Part 2 book “Self assessment & review gynecology” has contents: Uterine fibroid, endometriosis and dysmenorrhea, disorders of menstruation, gynecological diagnosis and operative surger, gynecological oncology, miscellaneous question bank.
Chapter 11 Leiomyomata/Fibroids: Benign smooth muscle tumor of the uterus Fibroid is an estrogen- Uterine Fibroid FIBROIDS ¾¾ Fibroids are the most common benign solid tumors in females.Q ¾¾ It is the most common pelvic tumor.Q ¾¾ Most common age group affected is 35–45 yearsQ ¾¾ Fibroids are most commonly seen in nulliparous female.Q ¾¾Locations of fibroid is described as follows (Fig 11.1): dependent tumor Etiology/Pathogenesis of Fibroids Fig 11.1: Locations of fibroid Diseases commonly associated with leiomyomas— • Follicular cysts of ovary • Endometrial hyperplasia • Endometrial cancer • Endometriosis Fibroids are more common in— • Nulliparous females • Infertile females • Black women Fibroid is monoclonal in origin Multiple chromosomal abnormalities are detected in 50% of all fibroids—most common being translocation between the long arms of chromosomes 12 and 14 followed by deletion of long arm of chromosome Y Fibroids are related to both estrogen and progesterone Risk of fibroid increases as obesity increases Smoking is protective for fibroids Increasing parity decreases its incidence Most Common in Fibroid • Most common (M/c) variety of fibroid • • • • • • • • • • • • • • Fibroid with maximal symptoms To start with, all fibroids are M/c fibroid to undergo malignant change M/c fibroid to cause retention of urine Torsion is most common in Fibroid causing pseudo Meigs syndrome M/c menstrual symptom of fibroid Inversion is seen in M/c symptom of fundal fibroid Fibroid which leads to maximum abortion Wandering or parasitic fibroid Lantern on dome of St Paul Pseudocervical fibroid M/c fibroid to undergo calcareous degeneration – Intramural/interstitial (75%) followed by submucous (15%) and subserous (10%) – Submucous fibroid – Interstitial (Intramural) – Submucous – Posterior cervical – Large pedunculated subserous fibroid – Subserous fibroid – Menorrhagia – Fundal fibroid – Menorrhagia – Submucous fibroid – Subserous fibroid – Cervical fibroid – Fibroid polyp – Subserous fibroid Chapter 11 Uterine Fibroid Structure of Fibroids ¾¾ Fibroid is a well circumscribed tumor with a pseudocapsule which is formed by compressed adjacent myometrium ¾¾ The blood vessels supplying the fibroid lie in the capsule and run radially so that the center is the least vascular and periphery is the most vascular part of the fibroid ¾¾Thus, calcifications begin from the periphery of fibroid and degenerations begin from the center.Q ¾¾Most fibroids are slow growing Degenerations/Secondary Changes in a Fibroid Avoid = Atrophy Red = Red degeneration Hot = Hyaline degeneration (MC) Fatty = Fatty degeneration or calcification Meat = Myxomatous degeneration of Chicken = Cystic degeneration (Mnemonic: Avoid red hot fatty meat of chicken) Red Degeneration of Fibroid (also called as Carneous Degeneration) ¾¾It Smoking (both active and passive) is protective against fibroids as it leads to hyperestrogenism Broad ligament of fibroids are of types— • Those which arise from the uterus and grow toward the broad ligament and displace the ureter laterally – they are known as false broad ligament fibroids • Those which arise de novo from broad ligament and ureter is medial to this type of fibroid (i.e ureter is between uterus and fibroid) is seen mostly during pregnancy, especially mid pregnancy-2nd trimesterQ (But can occur at other times as well and in nonpregnant females also).Q ¾¾ It is an aseptic condition.Q ¾¾ The myoma suddenly becomes acutely painful,Q enlargedQ and tender.Q ¾¾Patient presents with: – Acute abdominal painQ Q – Vomiting – MalaiseQ – Slight feverQ Lab investigations: – Moderate leukocytosisQ Calcifications begin from – Raised esrQ the periphery of fibroid and Pathological changes in the tumor degenerations begin from the center ¾¾ Fibroid becomes soft, necrotic or homogenous especially in its center is stained Salmon pinkQ, or red (due to diffusion of blood pigments from the thrombosed vessels) ¾¾ It has a fishy odorQ (due to secondary infection with coliform organisms) ¾¾ Histologically: There is evidence of thrombosis in some vessels.Q ¾¾ Pathogenesis: There