This presentation is prepared to meet out the undergraduate medical student needs especially to understand the practical aspects of uterine fibroid and to rapidly revise some important viva questions. Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan and Dr. Hannah Jane and our REVELLIONZ 08’ batch.

1. UTERINE FIBROID
CASE SCENARIOS
&
DISCUSSION
By
Dr. K. Haynes Raja,
Junior Resident,
Rajah Muthiah Medical College & Hospital,
Annamalai University.

2. PREFACE
This presentation is prepared to meet out the
undergraduate medical student needs especially to
understand the practical aspects of uterine fibroid and to
rapidly revise some important viva questions.
DEDICATION
Dedicated to my Great Teachers
in the Dept. of Obstetrics & Gynaecology
Dr. Lavanya Kumari and Dr. Sangeereni,
Inspiring Friends Dr. Paulin Benedict,
Dr. Jeyakumar Meyyappan and Dr. Hannah Jane
and our REVELLIONZ 08’ batch.

3. CASE SCENARIO - 1
A 36 Year old woman has noticed
abdominal swelling for 10 months.
She has to wear large clothes and
people asked her if she is pregnant,
which she finds distressing having
been trying to conceive.

4. She has no abdominal pain and her
bowel
habit
nauseated
is
normal.
when
she
She
eats
feels
large
amounts. She has urinary frequency
but no dysuria or haematuria.

5. Her periods are regular, every 27
days and have always been heavy,
with clots and flooding on the second
and
third
days.
She
has
never
received any treatment for her heavy
periods.

6. She has been with her partner for 7
years
and
despite
not
using
contraception she has never been
pregnant.

7. Examination
The woman has a very distended
abdomen.
A
smooth
firm
mass
is
palpable extending from symphysis pubis
to midway between the umbilicus and the
xiphisternum (equivalent to a 32 week
pregnancy). It is non-tender and mobile.
It is not fluctuant and it is not possible to
palpate beneath the mass.

8. On speculum examination it is not
possible
Bimanual
to
visualise
examination
the
cervix.
reveals
a
non-tender firm mass occupying the
pelvis.

9. Investigations
Haemoglobin
6.3 g/dL
Mean cell volume
68fl
White cell count
4.9 * 109/L
Platelets
267 * 109/L

10. Magnetic resonance imaging

11. Diagnosis
The woman has a large uterine
fibroid. This is causing menorrhagia
and hence the microcytic anaemia
from iron deficiency. It is also likely
that
fibroid
is
infertility history.
accounting
for
her

12. DISCUSSION

13. What is the differential diagnosis?
Uterine fibroids
Pregnancy
Full bladder
Haematometra/pyometra
Adenomyosis
Bicornuate uterus
Bilateral tubo-ovarian masses
Ectopic pregnancy
Pelvic Endometriosis
Endometrial carcinoma
Uterine sarcoma
Ovarian neoplasms

14. What is fibroid?
 Fibroid is the commonest benign tumour of uterus
 Arises from smooth muscle cells and hence called
as Leiomyoma

15. What is the incidence?
At least 20% of women in the reproductive age group

16. Whether fibroid is hormone
dependant?
 Fibroid
is
hormone
dependant.
Predominantly
oestrogen dependant.
 Other hormones implicated are growth hormone,
human placental lactogen

17. What are the hyperoestrogenic
states?
 Nulliparity
 Obesity
 Polycystic Ovarian syndrome
 Endometrial hyperplasia

18. Explain the Anatomy & pathology
of fibroid?
 Derived from smooth muscle cell rests, either from
vessel walls or uterine musculature
 Well circumcised, firm, round tumours with a
pseudocapsule
 They become soft and cystic when degenerative
changes occur
 They may be single or multiple

19. Explain the Anatomy & pathology
of fibroid?
 Usually arises from body of uterus and
less
commonly from cervix
 The vessels which supply lie in capsule and send
radial branches, so innermost part receives least
blood supply
 The
innermost
part
is
the
first
to
undergo
degeneration whereas the outermost part is the
first to calcify
 Cut surface shows whorled appearance

20. What are the synonyms of fibroid?
Fibromyoma
Leiomyoma
myoma

21. What are the types of fibroid?

22. What are the types of fibroid?
Uterine
Body of uterus
Extrauterine
Cervix
Ovary
Subserous (10%)
Broad ligament fibroid
Intramural(75%)
1. True (originates in broad
Submucous (15%)
ligament)
2. False (arises in uterus &
grows into broad ligament)

23. What is parasitic fibroid?
Rarely, a extruded fibroid gets detached from
uterus and attaches to a vascular organ (omentum or
bowel). This fibroid is called parasitic fibroid or
wandering fibroid.

