
Iron supplementation	Corrects anemia	Pre-operative preparation

3. Surgical Treatment

a) Myomectomy (uterus-conserving)

Indications: Symptomatic fibroids in women desiring fertility or uterine preservation.

Abdominal (open) myomectomy: For large, multiple, intramural fibroids. Classic incision over fibroid, enucleation, layered repair. Risk: adhesions, recurrence (~27%), conversion to hysterectomy.
Laparoscopic myomectomy: For accessible subserosal/intramural fibroids <10 cm; fewer adhesions, quicker recovery; requires advanced laparoscopic skills.
Hysteroscopic myomectomy: For submucous fibroids (Types 0, 1, 2); via resectoscope; day-case procedure.

Pre-operative: GnRH agonist to reduce fibroid size and blood loss; treat anemia with iron ± GnRH agonist.

Recurrence: New fibroids appear in ~27% within 10 years after myomectomy.

b) Hysterectomy (definitive treatment)

Indicated in: completed family, multiple large fibroids, failed myomectomy, sarcoma.
Can be abdominal, vaginal (if mobile), or laparoscopic.
Total hysterectomy preferred; cervical stump left only if subtotal.

c) Endometrial Ablation

For women with HMB and small submucous fibroids who have completed childbearing.
Not a treatment for fibroids per se; treats abnormal bleeding.

4. Radiological / Minimally Invasive Procedures

a) Uterine Artery Embolization (UAE)

Interventional radiology procedure; bilateral occlusion of uterine arteries with polyvinyl alcohol (PVA) particles.
Reduces fibroid volume by ~50-60%; controls HMB in ~85-90%.
Avoids surgery; uterus preserved.
Complications: post-embolization syndrome (fever, pain, nausea), amenorrhea, premature ovarian failure (~1-3%), expulsion of fibroid.
Contraindicated in women desiring pregnancy (effects on fertility unclear).

b) Magnetic Resonance-guided Focused Ultrasound (MRgFUS / HIFU)

High-intensity focused ultrasound causes thermal coagulative necrosis of fibroid under MRI guidance.
Non-invasive; outpatient procedure.
Limited availability; suitable for women with <3 accessible fibroids.

c) Radiofrequency Ablation (Acessa, Sonata)

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation of fibroid.

Differential Diagnosis

Ovarian cyst/tumor
Adenomyosis (uniformly enlarged, tender uterus)
Endometrial polyp
Pregnancy
Pelvic kidney
Carcinoma of the uterus or ovary

Complications

Anemia (iron-deficiency due to HMB)
Urinary tract obstruction / hydronephrosis
Torsion of pedunculated fibroid
Sarcomatous change (<0.5%)
Infertility and recurrent miscarriage
Complications in pregnancy and labour (see above)

Key Points for 15-Mark Answer (Summary)

Fibroids = benign monoclonal smooth muscle tumors of the myometrium
Most common benign pelvic tumor; most common cause of hysterectomy
Estrogen-dependent; regress after menopause
Types: intramural (most common), subserosal, submucous (most symptomatic)
Degeneration types: hyaline (most common), cystic, calcific, red/carneous (in pregnancy), sarcomatous (most dangerous)
Cardinal symptom: menorrhagia (especially submucous fibroids)
Diagnosis: USG pelvis (IOC), MRI (gold standard for mapping)
Red degeneration in pregnancy → conservative management
Treatment depends on: age, symptoms, desire for fertility
- Medical: GnRH agonists (pre-op)
- Surgical: Myomectomy (fertility-preserving) vs Hysterectomy (definitive)
- Interventional: UAE
Submucous fibroids reduce fertility; resection improves fertility

Sources: Berek & Novak's Gynecology (15th ed.), Chapter 11 - Uterine Fibroids (Parker WH); Shaw's Textbook of Gynaecology (standard reference content)

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