Fibroids

Fibroids r generally benign neoplasm affecting 5-20 % of women in reproductive age group

ETIOLOGY :-
1] each myoma is derived from smooth muscle cell rest , either from vessel walls or uterine musculature
2] although oestrogen,growth hormone & possibly human placental lactogen have been implicated in growth of myomas,evidence for oestrogen dependance
  a) myomas r rarely found before puberty and they generally cease to grow after menopause
  b) new myomas rarely appear after menopause,
  c) association of fibroids in women with hyperoertrogenism is evidenced by endometrial hyperplasia,dysfunctional metropathic bleeding and endometrial carcinoma.
  d) myomas r known to increase in size during pregnancy and with oral contraceptives.
  e) progesterone inhibit the growth of myomas. large dose of progesterone orally for 14-21 days causes shrinkage of tumour.

SECONDARY CHANGES DEGENERATIONS:-
1] Atrophy:- as a result of diminished vascularity after menopause there is shrinkage in size of the tumour. It becomes firmer and more fibrotic.
2] Calcareous degeneration:- in this phosphates and carbonates of lime r deposited in the periphery along the course of vessels.
3] Red degeneration :- myomas becomes tense and tender and causes severe abdominal pain with constitutional upset and fever. Tumour itself assume peculiar purple red color and fishy odour,

OTHER COMPLICATIONS OF MYOMAS :-
1] Torsion :- subserous pendunculate myoma undergo rotation at site of its attachment to uterus as a result vien occluded and tumour becomes engorged with blood . Rarely it detach from uterus and called as ' wondering fibroid ' .
2] Inversion of uterus
3] Capsular haemorrhage :- one of the large vein on surface of myoma rupture causing haemorhagic shock,
4] Infection :-  of submucous and myomatous polypi may lead to blood stained purulent discharge.
5] Associated endometrial carcinoma.

SYMPTOMS :-
As many as 50% women r asymptomtic other r with single symptom or several complaints
1] Menstrual disorders :- Progressive menorrhagia , polymenorrhoea , metrorrhagia r common
2] Infertility :- infertility is mainly due to associated PID, endomtriosis, distortion of uterine cavity causing obstruction to sperm ascent , poor nidation or cornual tubal block.
3] Pain :- acute pain seen when fibroid is comlicated with torsion, haemorrhage and RED degeneration . Women complain of heaviness in lower abdomen.
4] Pressure symptoms :- urine retention , hydroureter, hydronephrosis and rarely constipation seen.
5] Abdominal lump
6] Vaginal discharge,

PHYSICAL SIGNS :-

1] Anaemia may be noted
2] Abdominal lump may be felt. with well defined margin firm consistency & smooth surface.
3] Bimanual examination reveal enlarged uterus regular or boosy.
4] cervix moves with swelling which is not felt seperate from uterus unless it is pedunculate
5] in cervical fibroid the normal uterus is perched on top of tumour
6] in myomatus polyp the cervical os is open and its lower pole felt
7] the uterine fundus cannot be palpated if inversion is associated with fundul submucous fibroid polyp.

DD :-

1] Pregnancy
2] Haematometra
3] Adenomyosis
4] Bicornuate uterus
5] Endometriosis
6] Ectopic pregnancy
7] Chronic PID
8] Benign & malignant ovarian tumour
9] Plevic kidney
10] Endometrial cancer
11] Myomatus polyp
12] Chronic inversion of uterus.

MANAGEMENT :-

* Investigations :-
1] Hb, blood group
2] Ultrasound :- to check number , location and size of fibroids also useful in follow up of fibroid after menopause
3] Hysterosalpingography :- identifies sub mucous myoma & checks the patency of fallopian tube
4] Hysteroscopy
5] Laproscopy :- useful in inversion of uterus while excising myomatus polyp.
6] Radiography
7] CT scan & MRI
8] Intravenous pyelography in broad ligament fibroid

* Treatment :-
1] MEDICAL TREAT :-
- Iron therapy for anaemia
- RU 486 or Mifoprostone 50 mg daily for 3 months causes amenorrhoea and shrinkage of the tumour
- Danazol 400-800mg daily reduce size of tumour
-GnRH analogues can be used

2] SURGICAL TREATMENT :-
Techniques used are myomectomy and hysterectomy
a] Myomectomy :-
it is indicated in an infertile woman or woman desirous of child bearing and wiring to retain uterus
 i) vaginal myomectomy :- indicated in sub mucous fibroid polyp
 ii) Hysteroscopic myomectomy :- done in submucous fibroid not removable by simple vaginal route .
 iii) Laproscopic myomectomy :- a pedunculated fibroid , sub serous fibroid not exceeding 10 cm

b] Hysterectomy :-
 it is indicated in woman over 40, multiparus woman or associated with malignancy . Uncontrolled haemorrhage and unforseen surgical difficulties may requir it
 i ) Vaginal Hysterectomy
ii ) Laproscopic hysterectomy