Benign Tumor of Uterus- Fibroid Uterus | A Deep Analysis.

in StemSocial4 years ago

Hey everyone, Welcome to my new article. Today we are going to discuss benign tumors of Uterus, specifically Fibroids of Uterus. This condition is the most common benign condition of the uterus and also the most common benign solid tumor in females.


Image credits, Wikimedia(Under reuse license)

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Short Introduction.

A fibroid is mainly composed of smooth muscles of the uterus. Therefore, it's also called as Leiomyomas. "Leio" means smooth, "myo" means muscles and "mas" means tumor. The prevalence is highest between 35-45 years. It's been estimated that 21% of women above age 35 have got fibroids but fortunately, 50% of them remain asymptomatic. The incidence of symptomatic fibroid reported in hospitals is only about 3% with a higher incidence of 10% in England.

Etiology

The complete cause of this tumor is still not certain. However, there is a hypothesis that, it arises from a single neoplastic smooth muscle cell. The stimulus for this neoplastic change is not known but these theories are implicated.

Chromosomal Abnormality: About 40% of the cases have different types of chromosomal mutations, specifically at chromosome 6 or 7.

Role of Growth factors: Different growth factors like epidermal growth factors, insulin-like growth factors, transforming growth factors can stimulate the growth of fibroids. Also, a family history of fibroid is often present in the patient.

I mentioned, the cause is still not clear, but there are some pieces of evidence that suggest the fibroids are predominantly estrogen-dependent.

  1. The growth is limited during the reproductive period.
  2. This does not occur before menarche.
  3. After menopause, the growth ceases to exist.
  4. The tumor contains more estrogen receptors.

Types of Fibroids.

There are numerous types of fibroids found from the body to the uterus to the cervical part of the uterus. But mostly they are located on the body of the uterus and rarely on the cervical part. Different types of fibroids found on the body are as listed below.

Interstitial or intramural: Initially, the tumor is in interstitial position but later it is pushed outward on inward.

Subperiteoneal or Subserous: here, the interstitial or intramural tumor is pushed outward into the peritoneal cavity. it is covered by peritoneum completely or partially. when it is covered by the peritoneum, it stands on a pedicle and is called a subserous fibroid. if the pedicle is torn then the tumor gets its nourishment from the other parts, called a parasitic fibroid. IF this tumor is pushed toward the broad ligament, its called broad ligament fibroid.

Submucous: if the tumor is pushed inward into the endometrium, it's known as submucous fibroid. This fibroid has the ability to distort the uterus. Therefore, this type of fibroid produces maximum symptoms.

Cervical fibroid: This is the rarest variety. The incidence is only about 1-2%. Found mainly in the supravaginal part. Depending upon the position, it can be found on the anterior, posterior, lateral, or central region. This might also distort the cervix and compress the ureter.

Gross appearance

The uterus is usually enlarged with distorted shape and multiple nodular growths of varying sizes. The growths are firm and occasionally there might be only one uniform growth. The surface of the tumor is smooth and greyish.

There is the formation of a false capsule by the compression of the muscles. This false capsule might be separated from the growth by a thin layer of tissue. The periphery of the tumor contains lots of blood vessels than the center.


Image: Large fibroid inside the uterus cavity(Credits, Wikimedia, Under reuse license)

There are various other secondary changes in the uterus associated with fibroids.

Hyaline degeneration: This is the most common change in fibroid affecting all sizes except the small ones. as mentioned above the central part which is less vascular is the most affected. hyaline change makes the tumor more elastic.

Cystic changes: This change usually occurs after the menopause when the tumor starts to die. The walls of the fibroid become ragged.

Fatty changes: This too occurs after menopause. Fat globules deposition is seen on the surface.

Calcific changes: This is usually preceded by fatty changes. The precipitates of calcium carbonate deposition occur within the tumor. With time, the whole tumor is converted into calcified mass. Its also known as "womb stone".

Red degeneration: This type of change usually occur during pregnancy. The tumor shows dark areas with a raw-meat appearance. This might be due to high vascular supply during pregnancy. Also, there are many other changes like atrophy of the tumor, necrosis, infection, etc.

Clinical features of the Presenting patients.

The presenting patients are usually nulliparous or have been in the period of long term infertility. The age of the patient is usually between 35-45 years. As I already said, the majority of this is asymptomatic, and there might be accidental discovery during routine examinations. But if it's symptomatic, these are the common symptoms that they are usually present with.

