Uterine Fibroid | Medical Science Optional Notes for UPSC PDF Download

Types of uterine fibroids

Leiomyomas are classified according to their location within the uterus: 

• Intramural/Interstitial leiomyoma (most common)-75% 
• Submucosal leiomyoma-15% -- > submucous myomatous polyp (Usually single) 
• Subserosal leiomyoma -10% - > Pedunculated fibroid -- > Parasitic fibroid 
• Diffuse uterine leiomyomatosis

Clinical features

• Clinical Presentation:
  • Fibroids don't always cause symptoms, with up to 50% of women being asymptomatic.
• Menstrual Disturbances:
  • Manifestations include menstrual disturbances such as menorrhagia, polymenorrhagia, intermenstrual bleeding, continuous bleeding, and postmenopausal bleeding.
• Infertility:
  • Fibroids may contribute to infertility.
• Pain:
  • Pain symptoms encompass spasmodic dysmenorrhea, backache, and abdominal pain.
• Abdominal Lump or Mass:
  • Patients may notice a lump in the abdomen or a mass protruding at the introitus.
• Pressure Symptoms:
  • Fibroids can exert pressure on adjacent viscera, leading to symptoms involving the bladder, ureters, and rectum.
• Pregnancy-Related Complications:
  • Pregnancy-related complications include pregnancy losses, postpartum hemorrhage, and uterine inversion.
• Vaginal Discharge:
  • Vaginal discharge may be present.
• Pseudo-Meigs Syndrome:
  • In rare cases, a pedunculated fibroid with ascites can lead to pseudo-Meigs syndrome.

Fibroids-Secondary changes/Complications

• Atrophy (after menopause, HCG therapy, after delivery)
• Hyaline change, cystic degeneration and fatty degenerations (no clinical significance)
• Calcareous degeneration, osseous degeneration (Womb-stones in graveyards)
• Red degeneration
• Sarcomatous change
• Torsion, haemorrhage
• Infection/ulceration, particularly in the dependent part of a submucous polyp
• Inversion of the uterus
• Endometrial carcinoma associated with fibromyoma
• Endometrial and myohyperplasia
• Accompanying adenomyosis
• Parasitic fibroid

Red degeneration 

• Seen during pregnancy, particularly after the age of 40.
• Presentation includes fever, abdominal pain, and a tense and tender myoma.
• Gross appearance is characterized by a purple-red color with a fishy odor.
• Microscopic features involve thrombosed blood vessels with the diffusion of blood pigments.
• Clinical indicators include elevated ESR, moderate leucocytosis.
• Ultrasound is helpful in the diagnosis.
• Differential diagnosis includes appendicitis, twisted ovarian cysts, pyelitis, and accidental hemorrhage.
• Management is typically conservative.

Sarcomatous change

• Occurs after the age of 40 with a 0.5% incidence.
• Intramural and submucous tumors have a higher potential for sarcomatous change.
• Sudden growth of the tumor, along with pain and bleeding, is characteristic.
• Presentation includes fever, abdominal pain, and a tense and tender myoma.
• Gross appearance is yellowish-grey and hemorrhagic, with a soft and friable consistency.
• Microscopic examination reveals nonencapsulation and hematogenous spread.

Differential diagnosis

Haematometra/Pyometra Causes:

• Pregnancy
• Adenomyosis
• Bicornuate uterus
• Endometriosis
• Ectopic pregnancy
• Chronic pelvic inflammatory disease (PD)
• Ovarian tumor
• Chronic inversion
• Full bladder

Pyometra-Specific Causes:

• Bilateral tubo-ovarian masses
• Pelvic endometriosis
• Endometrial carcinoma
• Uterine sarcoma
• Ovarian neoplasms
• Fibroid polyp/uterine inversion
• Paraovarian cysts
• Pelvic kidney

Investigations

• Blood Glucose Test (BGT) / Hemoglobin (HB)

Ultrasound:

