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Benign disease of Uterus: Fibroid / Leiomyoma

Benign disease of Uterus

 

Benign diseases:

  • Leiomyoma
  • Adenoma
  • Angioma
  • Fibroma

 

Specimen of Fibroid uterus:

 

Why?

  • Identified by cervix
  • Cervix is identified by external os

Specimen is collected by Total abdominal hysterectomy cause Fallopian tube and ovary present in patient’s body.

 

Fibroid / Leiomyoma

Arise from smooth muscle cell (myocyte) – myometrium

 

Characteristics:

  • Slow growing
  • Capsulated
  • Excessive proliferation
  • No metastasis

 

Type:

1)      In the body- 3 types

a)      Intramural / Interstitial:  In the myometrium

b)      Submucous:  Grows within cavity / Just beneath endometrium

c)      Subserous:  Towards the peritoneal surface grows (Just beneath the serosa)

 

2)      In the cervix:

a)      Intramural

b)      Submucous

 

NB: [Intramural and subserous – No symptom; only mass present]

[Submucous- Produces symptoms]

 

Site:

  • 98- 99% arise from body of uterus
  • 1-2% from cervix

 

Symptoms:

1)      Patient profile

  • Age: 35-45 years
  • Relatively infertile / infertile
  • Parity- Common in nulliparous

2)      May be asymptomatic – 75% case

3)      Menorrhagia: Submucous type only

 

[Off topic: Menorrhagia]

 

Definition of Menorrhagia:

It is a cyclical bleeding which is excessive in amount or prolonged in duration or both.

 

Causes of Menorrhagia:

  • Endometriosis
  • Adenomyosis
  • Chronic pelvic inflammatory disease
  • IUCD user

 

4)      Lower abdominal mass

5)      Pain: Normally benign tumor is painless. But pain occurs only when-

  • Degenerative changes occur
  • Sarcomatous change
  • Infection
  • Endometriosis

 

Why menorrhagia occurs?

  • ↑surface area of endometrium
  • ↑vascularity
  • ↓ contractility due to interposition of fibroid
  • Associated endometrial hyperplasia due to hyper-oestrogenism

 

6)      Secondary dysmenorrhagia: Generally occurs in cornu of uterus. Because it provides space for uterus.

If polyp in submucous layer the uterus contract to expelled out.

 

7)      Menorrhagia: Due to ulceration (after abortion/ delivery)

Endometrial Carcinoma

 

 

Conditions associated with fibroid

 

  • Endometrial Hyperplasia
  • Endometrial carcinoma
  • Endometriosis
  • Follicular cyst of ovary

[Due to estrogenic stimulation anovulatory due to fibroid]

 

8)      Pressure symptom:

  • Frequency of micturition / Retention (When lower part of cervix)
  • Constipation (posteriorly)
  • Varicose vein
  • Heaviness of pelvis

 

 

On examination:

  • Frequency of pad change
  • Clotted blood (Fibrinolysin cannot control it)
  • Duration

 

General examination:

  • Feature of anaemia
  • Rapid pulse
  • Decrease Blood Pressure
  • Oedema of leg
  • Varicose vein

 

Per abdominal examination:

  • Mass present
  • Size: Pregnancy weeks size (<12week – not found)
  • Site: Abdominal region
  • Surface: smooth
  • Margin: Irregular (multiple nodular) well defined
  • Consistency: Firm (whorled appearance)
  • Mobility: Side to side due to attachment with cardinal ligament.

 

Per vaginal examination:

  • Mass is continuous with uterus (bimanually) and the mass moves with the movement of cervix.
  • Uterus hard in consistency
  • Uterus size (<12 week – also found up to 8 week)

 

 

Differential Diagnosis:

1)      Physiological

  1. Full bladder
  2. Pregnancy (LMP-exclude)

2)      Adenomyosis

3)      Endometriosis

4)      Ovarian tumor

5)      Tubo-ovarian abscess or mass (acute PID, Pain, Temp, USG)

6)      Retroperitoneal tumor- Hard, fixed, USG- exclude)

7)      Pelvic Kidney- Fixed, USG, IVU.

 

[N.B: Ovarian tumor- Usually no menstrual abnormality. Cystic, well defined, all direction movement present, mass is separated from uterus, cleft present, USG, No relation with parity.]

 

Investigation:

a) Confirmed by

  • USG of lower abdomen- Hypoechoic mass is seen.
  • Laparoscopy
  • Hysteroscopy

 

b) For pre-operative assessment:

  • Hb%, TC, DC, ESR
  • Blood grouping, Rh typing
  • Urine- R/E
  • fasting blood sugar and post prandial
  • serum creatinine
  • chest x-ray P/A view
  • ECG

 

 

Treatment:

 

A. No treatment if asymptomatic but follow up.

 

B. Medical Treatment:

  • Progesterone (Donazol)
  • GnRH analogue
  • Correction of anaemia
  • Avoid use of contraceptive

 

C. Surgical Treatment:

  1. Total abdominal hysterectomy: If-
  • Age > 40 years
  • Family complete
  1. Myomectomy: If
  • Age < 40 years
  • Hb% – 11gm/dL
  • Semen analysis
  • Counseling of patient about operation.

[Counseling:

  • After operation menorrhagia may persist
  • Fibroid mass recur -5 %
  • May lead to laparotomy (hysterectomy)
  • After operation – pregnancy rate – 30%]

 

[Note: Hyomectomy]

  • Preserving ovary, myoma should be out of bed.
  • Inoculation is easy, as false capsule present.
  • Compression of surrounding myometrium.

 

Relation with Pregnancy:

  • Infertility
  • Abortion
  • PROM
  • Malpresentation
  • IUD
  • Retained placenta
  • PPH
  • Sub involution
  • Puerperal sepsis

 

Complication:

  1. Twisting of subserous pedunculated fibroid
  2. Infection of the fibroid
  3. Ruptured surface vein and Intraperitoneal haemorrhage
  4. Degenerative change of fibroid
  • Hyaline
  • Cystic
  • Fatty
  • Red (Fibroid with pregnancy with early peurperium)
  1. Calcification
  2. Pseudo- Meig’s syndrome
  • Subserous pedunculated fibroid
  • Ascitis
  • Hydrothorax
  1. Sarcomatous change (0.1%): Leiomyoma

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