Management Of Uterine Fibroid 2

MANAGEMENT OF UTERINE FIBROIDS BY Dr Bennett Ariweriokuma Department of O & G UPTH Port Harcourt

INTRODUCTION CLINICAL PRESENTATION DEFFRENTIALS INVESTIGATIONS TREATMENT MODALITIES COMPLICATIONS SPECIAL CONDITIONS

–INTRODUCTION Uterine leiomyomas are benign neoplasia of the uterus commonly refered to as myomas, fibromyomas or fibroids because of their fibrous character and high collagen content. Uterine fibroids are the most common pathologic abnormalities of the female reproductive system.

Not seen before puberty 20-25% of reproductive age group of women 3-9x more in blacks than whites. In Nigeria 80% of women above 25yrs have fibroids

The cause of fibroid remains unknown. It can arise from a single cell- monoclonal Fibroids can be single or multiple The transformation from a normal cell to fibroid may be genetic. Paternal genetic up-regulation Somatic genetic mutation, deletion or translocation in chromosome 12q14 -15 and 7q22. Such mutations predispose the leiomyocyte more sensitive to estrogens and insulin like growth hormones .

This means that there is familial inheritance Common in nulliparity but reduces with pregnancies. Women weighing >70kg have x3 risk. Smoking, COC and progestogens protect occurrence of the condition.

The management of fibroid is very important because there is a growing social trend in delayed childbearing in developed and developing countries. Many women in search of education may delay pregnancy until the age of 25 – 30yrs and that is the period when the incidence of fibroid rises.

Although women want gynaecological solutions to fibroids they dislike the traditional myomectomy or hysterectomy. They prefer minimal access surgery or medical treatment to cure the fibroid and also preserve their fertility. It was against this barground that the 3rd world congress on controversies in obstetrics, gynaecology and infertility meeting held in W-DC June 2002 challenged the traditional surgery and encourage minimal access surgery for the future.

CLINICAL FEATURES Most are asymptomatic Symptomatic present as:abdominal mass menstrual abnormalities infertility, recurrent abortions lower abdominal pains dysmenorrhoea Pressure symptoms on urinary, GIT. Lower limb vascular and lymphatic vessels.

CLINICAL SIGNS Depends on the size, shape and number. Palpable firm single or multiple fibroid nodules. Vaginal exam :-Cx fibroid polyp. Cx fibroid Uterine fibroids

DIFFERENTIAL DIAGNOSIS Adenomyosis Pregnancy Abortion Tubo ovarian mass Ovarian tumour Pelvic kidney Genetic carcinomas

INVESTIGATIONS:FBC URINALYSIS ULTRASOUND SCAN HSG for submucous fibroid and the state of the tubes. Hysteroscopy, laparoscopy EUA & Endometrial biopsy CT SCAN, MRI rarely used.

TREATMENT EXPECTANT NON SURGICAL - medical -radiological intervention -MINIMAL ACCESS SURGERY Laparoscopic-myolysis, myomectomy with endoscopic knotting. hysterospic –myomectomy, endometrial resection or ablation

SURGERY Myomectomy-abdominal - vaginal Hysterectomy –abdominal - vaginal Low tech uterine artery ligation - abdominal - vaginal -coagulation of uterine artery

PRINCIPLES OF TREATMENT Age of the patient Size of the fibroid Severity of the symptoms The reproductive desires of the patient

GENERAL TREATMENT Correct anaemia with – haematinics; tablets or parenterally Continuous COC therapy EXPECTANT MANAGEMENT Indications:Small fibroid 6-8cm in diameter Fibroid outside endometrium Asymtomatic fibroid Myoma co existing with pregnancy Post menopuasal woman

FOLLOWUP Review patient quarterly Patient should complete her family Postmenopausal should be regularly seen MEDICAL MANAGEMENT Indications:A young woman who has symptomatic fibroid but does not want surgery For elderly women- diagnostic curettage and ablation Drugs to shrink the fibroid

DRUGS IN USE Danazol (danacrine )-400mg-800mg daily in divided doses for 6-9 months. Suppresses –FSH/LH secretion by the ovaries leading to low estrogen and progesterone Causes endometrial atrophy. May reduce tumour size. Side effects:-Increase LDL, decrease HDL, weight gain, oedema, reduced breast size, oily skin and hirsutism

GnRH Agonists – peptides synthesized by substituting the 6th and 10th amino acid in the native GnRH molecule to achieve longer action and better binding to receptor site. It causes flare effect and after the 2nd week it down regulates the pituitary leading to low FSH, LH and oestrogen. When used for 6months tumuor size reduces by 57% with the hope to do surgery Side effects:- tumour size returns after use. Pseudomenopause, osteoporosis and fracture.

Mifepristone:-competively interferes with progesterone and oetrogen sites in the nucleus thereby reducing their effect. Given 25mg daily for 3 months. It may reduce the fibroid size. PROGESTOGENS:Gestrinone, depomedroxy progesterone acetate all cause atrophy of the endometrium and reduce uterine bleeding. LNG-IUCD atrophies the endometrium and inhibits the insulin like growth hormones thereby reduces the fibroid. Fadrosole which is an an aromatase inhibitor blocks the conversion of testosterone to oestrogen. GENE therapy:- Still exprimental.

