CASE : FIBROID UTREUS

HISTORY-        a:- age (peak between 35-45 years)

                          b:-patients are usually nulliparous or history of long period of secondary infertility.

C :- menstrual irregularities- menorrhagia or hypermenorrhoea commonest. Metrorrhagia can be due to ulceration of submucous fibroid or fibroid polyp.

D;- symptoms of anaemia like shortness of breath, palpitation may be present.

E:- Heaviness or lower abdominal lump. Progress of the Lump(static, slowly increasing, rapidly increasing or initially slowly increasing but later rapidly.)

F:- pain is not a common symptom.  It may be due to cervical dilation induced by submucosal myoma, torsion of a pedunculated myoma or red degenration associated with pregnancy.  Congestive variety of dysmenorrhoea may be present due to associated endometriosis or adenomyosis.

G:- Pressure symptoms- More common with cervical fibroids.    When the       uterine size is increased, pressure is exerted on adjacent organs.  Urinary manifestations include frequency, urinary incontinence or difficulty in urination.  Posterior wall myoma exerting pressure on the rectosigmoid may cause constipation or tenesmus.  Rectal pressure can occur due to incarceration of the myoma in the culde-sac.

H:-infertility

CLINICAL EXAMINATION :-

General examination:-

               Usually various degrees of pallor.

Abdominal examination:-

Inspections- number, site, size, shape, surface, margin, Consistency,    mobility, temperature, tenderness.

Fibroid uterus is usually firm to hard in consistency, maybe cystic in  cystic degeneration.  Margins are well-defined except the lower pole which cannot be reached.  Surface nodular or uniformly enlarged. Mobile from side to side but not from above downwards.

Rising test to confirm intra-abdominal or parietal swelling.  Knee-elbow position and examination of the swelling again to decide whether the swelling is intraperitoneal or retroperitoneal.Hernial sites should be examined.

Percussion – fibroid is dull. (shifting dullness and fluid thrill should be examined in any lump abdomen)

Pelvic examination:-

Uterus is not felt separated from the swelling.  No groove is felt between uterus and mass.  Cervix moves with the movement of the tumor.

INVESTIGATIONS:- a)To confirm diagnosis.

                                b) Preoperative assessment.

1)    USG-TVS is the gold standard. Mapping accuracy of USG decreases in larger uteri containing multiple fibroids.  Smaller fibroid and subserosal fibroid may not be detected by TVS.  Addition of sonohysterography to TVS generally improves the sensitivity in detecting submucosal fibroids.  USG assessment should include examination of ovaries, presence peritoneal fluid also.

2)    CT scan has no role in work up of fibroid.

3)    MRI- It is the most accurate imaging modality for the diagnosis, mapping and characterization of myoma.  MRI finding can suggest further investigation in the line of leiomyosarcoma.

4)    Diagnostic laparoscopy- when uterus is less than 12 weeks gestation and associated with pelvic pain and infertility, it may reveal coincidental endometriosis, pelvic adhensions or tubal pathology.  It

differentiated between ovarian neoplasm and pedunculated fibroid if it   is unclear on the basis of clinical findings or USG.

5)    Measurement of depth of uterine cavity with a sound can give an idea whether the mass is uterine or ovarian.

6)    Complete hemogram, sugar, urea, creatinine, x-ray chest, ECG, urine and stool examinations.

7)    Urinary tract study if urinary symptoms present.

-       cystoscopy may be required to rule out intrinsic bladder lesion.

-       IVU to demonstrate ureteral deviation, compression or dilatation in case of laterally located fibroid, broad ligament fibroid or cervical fibroid.

8)    PAP smear to rule out associated cervical malignancy.

9)    Endometrial sampling to rule out endometrial hyperplasia or carcinoma which may coexist.

DIFFERENTIAL DIAGNOSIS:-

Full Bladder- Strictly suprapubic, cystic or tense cystic, ill defined margin, tendency of  urge on pressure, disappear after catheterization.

Pregnancy- Recent history, amenorrhoea, soft elastic feelings, Braxton- Hick’s contraction, External ballotment present, USG confirmed.

Ovarian  tumor- Slow growing, no menstrual abnormality, cystic, tense cystic or sometimes solid in feel, well defined margin including lower one, usually freely mobile, uterus is separated from lump, USG confirmed.