24. CASE SCENARIO - 2
A 32 year old woman complains of
increasingly long and heavy periods
over the past 5 years. Previously she
bled for 4 days but now bleeding lasts
up to 10 days. The periods still occur
every
28
days.
She
experiences
intermenstrual bleeding between most
periods but no postcoital bleeding.

25. The
periods
were
never
painful
previously but in recent months have
become
extremely
painful
with
intermittent cramps. She has had four
normal
deliveries
and
had
a
laparoscopic sterilization after her last
child.

26. Her smear tests have always been
normal, the most recent being 4
months ago. She has never had any
previous irregular bleeding or other
gynaecological problems.

27. Examination:
The abdomen is soft and nontender
with
Speculum
no
palpable
examination
mass.
shows
a
normal cervix. On bimanual palpation,
the uterus is bulky (approximately 8
week size), mobile and anteverted.
There are no adnexal masses.

28. Investigations
Haemoglobin
9.2 g/dL
Mean cell volume
75 fl
White cell count
4.5 * 109/L
Platelets
198 * 109/L

29. Hysteroscopy

30. Diagnosis
This woman has a Submucosal fibroid.
Submucosal fibroids are a common cause
of menorrhagia and can cause, as in this
case, intermenstrual bleeding.
“Fibroids
usually
don’t
cause
intermenstrual bleeds other than when
there is ulceration or it is submucous or
cervical fibroid”

31. DISCUSSION

32. What are the clinical manifestations?
Menorrhagia, polymenorrhoea, metrorrhagia
Infertility, recurrent abortions
Pain – spasmodic dysmenorrhoea, backache, due
to pyelitis
Pressure symptoms – bladder, ureter, rectum
Abdominal lump or mass protruding at introitus
Vaginal discharge
As many as 50% women are asymptomatic

33. How do they cause menorrhagia?
 Increased surface area of endometrium
 Hyperoestrogenism
 Intramural fibroid prevents adequate contraction
and retraction of uterus
 Associated pelvic inflammatory disease

34. Can fibroids cause polycythaemia?
Yes. Huge fibroid compresses renal artery 
Reduced renal perfusion  Hypoxia  activation of
Renin-
angiotensin
aldosterone

Renal
erythropoietin secretion increases  polycythaemia

35. How do they cause infertility?
 Cervical fibroid does not allow nidation of sperms
 Fibroid in Cornual end does not allow fertilised
ovum to enter uterine cavity
 Increased
chances
of
abortion
is
seen
with
submucous fibroid due to improper implantation
 Associated
infertility
Hyperoestrogenic
state
can
cause

36. When do fibroids present as
emergency?
When do they cause pain?
 Acute
torsion
of
a
pedunculated
fibroid
or
degeneration are the main causes of pain
 Intracapsular haemorrhage
 Rarely, a submucous fibroid trying to get expelled
from the cervix will produce pain

37. CLINICAL SCENARIO - 3
A 33 Year old women complains of
worsening abdominal pain for 4 days.
She is 16 week pregnant in her third
pregnancy. She has a 10 year old son,
by normal delivery and a miscarriage
8 years ago. Her pregnancy has been
uneventful
until
now
with
unremarkable first trimester scan.
an

38. The
pain
is
in
the
left
lower
abdomen and is constant and sharp.
She has taken paracetamol with little
effect and she is unable to sleep due
to pain.

39. She has had no vaginal bleeding and
reports
urinary
frequency
since
the
beginning of the pregnancy. She is mildly
constipated and has no nausea and
vomiting. There is no history of trauma.
She has not felt the baby moving yet.

40. EXAMINATION
The woman is apyrexial and pulse
rate is 125/min, with blood pressure
110/68 mm Hg. The uterus is palpable
just above the umbilicus. There is
significant tenderness over the left
uterine fundal region, where it also
feels firm. The abdomen is otherwise
soft and non-tender.

41. There is voluntary guarding but no
rebound tenderness. Bowel sounds
are normal. Speculum examination
shows a normal, closed cervix and no
blood. The fetal heart beat is heard
with hand-held Doppler.