is subacute necrosis of the myoma caused by an interference in blood supply (aseptic infarction).Q ¾¾ It Management ¾¾ Conservative managementQ ¾¾ Patient is advised restQ ¾¾Analgesics are given to relieve the pain.Q ¾¾The acute symptoms subside in 3–10 daysQ and pregnancy proceeds uneventfully ¾¾Diagnosis is by ultrasound Differential Diagnosis ¾¾Appendicitis,Q twisted ovarian cyst,Q pyelitisQ and accidental hemorrhage.Q • M/c degeneration – Hyaline degeneration • Cystic degeneration is M/c in postmenopausal females and M/c in interstitial fibroid • Calcareous degeneration is M/c in subserous fibroids 221 222 Self Assessment & Review: Gynecology Sarcomatous Change ¾¾When Least common change in fibroid • Malignant change % = 0.2–0.5% • M/c fibroid to become malignant – Submucous fibroid • M/c malignancy – Leiomyosarcoma • Endometrial cancer is associated with fibroids in 3% cases a fibroid undergoes malignancy, the most common malignancy which is seen is leiomyosarcoma ¾¾Sarcomatous change is seen in only 0.2–0.5% of cases.Q ¾¾The malignant process begins from the center.Q ¾¾M/c in submucous followed by Intramural fibroid.Q ¾¾Diagnosis is made by histological examination of the removed myoma.Q ¾¾Changes seen in myoma are: Sarcomatous Myoma is yellowish gray in color (normally pinkish white), with soft and friable consistency (instead of firm consistency) Non encapsulation of the tumor (Normally fibroid is surrounded by a pseudo capsule) ¾¾Sarcomas with malignant behavior have 10 or more mitosis per ten high power field ¾¾Development of sarcoma can be suspected clinically, when a leiomyoma (usually in a post-menopausal woman) becomes painful, tender, grows rapidly, and produces systematic upset and pyrexia ¾¾Overall years survival rate in such patients = 20–30% Symptoms of Fibroid ¾¾Mostly fibroids are asymptomaticQ (M/C presentation) ¾¾Most common symptom—Menstrual disturbancesQ ¾¾Most common menstrual disturbance: Progressive menorrhagiaQ (seen in 30% cases) Other Menstrual Symptoms: MetrorrhagiaQ – (Continuous and irregular bleeding)Q Causes: Q Ulceration of submucous fibroid or polyp Q Sarcomatous change in leiomyoma Q Dysmenorrhea – congestive as well as spasmodicQ type seen ¾¾Pressure symptoms M/c fibroid to cause infertility and abortions is submucous fibroid ¾¾ Infertility: • M/c fibroid to cause urinary retention– posterior cervical fibroid • M/C fibroid to cause urinary frequency– Anterior cervical fibroid As a sole cause, fibroid is responsible for < 3% cases of infertility Causes: Q Fibroid hinders with the ascent of the sperm Q Interferes with implantation of fertilized ovum Q Can cause associated disturbance in ovulation Note: Presence of submucous fibroids decrease fertility rates and removing them increases fertility rates Subserous fibroids not affect fertility rates but removing them increases fertility Intramural fibroid slightly decreases fertility but removal does not increase fertility Chapter 11 Uterine Fibroid A fibroid usually does not cause pain Causes: Q Malignancy Q It is being extruded from body as a polyp Q Associated endometriosis Q Torsion of a pedunculated fibroma Q Degeneration ¾¾Pain: Mnemonic: My PET Dog ¾¾Other rare features of fibroid: Polycythemia: (Interesting as fibroids generally cause anemia due to blood loss Polycythemia is seen in broad ligament fibroids).Q Hypoglycemia and hypokalemia Fibroid Presenting symptom menorrhagia Irregular growth of uterus Non tender uterus Uterine size = 20 weeks pregnancy uterus IOC = USG Adenomyosis Menorrhagia and dysmenorrhea Symmetrical growth of uterus Tender to touch 10–20 weeks pregnancy size uterus MRI Gold standard– HPE Investigations ¾¾ M/c investigation done in fibroids or IOC is USG (It is most readily available, least cost-effective but not as accurate as MRI at determining the precise location or size of fibroids especially in larger uteri or those with multiple fibroids) ¾¾ Best investigation to detect a small submucous fibroid—hysteroscopy Differential diagnosis adenomyosis Management of Fibroids Indications for Operating an Asymptomatic FibroidQ: —Jeffcoate 7th/ed, p 496 ¾¾Fibroids larger than 12–14 weeks pregnancy.Q ¾¾Rapidly growing fibroids.Q ¾¾Subserous and pedunculated fibroid prone to torsion.Q ¾¾If it is likely to complicate a future pregnancyQ Note ¾¾If there is doubt about its natureQ According to the latest Q ¾¾Unexplained infertility and unexplained recurrent abortion concept - Asymptomatic —Dutta Gynae 4th/ed p 264 fibroids of any size can be ¾¾Uncertain diagnosis:Q If patient is symptomatic decide whether you give medical managed expectantly treatment or surgical treatment Indications of Medical ManagementQ ¾¾To treat anemia and recover hemoglobin levels before surgery.Q ¾¾To reduce the size of large fibroid and facilitate surgery.Q 223 224 Self Assessment & Review: Gynecology ¾¾Treatment of women approaching menopause to avoid surgery.Q ¾¾In women with medical contraindication to surgery or those who are postponing surgery.Q ¾¾For preservation of fertility in women with large myomas before conservative surgery like myomectomy.Q Indications of Surgical ManagementQ Definitive management of symptomatic fibroids is surgery Fibroids causing any symptoms like ¾¾MenorrhagiaQ or pressure symptomsQ like urinary retention (by a cervical or broad ligament fibroid) or chronic pelvic pain withQ severe dysmenorrhea, acute pelvic pain as in torsion of a pedunculated fibroid, or prolapsing submucosal fibroid ¾¾Unexplained infertility ¾¾Recurrent abortions due to submucous fibroid ¾¾Rapidly growing fibroid Medical Management of Fibroid Aims at ¾¾Decreasing the blood loss due to fibroid (as menorrhagia is the most common symptom of fibroid) ¾¾ Decreasing the size of fibroid But the main problem is that tumor may grow on cessation of treatment Hence, main role of medical management is preoperative and in women nearing menopausal age to avoid surgery A Drugs to decrease size of fibroid Mnemonic: U Are Gynae MD U: Are: Gynae M D Ullipristone Aromatase inhibitor–Letrozole GnRH agonist GnRH antagonist Mifepristone Danazol/Gestrinone B Drugs to decrease blood loss/menorrhagia in case of fibroids: • • • • All the drugs used to decrease size of fibroid can be used along with Progesterone releasing intrauterine devices–LNG IUCD OCP’s (Low dose pills) Tranexamic acid–non-hormonal drug Surgical management Chapter 11 Uterine Fibroid Some Specific Indications for Hysterectomy ¾¾In patients > 40 years of age.Q ¾¾Multiparous women.Q ¾¾If fibroid is associated with malignancy.Q ¾¾During myomectomy, if their is uncontrolled hemorrhage or other surgical difficulty.Q Hysterectomy for fibroids can be done by • Abdominal route • Vaginal route–done, if size of uterus is < 12 weeks in size Myomectomy ¾¾Myomectomy is specifically indicated in an infertile woman or woman desirous of bearing child and wishing to retain the uterus.Q ¾¾ Prerequisites: Anemia should be corrected.Q Q All other causes of infertility should be excluded Q Male factor infertility should be ruled out (husband semen analysis should be normal) Diagnostic D and C or hysteroscopy should be performed in case of irregular cycles, to detect any polyp and to rule out endometrial cancerQ Hysteroscopy or hysterosalpinography (HSG) should be done to detect a fibroid encroaching the uterine cavity or a polyp or tubal block.Q Time of Myomectomy ¾¾It should be performed in immediate postmenstrual phase to reduce blood loss during surgeryQ ¾¾It should not be performed during pregnancy and at the time of cesarean section.Q Laparoscopic ¾¾Route of myomectomy Abdominal Hysteroscopic Laparoscopic myomectomy: ¾¾Preferred as less operative time blood loss ¾¾Less post-operative stay ¾¾Early ambulation ¾¾It is done in subserosal/intramural/type submucosal (see next page FIGO classification of fibroid) ¾¾Disadvantage–higher recurrence rate ¾¾Less Hysteroscopic myomectomy: ¾¾Done for type and type submucosal fibroids with more blood loss ¾¾Due to saline distension media–it can lead to electrolyte imbalance ¾¾Perforation uterus can occur ¾¾Risk of infection present ¾¾Associated Contraindications of Myomectomy ¾¾Big broad ligament fibroid (as many large vessels are present which can cause uncontrollable bleeding and thus the need to abandon myomectomy and hysterectomyQ) ¾¾Multiple tiny fibroids scattered through the uterine wall.Q ¾¾Infected fibroid ¾¾Pelvic or endometrial TB ¾¾During pregnancy on following section Myomectomy Myomectomy is the enucleation of myomata from the uterus leaving behind a potentially functioning organ capable of future reproductionQ Instrument used to decrease blood loss during myomectomy: Bonney’s myomectomy clamp.Q Note: