2010 fibroid

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( also called uterine Leiomyoma , Myoma , Myomata uteri, fibromyoma ). FIBROID

objective : 

objective * There is many benign lesion of the uterus the most important is fibriod *In spit that fibriod is benign tumor it cause many structural and functional disturbance in reproductive life of women's. *50% asymptomatic and the other group has one or more of important symptoms. *Secondary changes in fibroids makes the tumor more difficult in diagnosis and management . *There is different ways in treatment the most curative is myomectomy which is bloody surgery needs preparation and a written consent for hysterectomy.

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. Definition : Circumscribed , benign tumor composed of muscle with fibrous connective tissue elements. . most common masses of uterine origin. . may occur singly but usually multiple ( as many as 100 or more have been found in a single uterus). . in 20 - 40% of women of reproductive age. . more often found in nulliparous women or in women who have not been pregnant for sometime. . 3 - 9 times more common in blacks. .may be found in organs outside uterus such as fallopian tube, vagina, round ligament, uterosacral lig., vulva, and GIT

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A etiology : localized proliferation of smooth ms.Cells and there is gradual addition of fibrous material . . fibroids arise from immature ms. Cells & cell nests. Contraction of uterine muscles  points of stress within the myometrium  act as growth stimuli to immature muscle cells  fibroids. . dependent on estrogen for growth : increase in pregnancy. Rarely found before puberty, and stop growing after menopause. New myomas rarely appear after menopause

Types of myomas:: 

Types of myomas : 1.Intramural myoma ( interstitial ) : most common, pseudo encapsulated , isolated nodules of varying sizes, occurring within the wall of the uterus.

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: 2.Sub mucous myoma : beneath the endometrium, grow into the uterine cavity, maintaining attachment to the uterus by a pedicle, may associated with disturbed bleeding pattern

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3.Sub serous myoma : beneath the serosa, usually asymptomatic , grow out toward the peritoneal cavity, may reach a large size , and also may develop a pedicle ( pedunculated ), it may be mobile and may attach to the surrounding structures.

Symptoms:: 

Symptoms: 1.Abnormal menstrual bleeding : most common symptoms, it's typically Menorrhagia. 2.Pain : acute pain associated with either torsion of a pedunculated myoma or infarction of myoma . 3.Pressure : as myomas enlarge , they may cause a feeling of pelvic heaviness or produce pressure symptoms on the surrounding structures: a. Urinary frequency : a common symptoms. b.Urinary retention : when myoma creates a fixed retroverted uterus. c.May cause unilateral urethral obstruction and hydronephrosis . d.Constipation and difficult defecation : by large posterior myoma . 4.Reproductive disorders : a. infertility. b.Increase incidence of abortion and premature labour.

Signs :: 

Signs : 1.Abdominal examination : may be palpated as irregular, nodular tumours protruding against the ant. Abdo. Wall, usually firm upon palpation. Softness and tenderness  suggest the presence of edema, sarcoma, pregnancy, or degenerative changes. 2.Pelvic examination : the most common finding is uterine enlargement. The shape of the uterus is usually irregular in outline.

Secondary changes in Fibroids: 

Secondary changes in Fibroids 1 .Atrophy. 2 .Necrosis. 3 .Degeneration (Hyaline degeneration, Cystic degeneration, Fatty degeneration, Calcification, Red degeneration or necrobiosis). 4 .Infection. 5 .Vascular changes. 6 .Malignancy (Sarcoma).

Differential diagnosis:: 

Differential diagnosis: 1.Dysfunctional uterine bleeding : irregular bleeding with slight enlargement of the uterus. 2.Adenomyoma : heavy menstrual bleeding accompanied by pain. 3.Ovarian tumours : rate of growth is rapid, u.s. 4.Inflammatory swellings : 2ry dysmenorrhea, tenderness, uterus not enlarged. 5.Abdominal & pelvic carcinomas : laparatomy is often justified. 6.Cervical & endometrial carcinomas : cytological exam. And biopsy. 7.Pregnancy : amenorrhea, soft elastic uterus enlargement. U.S., immunological tests for preg

Malignancy :: 

Malignancy : Rare , about 1 - 3 / 1000, may be increased if: Age >40 yrs, solitary fundal myoma , rapid increase of size.