42. Investigations
Haemoglobin
10.6 g/dL
Mean cell volume
79 fl
White cell count
7.2 * 109/L
Platelets
378 * 109/L
C-reactive protein
<5 mg/L

43. Diagnosis
The patient has fibroid undergoing Red
degeneration. The uterine size is larger
than dates and the localised uterine
tenderness are the important features in
making this diagnosis.
“Red
degeneration
happens
exclusively in pregnancy”
almost

44. DISCUSSION

45. What are the obstetric complications
of fibroid?
a) Increased risk of Abortions
b) Threatened preterm labour
c) Premature delivery
d) Abruptio placenta.
e) IUGR
f)
Intrapartum problems if fibroid large & located in the lower
uterine segment. Cervical fibroid 
caesarean delivery.
g) Interference with propagation of myometrial contractility
uncoordinated uterine contraction or PPH.


46. What are the general complications
of fibroid?
 Degeneration
 Torsion
 Inversion of uterus
 Capsular haemorrhage
 Infection
 Associated endometrial carcinoma

47. What are the secondary changes
in fibroid?
 Atrophy
 Hyaline/cystic/fatty degeneration
 Calcareous degeneration
 Red degeneration
 Sarcomatous degeneration

48. What is red degeneration?
 Occurs most frequently during pregnancy
 Becomes tense and tender and causes severe
abdominal
pain
with
constitutional
upset
and
fever.
 Fibroid becomes reddish with a particular fishy
smell.
 Leucocytosis and raised ESR may be present but
this is an aseptic condition
 Examination of fibroid shows thrombosed vessels

49. Differential diagnosis and
management for red degeneration
 Differential Diagnosis:
 Acute appendicitis
 Torsion of ovarian cyst
 Acute pyelonephritis
 Accidental haemorrhage
 Treatment: Self limiting and resolves by itself

50. When do fibroids grow rapidly?
In sarcomatous degeneration (not more than 0.5%)

51. What are the investigations to do?
General Investigations:
 Blood investigations:
 Haemoglobin & Haematocrit to rule out anaemia
 Random Blood sugar to know the diabetic status
 Blood grouping and Rh typing for transfusion if
necessary
 Serum urea and Creatinine for assessing the renal
function
 Urine Examination:
 albumin, sugar and deposit

52. What are the investigations to do?
Special investigations:
 Intravenous pyelogram:
 To trace the course of ureter to avoid injury during
surgery
 To rule out renal abnormalities (Eg. pelvic kidney)
 Ultrasound abdomen:
 To know the site and number of fibroid

53. Other investigations
 Hysterosalpingography and sonosalpingography
 Hysteroscopy
 Dilatation and curettage to rule out endometrial
cancer
 Magnetic resonance imaging

54. When do you treat a fibroid?
 Indications for treating an asymptomatic fibroid
are
 Infertility caused by cornual blocking or abortion
caused by submucous fibroid
 Fibroid more than 12 weeks size or a pedunculated
fibroid which can undergo torsion
 Fibroid causing pressure on ureter
 Rapidly growing fibroid
 If the nature of tumour cant be assessed clinically

55. When do you treat a fibroid?
All symptomatic fibroid needs treatment which
can be Medical or surgical

56. How will you manage Medically?
 Iron therapy for anaemia
 Surgery is the definitive treatment modality but
the use of medical management is to control
menorrhagia and to improve haemoglobin before
surgery
 Drugs
can
also
be
used
in
women
nearing
menopause or who are not fit for surgery
 Drugs used are low dose OCPs(have minimal
oestrogen),
mifepristone(RU
analogues like leuprolide
486),
GnRH

57. What are the indications for use
of GnRH agonists in women with
leiomyomas?
 Preservation of fertility before attempting conception or
preoperative treatment before myomectomy
 Treatment of anaemia to allow recovery of normal
haemoglobin levels before surgical management or
allowing autologous blood donation
 Treatment of women approaching menopause in an effort
to avoid surgery
 Preoperative treatment of large leiomyomas to make
vaginal
hysterectomy,
hysteroscopic
resection
or
ablation, or laparoscopic destruction more feasible
 Treatment of women with Medical contraindications to
surgery

58. What are the advantages and
disadvantages of GnRH analogues?
 GnRH analogues causes rapid shrinkage of tumour
and reduces vascularity
 Hence it decreases the need of surgery in young
women with infertility for cornual blockade
 It also facilitates vaginal hysterectomy or surgery
with minimal blood loss
 The main disadvantage is cant be extended beyond 6
months
(causes
osteoporosis),
fibroid
capsule
becomes thin and enucleation is difficult, recurrence
of fibroid is high.