RADIOLOGICAL INTERVENTION THERAPY (uterine artery embolizattion) It uses poly vinyl particles via a catheter through the femoral artrery to selectively occlude the uterine artery in order to cause ischaemic necrosis of the fibroid. Can be used for fibroid size <24wks and those who reject hysterectomy. Not used for pedunculated or infected fibroid. Menorrhagia is rapidly reduced.

Complications Allergy to contrast medium Haematoma and trauma to femoral artery Ischaemia and ovarian failure Infection Damage to endometrial vasculature & synaechia Maybe larger and more spherical particles may reduce the complications.

IMPACT ON FERTILITY OF NON SURGICAL PROCEDURES Literature review from Dec 2002 -2004 on current opinion in obstetrics and gynaecology states that:A large randomised trial showed that pre operative treatment with GnRH agonist did not improve surgical result or blood loss. In general non surgical therapy do not enhance fertility as they cause anovulatory cycles. Few data exist as regards the course of pregnancy and outcome following embolization Therefore non surgical therapy is experimental for those who need pregnancy but beneficial to those who do not desire pregnancy

TYPES OF SURGERY Myomectomy:- this involves the enucleation of myomas from the uterus . Indications:Fibroid polyp Symptomatic fibroid in a patient who desires to conserve her reproductive and menstrual function

A Fibroid polyp that prolapses through the cervix with a thin pedicle can be twisted and avulsed in theatre. Vaginal myomectomy A Fibroid polyp with a wide base: the cervico vaginal mucosa can be reflected for the myomectomy to be done. The wound is closed in two layers.

ABDOMINAL MYOMECTOMY This is full laparatomy Double consent should be obtained from the patient Techniques to reduce blood loss Pre operation:Surgery done in the proliferative phase of menstruation period. Haemodilution with normal saline, autologous blood transfusion, use of 200ug misoprostol intravaginally 1 hour before surgery Intraoperatively:Hypotensive anaesthesia

Application of rubber tourniquet at the anterior posterior lower uterine isthmus occluding the uterine vessels for 40 – 45mins Smaller rubber tourniquet is applied lateral to each ovary to occlude the vessels. Bonneys clamp can be used Diluted vasopressin into the superficial myometrium and the overlying serosa Use of laser for the incision Fast surgery Few incisions preferably at the anterior midline Use one incision to remove as many fibroid nodules as possible

PREVENTION OF ADHESIONS Application of bonney’s hood Reduce number incisions Cover uterine surface with cellulose material Wash off all blood clots instill into peritoneal cavity some normal saline or dextran 70 Insert a drain

POST OPERATIVE TREATMENT

Nil orally , I.V. fliuds until bowel sounds are established Analgesics Antibiotics Urethral catheter for 24 hours Blood transfusion where necessary Stitches out on the 7th or 8th post op day’ Follow up in two weeks

Complications Haemorrhage Trauma to bladder, GIT, Ureters Infections Adhesions Infertility Recurrence Rupture scar during labour if the uterine cavity was bridged during the myomectomy

ABDOMINAL HYSTERECTOMY Indications:Huge uterine fibroid > 24wks Patient who has completed her family with symptomatic fibroid Recurrent symptomatic fibroids Rapidly growing fibroid in the menopausal period Fibroids with recurrent PID

PRE OPERATIVE PREPARATION Counsel patient and obtain consent FBC URINALYSIS E/U PAP SMEAR ECG FOR THOSE > 50yrs ENDOMETRIAL BIOPSY OBESE PATIENT TO REDUCE WEIGHT

ANAESTHESIA :- Could be spinal or general Clean vagina and cervix with antiseptic solution, then paint with methylene blue Pass self retaining urethral catheter Clean anterior abdominal wall with antiseptic Surgery POST OP RX Adequate fluids Analgesic Urethral catheter out >24 hours Oral sips when bowel sounds return Open wound 5th day, stitches out on 7th -9th day post op

COMPLICATIONS Anaesthetic complications Haemorrhage intra-operatively, post – operatively, reactionary and secondary Cuff haematoma INJURIES Bladder- VVF Ureters –transection ,ligation, crushing and kinking. Uretero-vaginal fistula Infection Wound dehiscence Pelvic adhesion and intestinal obstruction Deep vein thrombosis

VAGINAL HYSTERCTOMY Indications: same as for abdominal hysterectomy but the size of the fibroid should be < 12wks CAESAREAN MYOMECTOMY Should be avoided as much as possible However may be done if leiomyoma is along the line of incision Bleeding is more but not statistically significant There should be some pints of blood available

MYOMECTOMY AND IVF For submucuos fibroid, myomectomy should be done first. For others, IVF first.

CONCLUSION The treatment of uterine fibroid has been very dynamic in recent times in order to cope with the trend of social needs of women in the reproductive age group. The non surgical procedures are experimental in women that have not completed their families but may be useful for those that have completed their families and are scared of any major surgery.