Adenomyosis- Along with menorrhagia, congestive

                         Dysmenorrhoea is most prominent symptoms, lump is rarely  more than                                         14-16weeks pregnant uterus, uniform swelling , USG confirm.

                        

                      

Encysted peritonitis- History of  Koch’s infection , usually associated with  amenorrhoea, cystic lump with ill defined margin, uterus is separated, USG.

Dysfunctional uterine bleeding-uterine lump usually is not more than 12-14 weeks pregnant uterus.  USG to rule out fibroid.

Pelvic inflammatory disease- Women may present with pelvic pain, tender pelvic mass, abnormal uterine bleeding.  USG and laparoscopy to confirm.

Endometriosis- Presented with chronic pelvic pain or congestive dysmenorrhoea, endometriotic cyst of ovaries may mimic myomas.  Laparoscopy is the gold standard of diagnosis.

                                                                                                              

      TREATMENT:

No treatment is required for asymptomatic fibroids which are less than  12  weaks size after clinical examination or found incidentally in USG.

                        

                         Non- surgical treatment

                        1.improvement of general condition and anemia.

2.Estrogen and progesterone therapy in combination or     progresteronealone, ofteb are the first line of treatment for patient with uterine myoma and abnormal uterine bleeding.  It brings endometrial atrophy and stabilization but as it is a temporary measure and they have not been shown to reduce myoma size.

3. GnRH agonist causes amenorrhea and rapid decline of uterine and   myoma size.  Mean uterine size decreases 30-64% after3-6 months of therapy.  Maximum response occurs by 3 month.  After stoppage of treatment menses return in 4-6 weeks and myoma and uterine size return to pretreatment level in 3-4 months.

      Indications of GnRH agonist:-

a)    Severe pre-operative anemia, minimizing the need for transfusion,

b)    Preoperative shrinkage of large and awkwardly situated fibroid to reduce blood loss and tissue injury.

c)    Preoperative shrinkage also facilitate vaginal hysterectomy, hysteroscopic resection or ablation and laparoscopic destruction possible.

d)    Preservation of fertility in women with large leiomyoma before attempting conception or preoperative treatment before myomectomy.

e)    Treatment of women approaching menopause to avoid surgery.

f)     Medical contraindications to surgery.

It should be commenced in the midluteal phase for most rapid pituitary gonadotrophin    down regulation no sexual intercourse that month to rule out pregnancy. Estrogen progesterone add-back can be given back to prevent osteoporosis, but it reduces the effectiveness of GnRH agonist .  Use of GnRH agonist in the preoperative phase may make surgical plane less distinct and myomectomy more difficult.  A small fibroid becomes a tiny one and may be missed during operation There is delay in diagnosis of leiomyosarcoma.

4)GnRH antagonist directly inhibits action of GnRh on the pituitary resulting in immediate gonadal suppression and avoidance of stimulatory phase seen with agonist.

5) Aromatase inhibitors directly inhibit ovarian estrogen synthesis and serum estrogen levels decrease after one day of treatment.

Myomas are known to over express aromatase, an estrogen synthetase, which suggests that myoma may produce their own estrogen and aromatase inhibitors can target the local source of estrogen and thus decrease myomavolume.

6) Mifepristone- antiprogestin, a progresterone receptor modulator with primarily antagonist action.  There are reports of shrinkage of uterine fibroids in response to continuous therapy with mifepristone.  A daily doses of 5-50 mg of mifepristone were used in various studies for a periods of 3-6months, highlights that  mifepristone therapy effectively regress myoma size while maintaining stable bone density; however endometrial hyperplasia may limits the long term therapy.

7) Danazole and gestrinone have been studied for treatment uterine myoma.  Both the drugs lead to significant reduction in myoma volume.  Androgen side effects of these drugs are there most prominent disadvantages.

8) Levonorgesteral containing intrauterine device has proven, effective, reversible treatment for menorrhagia by inducing endometrial atrophy.  Enlarged uterus with distorted uterine cavity or a submucosal fibroid is a contraindication for LNG-IUS use.

SURGICAL MANAGEMENT :-

Indications for surgery:-

ü  Abnormal uterine bleeding with resultant anaemia unresponsive to hormonal management.

ü  Chronic pain with severe dismenorrhea, dyspareunia, lower abdominal pressure or pain.

ü  Acute pain as in torsion of a peduculated leiomyoma or prolapsing submucosal fibroids.

