VOL. 47, No.

Janzuary, 1955

45

The Uterine Fibroid

JULIAN WALDO Ross, M.D.
Professor anzd Head, Department of Obstetrics and Gynecology,
Howard Unitersity, School of Medicine and Freedmen's Hospital, WVashinigton, D.C.

TEIOMYOMA, myoma uteri, uterine fibroid

or so-called round tumor of the uterus, the
most common tumor affecting the female, is a
benign organoid newgrowth consisting of the same
histologic elements as the uterine wall, viz., chiefly
muscular fibers and connective tissue.
It begins as a local hyperplasia, the result in
all probability of irritation, but the conditions
favoring such or the specific factor giving rise to
the irritation are as little known today as a century
and a half ago when the tumor was described first,
by Bayle, in 1803.
That it may be an expression of persistent and
excessive bombardment of the uterus (myometrium) by estrogenic stimulation, in the absence
of pregnancy, seems plausible in the light of the
known endometrial response (hyperplasia and
polyps) to such stimulation.
Although this tumor starts as a local hyperplasia
of the myometrium, its developmcnt does not follow the pattern of a generalized hypertrophy and
hyperplasia of the uterine-wall elements characteristic of a pregnant uterus. Instead, the tumor
origin and development are so focal and peculiarly
intensive that its pressure from growth causes compression and condensation of the surrounding
uterine tissue with the formation of a capsule.
This capsule, through which the tumor receives
its nourishment, separates the fibroid from the
normal uterine tissue and, from which, usually,
the tumor may be easily enucleated, is a characteristic peculiar to most fibroids. Another characteristic of these tumors is their tendency to cease
growing at menopause.
The blood supply to the fibroid is rather meager,
the arteries being very small and scant as compared to the veins and lymphatics which are large
and plentiful. Hence, the usual fibroid, in the
absence of certain degenerative changes, appears
white, hard and dry. These latter characteristics
are dependent more largely, however, upon the
relative proportion of the fibrous tissue to the constituent muscular elements.

Predominance of the fibrous tissue gives the

so-called fibroma dura, easily shelled out of its
capsule; with predominance of the muscular elements, the fibroid appears darker, more vascular,
softer and juicy, the so-called fibroma molle not
so easily, if at all, shelled out or separated from
the surrounding muscle fibers.
On section, the tumor bulges from the cut edges
showing a release of pressure; the tumor elements
exhibiting the characteristic silvery grey whorls of
a fibromyoma with, not infrequently, a concentric
arrangement about the periphery of the tumor.
Microscopically, the tumor is seen to be made up
of interlacing bundles of unstriped muscle fibers
and a network of connective tissue. These muscle
(tumor) cells are longer, narrower and more closely compact than those of the normal uterine tissue;
and their nuclei are long and, with their cytoplasm,
stain deeper than those of the normal uterine
muscle. With Von Giesson's method, the muscle
fibers of the tumor stain yellow and the fibrous
tissue pink.
Etiology: While the cause of fibromyomata uteri
is as yet unknown, a few pertinent observations are
deservcd of more than casual interest. Seldom, if
ever, are these tumors encountered, for the first
time, before puberty or after the menopause; the
largest age-group is between the thirtieth and
fiftieth years, nearly 80 per cent; 43 per cent to
46 per cent between the ages of thirty-five and fortyfive; 20 per cent of all women over thirty-five
years have fibroids and 50 per cent over 50 years
of age have them; the clinical incidence of fibroids
is about 5 per cent; non-parous women seem more
likely to have these tumors.
It is reported by American and English authors
that fibroids are more common among Negroes
and Mulattos than among the Whites and, that
ovarian cysts and carcinoma of the uterus are rare
in Negroes and Mulattos. Contrariwise, we have
encountered the latter conditions (ovarian cysts
and uterine carcinoma) not infrequently in our
service in Freedmen's Hospital, during the past

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

forty-two years. It is interesting to note that, in

the full-blooded African, uterine fibroids are, practically, a non-entity.
Number and Size of Fibroids: As many as fifty
or more tumors have been seen in one uterus, and
the size ranges from pin-head to as much as 40
kgms. in one reported case.
Classification as to Location: 95 per cent of
uterine fibroids have their origin in the body of
the uterus and 5 per cent in its cervix. The majority of the body tumors starts in the posterior wall
of the uterus near the fundus, next the anterior
wall, next the fundus, then the sides. The majority
of cervical fibroids arises from the anterior lip.
All fibroids begin as interstitial or intramural
and 60 per cent to 70 per cent develop and remain
as such; while 20 per cent to 30 per cent develop
or grow centrifugally and are known as subserous
fibroids (sessile or pedunculated) and 10 per cent
to 15 per cent develop or grow centripetally to
become submucous (sessile or pedunculated). Fibroids are also encountered infrequently as intraligamentous and parasitic or "wandering fibroids."
Rarely, very large interstitial fibroids are so
vascular as to form large blood-filled sinuses resembling those at the site of placental attachment,
in advanced pregnancy; to such a tumor Virchow
gave the designation "myoma telangiectodes, sue
cavernosum." Such tumors lend weight to the
theory that, at least some fibroids may develop from
the walls of blood vessels in the uterus.
Rate of Growth: As a general proposition, the
growth of fibroids is slow. A clinico-histologic
rule is: the rate of growth is inversely proportional to the ratio of the amounts of its fibrous
tissue to its muscular element; that is, the greater
the predominance of fibrous tissue, slower is the
growth and visa versa. Growth of the tumor is
increased by pregnancy and menstruation; also,
fibroids encountered near puberty are prone to a
more rapid growth. A sudden rapid growth of a
fibroid in the very young or in a woman past the
menopause should be strongly suspected as sarcomatous degeneration of the fibroid.
Symptoms: Uterine fibroids may be asymptomatic; however, the symptomatology of fibromyomata
depends upon the location, size, number and condition of the tumor. Chief to be considered are
uterine hemorrhage, leucorrhea, pressure symptoms,
pain and symptoms of certain degenerations of

