77. Uterine myoma. Treatment methods.
Diagnosis
1. Ultrasound & Color Doppler (TVS) 2. Saline Infusion Sonography (SIS) - helpful for submucous fibroid 3. MRI - Helps to differentiate adenomyosis from fibroids. 4. laparoscopy - Laparoscopy differentiate a pedunculated fibroid from ovarian tumor 5. Hysterectomy - helps to detect submucous fibroid in unexplained infertility and repeated pregnancy wastage 6. Hysterosalpingography - when performed, a filling defect can be seen 7. Uterine curettage - detect any co-existing pathology
Complications of fibroids
Severe complications: - Persistent menorrhagia, metrorrhagia, continued vaginal bleeding → SEVERE ANEMIA - severe intraperitoneal hemorrhage due to rupture of veins over subserious fibroid - Severe infection leading to peritonitis or septicemia - Sarcoma
Examination
- General: displays pallor (depending on duration of menstrual loss) - Abdominal examination - tumor may not be large enough to be felt. If enlarged: firm, hard. Margins well-defined except the lower pole, nodular surface, uniformly enlarged single fibroid, mobility: can move side to side Bimanual pelvic exam - uterus is irregularly enlarged by swelling felt from abdomen. - submucous fibroid = maybe symmetrical enlargement of uterus
BODY fibroids: secondary changes in Fibroids - Degenerations
- Hyaline degeneration - central part of tumor (least vascular) commonly, soft elastic feel - Cystic - Occurs following menopause, formed by liquefaction in areas with hyaline changes - Fatty - fat globules deposited in Muscle cells - Calcific - comes after fatty degeneration, Precipitation of calcium carbonate or phosphate, whole tumor turns into calcified mass - Red - inside raw beef appearance (redness due to hemolysed red cells, Hb), fishy odour
Embolotherapy
- Improves of menorrhagia - Complication - Postembolization syndrome: Fever, sepsis, myometrial infarction and necrosis, amenorrhea and ovarian failure Contraindications: Active pelvic infection, desire for future pregnancy, drug allergy
What are the clinical features of fibroids?
- Infertility - Lower abdominal pain - fibroids are usually painless but pain is due to complications - Abdominal swellings (lump) - Pressure symptoms - rare in body fibroids, Fibroids in the posterior wall may be impacted in the pelvis producing constipation, dysuria or even retention of urine.A broad ligament fibroid may produce ureteric compression → hydroureteric & hydronephrotic changes → infection → pyelitis.
Surgical options
- Myomectomy - Endoscopic surgery - hysteroscopy, laparoscopy - Hysterectomy - Embolotherapy
What are the associated pelvic changes?
- Uterus - Asymetrical, distorted shape, myohyperplasia (to get rid of fibroid), Endometrium is thick, congested & edematous, uterine cavity may be elongated & distorted in intramural & submucus variety - Ovary - enlarged, congested with scattered multiple cysts due to hyperestrinism - Ureter - displacement ureter in broad ligament fibroid. The compression effect results in hydroureter & or hydronephrosis. - Endometriosis - 30% increased association of pelvic endometriosis & adenomyosis
Myomectomy
Myomectomy is the enucleation of myomato from the uterus leaving behind a potentially functioning organ capable of future reproduction. Indications - Persistent uterine bleeding despite medical therapy, Excessive pain, Unexplained infertility, Recurrent pregnancy wastage due to fibroid, Rapidly growing myoma. Prior to surgery - Give GnRH analogue (Goserelin) to shrink fibroid size. Contraindications = infected fibroid, if its malignant, during preg/c-section.