ü  Urinary symptoms or signs such as hydronephrosis after complete evaluation

ü  Infertility with leiomyoma as the only abnormal finding.

ü  Markedly enlarged uterine size with compression symptoms or discomfort.

ü  Rapid enlargement of the uterus during premenopausal years or any increase

in uterine size in postmenopausal women because of the inability to exclude uterine sarcoma.

Types of surgery:-

Hysterectomy:-

Routes depend upon the size of uterus, the situation of fibroids, history of previous surgical procedures.  Hysterectomy can be done by abdominal route, vaginal route or laparoscopic assisted vaginal route.  Shrinkage of myoma with GnRH can be done prior to LAVH or vaginal hysterectomy for large fibroids will be rendered easier by prior enucleation of fibroid.  Ureters maybe vulnerable during removal of a broad ligament fibroid or lateral fibroid and their pathways almost be identified.  Incase of large cervical fibroid hemisectionof the uterus followed by enucleation  of the fibroid is an alternative approach in order to gain access  to uterine artery and cervix.

Myomectomy:-

Indications-a) Patient is in the reproductive period, desirous of having a baby. b) In case of recurrent pregnancy loss due to fibroid.

Infertility evaluation, hysteroscopy to detect a fibroid encroaching uterine cavity or tubal block and endometrial carcinoma should be done before myomectomy.

Myomectomy can be done by hysteroscopy incase of submucosal fibroid, or laparotomy.

Patients should be counseled about the recurrence  of myoma which is as high as 50% and about one third patient requires repeat surgery.  She may requires hysterectomy at any time during operation.  It is better to remove as many fibroids as possible through a single incision to prevent postoperative adhesion. 

Incision on the posterior wall be better avoided to prevent adenexal adhesion.  Prevention of blood loss during myomectomy can be done by Bonney’s clamp and Rubin’s tourniquet.  Now these procedures are replaced by use of vaso-occlusive injection Vasopressin used either intramurally, or perivascularly  in the broad ligament at the junction of anastomosis of ovarian and uterine blood supply.  Myoma greater than 4-5 cm and not having greater than 50% protrusion into the uterine cavity are not good candidates for hyteroscopic removal.

Uterine artery embolization(UAE):-

It is a minimally invasive technique for any symptomatic fibroid except pedunculated subserous  fibroid. Other contradiction is pelvic inflammation. The disadvantage is no pathological confirmation of uterine fibroid is obtained and uterine sarcoma could be missed. UAE may be an ideal conservative treatment for leiomyoma to eliminate symptoms, reduce the size of myoma, limit recurrence of future myoma and preserve fertility.  But UAE is not without complications like pain, nausea and vomiting and general malasia, (Post embolization syndrome). Expulsion or sloughing f fibroid occur in few case particularly common in submucous fibroid.

Myolysis:-

It can be done laparoscopically by electrosurgical heat, laser energy or cryotherapy.  This procedure termed myolysis is accomplished by destruction of tumour tissue or obliteration of vascular supply of fibroid.

Other points to remember:-

Ø  Ascites may present along with myoma.  Myoma may attach to omentum and get blood supply from omental vessels (floating myoma) , If there is torsion and obstruction of these vessels there may be transduction of fluid and development of ascites.

Ø  Polycythemia may be present due to elevated level of erythropoietin.

Ø  Benign metastasizing uterine myoma characterizied by myoma like lesion in lung.

Ø  Intravenous leiomyomatosis is a hormonally responsive disease that manisfests as vermiform extensions originating in the uterus that can extend as far as the heart.

Ø  Shrinkage of myoma with GnRH against can be done before. Performing vaginal hysterectomy or LAVH.

Ø  It is difficult to assess pelvis during hysterectomy for large fibroid.  It can be made easy by prior enucleating the fibroid.

Ø  Ureter may be vulnerable during operation of broad ligament fibroid, so their pathways may be identified.

Ø  There is no contraindication to oral contraceptive in women known to have fibroids provided uterine volume is monitored and there is no increase in size of fibroids.  In women with out fibroid long term oral contraceptives may have a protective against tumor development.

Ø  Pregnancy related manifestation-

Increase in size, mostly in the early pregnancy, myoma less than in 5 cm diameter increased in size and larger myomas decrease in size during the second trimester.

Red degeneration.

Miscarriage, PROM, placental abruption , malpresentation, prolong labor, increase operative interference.