If Bonney’s clamp or tourniquets are being used, they must be released after every 20 minutes during surgery as there can be accumulation of histamine like substances, which if suddenly released into circulation can cause shock • Myomectomy operation should always be followed by shortening of round ligament to prevent retroversion.Q • Bonney’s hood technique: is done in interstitial fibroid on the fundal posterior wall.Q 225 226 Self Assessment & Review: Gynecology Contraindications for laparoscopic myomectomy: • Medical conditions likely to be worsened with abdominal distension and Trendelenburg position for a long period • Diffuse leiomyomas • More than three myomas equal to or more than cm • Uterine size more than 16 weeks of gestation • Myoma more than 15 cm in diameter • Incision totaling to more than 15 cm Results (Important) ¾¾Pregnancy rate following myomectomy: 40–60% rate: 30–50% ¾¾Persisting menorrhagia: 1–5%Q ¾¾20–25% women subjected to myomectomy ultimately come for hysterectomy ¾¾Rupture of myomectomy scar during pregnancy is rare ¾¾Low-grade postoperative pyrexia is a rule and should not be treated by antibiotics (pyrexia is due to slight extravasation of blood in uterine wall or peritoneal cavity and settles spontaneously in 7–14 days) ¾¾Recurrence Measures to Control Blood Loss during Myomectomy Dutta Gynae 6th/ed p 604 the surgery in immediate postmenstrual phase ¾¾ Preoperative treatment with GnRH analogue reduces the vascularity of the tumour and thereby reduces operative blood loss ¾¾ Injection of vasoconstrictive agents (commonly used is vasopressin) into the serosa overlying myoma ¾¾ Use of tourniquets: To occlude the uterine vessels and also the ovarian vessels at the infundibulopelvic ligament ¾¾ Use of Victor Bonney’s specially designed clamp to reduce uterine artery blood flow This clamp is placed around the uterine vessels and the round ligament ¾¾ Controlled hypotensive anaesthesia (using sodium nitroprusside) to reduce venous tone and moderate degree of Trendelenburg position (enhance venous drainage) reduce operative blood loss ¾¾ Timing Embolotherapy ¾¾Uterine artery embolization is done using polyvinylQ alcohol or gel foamQ It is performed by an interventional radiologists and involves catheterization of the femoral artery to gain access to the hypogastric arteries Under fluoroscopic guidance the uterine arteries are occluded using gel foam, polyvinyl alcohol, in patients not suited for or not desirous of surgical therapy ¾¾In this manner, uterine blood flow is obstructed producing ischemia and necrosis ¾¾It shrinks the fibroid by 40–50% in selective young womenQ and menorrhagia resolves by 90% If patient is still symptomatic after year then surgery should be considered ¾¾It can be used preoperatively before surgery to decease blood cans during surgery on can be used aline for therapeutic purpose Results These patients experience: ¾¾ Lowered fertility rateQ ¾¾ Risk of placental insufficiencyQ ¾¾ Uterine rupture in subsequent pregnancyQ because of interference with the blood supply and embolotherapy induced necrosis of the leiomyoma ¾¾ Early ovarian failure, thus uterine artery embolization should not be done in females who desire future childbearing ¾¾Rate of reoperation is as high as 30% and reoperation rate is age-dependant, with higher likelihood in women over 40 years of age ¾¾MRg HIFU Magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) is used in managing fibroid In MRgFUS, fibroid tissue is heated and destroyed using targeted ultrasonic energy passing through the anterior abdominal wall Chapter 11 Uterine Fibroid ¾¾Normal uterine muscle cells, at a temperature ≥ 57°C remain intact following the procedure ¾¾The fibroid does not disappear; however, it shrinks in size leading to a reduction in symptoms ¾¾It is not appropriate for pedunculated myomas or those adjacent to bowel or bladder ¾¾Potential side effects include skin or nerve burns ¾¾It is not done in fibroids more than in number degenerated fibroids, peduncutaled fibroids > 12 cm from semi surface Extra edge Fig 11.2: FIGO Classification of fibriods FIGO Fibroid Classification FIGO Leiomyoma Classification System SM-Submucosal Pedunculated intracavitary < 50% intramural ≥ 50% ntramural O-Other Contacts endometrium; 100% intramural Intramural Subserosal ≥50% intramural Subserosal