• Fibromyoma:
  • Well-defined rounded tumor
  • Hypoechoic with cystic spaces
• Adenomyosis:
  • Diffuse growth within intramural cystic spaces
• Additional Ultrasound Techniques:
  • 3D USG: Precise localization and identification of fibroid type (management role)
  • Doppler USG: Shows vascularity of the uterus and fibroid; differentiates between fibroid and adenomyosis (blood flow surrounds a fibroid but diffuses through adenomyosis)
  • Note: USG cannot recognize sarcomatous change in fibroid (MRI is required for this).
• Hysterosalpingography and Sonosalpingography
• Hysteroscopy
• Dilatation and Curettage (D&C)
• Magnetic Resonance Imaging (MRI):
  • Accurate in identifying adenomyosis and sarcomatous changes

Treatment

• Small and asymptomatic uterine fibroids do not require removal or medical treatment.
• Observation every 6 months is a suitable approach.

Indications for Treatment in an Asymptomatic Fibroid

• Infertility
• Habitual abortions
• A fibroid larger than 12 weeks in size
• Pedunculated fibroid capable of causing torsion
• Pressure effects, such as urinary retention leading to urinary tract infection (UTI)
• Rapidly growing fibromyoma

All symptomatic fibroids needs treatment

One should remember that the tumour can regrow after stoppage of the drug.

Advantages and Disadvantages of GnRH Therapy

Indications for surgery 

• Size > 12 weeks 
• Cornual fibroid causing infertility 
• Pedunculated cornual fibroid 
• Pregnancy with torsion of pedunculated fibroid

Woman desirous of child bearing and wishing to retain uterus with infertility

Myomectomy instruments

Treatment

• Woman over age 40 years, multiparous or associated with malignancy 
• Uncontrolled hemorrhage or unforeseen surgical difficulties during myomectomy

Adenomyosis of the Uterus

Adenomyosis is characterized by the ingrowth of endometrium (including stromal and glandular components) directly into the myometrium.

Etiology

• Vigorous curettage
• Repeated childbirth
• Excess estrogen

Clinical Features

• Multiparous females aged over 40
• Most common symptom: Menorrhagia followed by dysmenorrhea
• Additional symptoms include pelvic discomfort, backache, and dyspareunia
• Per-Vaginal Examination:
• Symmetrical enlargement of the uterus corresponding to less than 12-14 weeks of pregnancy
• Bimanual Examination:
• Halban's sign: Tender, softened uterus

Diagnosis

• Primarily clinical
• Diagnostic hysteroscopy with curettage

Management of Adenomyosis

• Total hysterectomy (treatment of choice)
• Localized excision
• Levonorgestrel-containing intrauterine contraceptive device (IUCD) may be attempted in younger women.

Fibroids complicating pregnancy

• Pregnancy usually causes increase in the size of the fibroids
• High tendancy to undergo degenerative changes (Hyaline, cystic and red degeneration)
• May cause Pressure symptoms (Respiratory distress, urinary retention) and obstructed labour
• Increased risk of abortion or miscarriage, preterm labour, abnormal presentation, accidental haemorrhage, dystocic labour, postpartum haemorrhage (PPH), puerperal sepsis and uterine inversion.
• Management
• Conservative
• SURGERY IS CONTRAINDICATED (exception-if pedunculated fibroid undergoes torsion) In case of acute urinary retention-Continous catheterisation for 48-72 hours. Myomectomy at the time of cesarean section is not advised, because of the risk of uncontrolled bleeding (Exception-pedunculated fibroid)

Fibroid uterus-Repeats

Q1: Enumerate the common causes of menorrhagia in a 40-year-old woman. What are the different types of fibroid uterus? How would you manage the case of a 40-year-old woman suffering from menorrhagia due to fibroid uterus? (2017)

Q2: A 45-year old multiparous woman presents with a 2-year history of heavy, irregular periods and increasing tiredness. On clinical examination, she appears pale. The uterus is enlarged to 12 weeks in size. The cervix and adnexa are unremarkable. Describe, giving reasons, how you would manage the case. (2018)