59. What are the potential indications of
surgery?
 Abnormal uterine bleeding with resultant anemia,
unresponsive to hormonal or other conservative
management
 Chronic pain with severe dysmenorrhea, dyspareunia, or
lower abdominal pressure or pain
 Acute pain, as in torsion of a pedunculated leiomyoma
or prolapsing submucosal fibroid

60. What are the potential indications of
surgery?
 Urinary symptoms or signs such as hydronephrosis
after complete evaluation
 Infertility with leiomyomas as the only abnormal
finding
 Recurrent pregnancy loss with distortion of
endometrial cavity
 Markedly enlarged uterine size with compression
symptoms or discomfort

61. What are the surgical management
options?
 Myomectomy – Laparotomy / Laparoscopy /
Hysteroscopy
 Hysterectomy – Abdominal / vaginal /
laparoscopic
 Uterine artery embolization

62. What is myomectomy?
 Removal of fibroids leaving behind the uterus
 Indicated in infertile women or a women desirous
of childbearing and wishing to retain uterus

63. What are the preoperative requisites
of myomectomy?
 Haemoglobin should be restored
 In infertility cases, other causes should have been
excluded
 SIGNATURE FOR HYSTERECTOMY IS REQUIRED IN
DIFFICULT CIRCUMSTANCES
 Should be performed in preovulatory period
 Endometrial cancer to be ruled out by D&C

64. Explain the steps of myomectomy
 Patient in supine position
 The abdomen is draped and opened by pfannenstiel
incision
 Confirm the feasibility of myomectomy
 Anterior uterine wall is incised and as many fibroids are
removed by tunneling incisions
 Haemorrhage is controlled by myomectomy clamp
 The capsule should be incised and fibroid enucleated
with the help of myoma screw
 Following enucleation, cavity is obliterated with catgut
 Release the clamp and secure haemostasis

65. What are the complications of
myomectomy?
 Haemorrhage – primary, secondary and
reactionary
 Trauma to adjacent structures – ureter, bladder,
bowel
 Infections
 Adhesions and intestinal obstruction
 Recurrence of fibroids and persistent menorrhagia

66. When do you employ laparoscopic
myomectomy?
 Pedunculated fibroid
 Subserous fibroid not exceeding 10 cm in size and
not more than 4 in number

67. What are the advantages of subtotal
hysterectomy over total hysterectomy?
 Cervix is retained for sexual function
 Vault prolapse is less
 Less surgical morbidity

68. Will you remove ovaries during
hysterectomy for fibroid?
Ovaries should be retained to avoid menopausal
symptoms in a premenopausal woman provided they
look normal.

69. What is panhysterectomy?
Removal of uterus, cervix and ovaries

70. What is LAVH? Contraindications
for this procedure?
 LAVH stands for Laparoscope assisted vaginal
hysterectomy.
 Contraindications are
 Uterus more than 14 – 16 weeks size
 Fibroid located in broad ligament, cervical fibroid and
extensive pelvic adhesions, endometriosis

71. What are the complications of
hysterectomy?
 Haemorrhage – Primary, secondary and reactionary
haemorrhage
 Trauma to adjacent organs – bladder, ureter, bowel
and ureter
 Postoperative infection and Sepsis
 Anaesthetic complications
 Paralytic ileus, intestinal obstruction or chronic
abdominal pain due to postop adhesions
 Thrombosis, pulmonary embolism, chest infection
 Burst abdomen, scar, hernia
 Residual ovarian syndrome
 Dyspareunia

72. Explain about uterine artery
embolization?
 Through percutaneous femoral catheterisation,
Polyvinyl alcohol (PVA), gel foam particles or
metal coils are injected.
 This reduces vascularity and size(40% at 6 weeks
and 75% at 1 year)
 Contraindications:
 Subserous, submucous and pedunculated fibroids
 Infertility and desire of pregnancy

73. Explain about uterine artery
embolization?

74. Explain about uterine artery
embolization?
 Advantages:
 No major surgery, intraoperative bleeding, adhesions
 Short hospital stay
 75 – 80% women are satisfied

75. Can fibroids grow beyond Menopause?
Yes. If the woman is on hormone replacement therapy.

76. Polypectomy