  1. Menorrhagia: this means very heavy bleeding at menstruation. The causes might be increased endometrial surface area, interference of the uterine cavity, congestion of the vascular supply, etc.
  2. Metrorrhagia: This means irregular bleeding. The reasons might be ulceration or torn out blood vessels due to growing tumors.
  3. Dysmenorrhea: This means painful menstruation. This may be due to pelvic congestion.
  4. Infertility: This is one of the major complaints. There are various reasons for this. some of them are, sperm cannot ascent in the uterine cavity due to its distortion, there is no rhythmic concentration of the uterus, the walls of the uterus does not favor implantation of the embryo due to different types of changes mentioned above.
  5. Pregnancy-related problems: abortion, growth restriction, etc are seen.
  6. Lower abdomen pain: Although fibroids are usually painless, pain may occur to compression of the surrounding structure by the growing tumor.


Image: Symptoms of Fibroid (Credits, Wikimedia, under reuse license)

These symptoms are reported by the patients themself. Here are some signs that a doctor observes with clinical examination,

The tumor may be large enough to felt through the abdomen. The feel is firm or may be cystic. Margins of the tumor are well defined. the surface is nodular and can be moved side to side.

Different investigations for fibroids.

Here, investigations are done for two main purposes, to confirm the diagnosis and for preoperative assessments. Although, most of them can be easily diagnosed by pelvic examinations but at times pose some problems in diagnosis.

Ultrasound and color doppler investigation: By this investigation, the uterus is seen enlarged and distorted, vascularization at the periphery is seen. This investigation is mainly diagnostic also tells the exact location of the tumor.


Image: Usg showing fibroid (Credits, Wikimedia, Under reuse license)

Saline infusion sonography(SIS): this investigation is helpful to detect the submucous type of fibroid.

MRI: Although this is more accurate compared to USG, it's not done routinely. This shows the exact location, volume, and adnexal pathology.

Laparoscopy: this means the visualization of the abdominal wall by passing a fiber-optic camera. Here, the uterus is seen enlarged and infertile. This is also helpful for differentiating it from different other types of tumors.

Hysteroscopy: This means the direct visualization of the uterus. The tumor can be directly seen if it is of the submucosal type.

Management of Fibroids.

We have different management protocols for asymptomatic and symptomatic cases. Asymptomatic cases are detected accidentally on routine examinations. In this case, we generally prefer observation for at least 6months and Ultrasound investigations. If the symptoms of the fibroids appear to grow and increase in volume, surgery is indicated.

For Symptomatic cases, we have different sorts of medical management and surgical management. Medical management means drug therapy. This therapy has shown some promising results. But prior to this therapy, the diagnosis must be certain. Different drugs used are antiprogesterone drugs which are very effective to reduce fibroid size. Selective progesterone receptor modulator (SPRMs) like Asoprislin and Danazol is used which too reduce the size of fibroids. Similarly, Prostaglandin synthase inhibitors are used to relieve pain symptoms.

Surgical Management: Different surgical methods are currently being used for the treatment. The main surgeries performed nowadays are Myomectomy and Embolotherapy.

Myomectomy: This means the removal of myomata from he uterus leaving behind a fertile uterus. Myomata means a tumor compressed with muscles. A surgeon must be satisfied with the operation to serve the objective. It is indeed useless to perform a difficult surgery and leave behind an organ that is not capable of fertility. Restoration of the functions of the uterus, ovaries, tubes following the surgery is very important.


Image: Myomectomy surgery.(Credits, Wikimedia, Under reuse license)

Embolotherapy: This simply means intentional blockage of the artery, which causes necrosis of the tissue. this causes vascular necrosis followed by shrinkage of the tumor. uterine arteries are blocked by injecting polyvinyl alcohol particles. This surgery has a success rate of 70% and relatively easier to perform. But there can be complications like femoral artery injury. Also, this is contradicted in women with active pelvic infection.

Hysterectomy: This means the removal of the uterus and is most preferred if the woman is over 40 years and has completed the family. This is mostly preferred in old aged patients.

You stayed until the end. Hope you liked it.


*All images used are copyright free and are provided with appropriate credits*

References:

[1]
https://www.healthline.com/health/uterine-fibroids

[2]
https://en.wikipedia.org/wiki/Uterine_fibroid

[3]
https://academic.oup.com/humupd/article/22/6/665/2420585

[4]
https://emedicine.medscape.com/article/405676-overview


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Very interesting and well-written, as usual. Thanks for sharing :)

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Thank you so much :)


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