Treatment:: 

Treatment : . if the tumour is not excessively large, and there are no symptoms, treatment may not be necessary

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1.Observation : in absence of pain , abnormal bleeding, pressure symptoms, or large myomas, periodic examinations are sufficient management especially if the patient is nearing menopause ( the myoma will atrophy as estrogen level falls ). a. Bimanual examination every 3-6 months. b.Palpation of uterosacral lig . for evidence of endometriosis ( often coexists with fibroids ). c.Regular blood counts , and oral iron may be required. d.Pelvic u.s.

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2.Gonadotropin - releasing hormone ( GnRH ) agonists : Long acting GnRH agonists  suppress gonadotropin secretion  pseudomenopause, 55% reduction in the size of the myomas, the myomas usually regrow after the GnRh therapy is discontinued. Gnrh therapy may cause osteoporosis in prolonged therapy.

3.Surgery: : 

3.Surgery : * Indications: I. bleeding , usually with sub mucous or intramural myomas. II.Pain. III.When the size of the uterus exceeds that of a 12 week gestation. IV.Sign & symptoms of pressure on the bladder , bowel, or GIT.

* Surgical procedures:: 

* Surgical procedures : a.Myomectomy: removal of single or multiple myomas while preserving the uterus. usually reserved for women who desire pregnancy. 30% recurrence rate within 10 years, higher in blacks. the incidence of becoming pregnant is 40% after myomectomy.preoperative GnRH agonist can reduce size of myoma up to 55%. Pelvic pain , menorrhagia, infection, and adhesion formation may occur after myomectomy.

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b.Hysterectomy : if the indications for surgery are present & if the patient's childbearing is complete , total removal of the uterus is the procedure of the choice. With hysterectomy both leiomyoma and any Associated disease are removed permanently And there is no risk of recurrence. . Ovaries should be retained in women less than 40-50 years of age

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Example: 25 years old woman with 4 children and symptomatic fibroid  Hysterectomy.

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*glandular proliferation with or without cytological atypia. *The aetiology may be attributed to the unopposed secretion of estrogen by progesterone. *Unopposed estrogen is characteristic of chronic anovulatory states such as polycystic ovary disease; and estrogen-secreting tumours such as granulosa-theca cell tumour. *The risk of progression to endometrial carcinoma is 1 - 14% in untreated cases, it is greatest in postmenopausal women and in women with atypical adenomatous hyperplasia. ENDOMETRIAL HYPERPLASIA

Types:: 

Types: 1.Adenomatous hyperplasia : The glands are hyperchromatic and separated by strands of stroma, there is no invasion or cytologic atypia. 2.Atypical adenomatous hyperplasia: It is concedered carcinoma-in-situ of the endometrium. The glands are with intense hyperchromatism and nuclear atypia, there is little intervening stroma but no invasion

Treatment:: 

Treatment: I. Teenagers : . cyclic estrogen with progestin for 6 months, and endometrial sampling should be done regularly. . if the patient continues to be anovulatory after medical treatment, oral estrogen and progestin or cyclic medroxyprogesterone acetate ( 10mg for 10 days every other month) should be continued to induce stabilization of the endometrium and to control withdrawal bleeding

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ii.Women of childbearing: . 3 courses of cyclic estrogen with progestin followed by a repeat of endometrial sampling. . if the pregnancy is desired , ovulation can be induced with clomiphene citrate. . If the pregnancy is not desired, cyclic estrogen with progestin or cyclic medroxy- progesterone acetate.

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iii.Perimenopausal and postmenopausal women : 3-6 months of cyclic medroxyprogesterone acetate ( 10-20mg for 10-12 days every month) or a depot of medroxyprogesterone acetate ( 200mg I.M. every 2 months for three courses), repeat sampling at 3-6 months is mandatory. Hysterectomy: especially in persistent hyperplasia following treatment with progestational agents or in women with severe atypical adenomatous hyperplasia

Dr. Essam Abushwereb. Consultant Gynae&obst.: 

Dr. Essam Abushwereb. Consultant Gynae&obst. Thank you