JANUARY, 1955

the tumor; also, infertility following the production of a pathologic flexion of the uterus, or a
bilateral compression of the tubes, by the tumors;
and, rarely, pyometra may result from plugging
the cervical canal by a submucous fibroid.
Only the interstitial and submucous varieties of
fibroids cause abnormal uterine bleeding. A large
interstitial tumor, by increasing the responsive area
(the endometrium), or many small interstitial
fibroids producing atony of the uterine musculature, would produce menorrhagia (too much or
too long menstrual flow), respectively.
The submucous fibroid, on the other hand, by
superficial necrosis of the endometrium would
produce metrostaxis, characteristically, and menorrhagia, dysmenorrhea from irregular uterine contractions, leucorrhea from congestion and edema
and gland secretion from irritation.
Pressure symptoms depend on the extent to
which an organ or structure may be encroached
upon. For example, the rectum resulting in constipation and rarely fistula formation; the urinary
bladder or constriction of the urethra giving symptoms of cystitis; the lumbo-sacral plexus of nerves
causing backache; the ureters giving hydronephrosis and what may follow; the pelvic veins giving
edema or hemorrhoids and, finally, pressure on
the upper abdominal organs giving circulatory
and/or respiratory embarrassment.
Pain, in addition to the dysmenorrhea, mentioned above, may be caused by peritoneal irritation by the subserous pedunculated fibroid or by
necrobiosis of the tumor; rarely twisting of pedicle
of the subserous fibroid may give the signs of an
acute abdomen.
Degeneration: The degeneration of the fibroid
is dependent predominantly upon interference with
the blood supply through the capsule. Pressure on
or interference with the arterial supply would result in hyaline degeneration, necrobiosis (red
degeneration) and necrosis, depending directly
upon the amount of nutritional deprivation. Pressure on or interference with the venous or lymph
return would result in edema, liquefaction necrosis
and cystic formations, depending directly upon
the amount of interference.
Hyaline is the most common and generalized
of all uterine fibroid degenerations and, at the
same time, is of the least clinical significance. However, red degeneration and necrosis are of such

VOL. 47, No. 1

The Uterine Fibroid

clinical importance, in that they produce disturbing

clinical manifestations, such as pain and tenderness over the tumor where pain was not before,
rapid pulse, rapid sedimentation rate, fever, leucocytosis and, rarely, sepsis, that surgical removal
of the fibroid becomes imperative. Lately, in such
cases, we have successfully combatted the symptomatology by bed-rest, ice-bag over the tumor and
coal-tar derivatives with or without codeine for the
tenderness and pain; at the same time, the use of
sulfa and antibiotic therapy has effectively immunized the circulation and confined the necrotic effect
within the tumor. Such management, in obstetrics,
has enabled us both to postpone the immediate resort to surgery, until after delivery, and to carry
the pregnancy safely to term.
Calcareous degeneration giving the so-called
"womb stones" by the old gynecologist should
rather be designated an infiltration.
Sarcomatous degeneration of fibroids, estimated
as high as 4 per cent is much too high; in our
experience, it is less than one-half of one per cent.
While such a degeneration is possible through metaplasia, it is a question, in my mind, whether or not
sarcoma was present from the beginning. Carcinomatous degeneration of fibroids discussed in some
of the older textbooks on gynecology does not exist
histo-pathologically. It is difficult to conceive of a
muscle cell metaplasing into an epithelial cell. But,
what does happen, rarely, is that a fibroid is the
habitat of adenomyosis which, by virtue of its
epithelial element, may undergo carcinomatous development.
Diagnosis: The diagnosis of fibromyoma uteri
is made on the history, abdomino-pelvic examination, uterine curettage or hysterography. Calcified
fibroids may be detected by use of the x-ray.
Large fibroids must be differentiated from uterine pregnancy (uterine fibroids never produce
amenorrhea), hydatid mole, large ovarian cyst, extensive adenomyosis interna, ascites, tympanites, abdominal fat, omental tumor and, rarely, old chronic

salpingitis.
Prognosis: Being benign, uterine fibroids, per
se, do not cause death; however, severe anemia
from blood loss, marked pressure symptoms, signs
of an acute abdomen, certain tumor degenerations
or pyometra may render the prognosis unfavorable.
Treatment: Asymptomatic fibroids should be
left surgically alone, unless they be removed for

47

cosmetic purposes; and, only such symptoms or

complications as hemorrhage, pressure, pain, signs
of tumor degeneration or rapid tumor growth, an
acute abdomen, interference with the pregnant
states or marital purposes should warrant coeliotomy. A brief sketch of the evolution of the treatment of uterine fibromyomata might not be amiss,
here.
Prior to 1843, women having uterine fibroids that
needed surgical removal had to forego the fulfillment of that requirement; for then the surgeon
had neither acquired the technique of a safe coeliotomy nor achieved acquaintanceship with surgical
asepsis and antisepsis. As consequence, the treatment was medicinal (ergot by mouth and the use
of intrauterine styptics). Prolonged use of the
ergot produced obliterative endarteritis and hypertension with resulting cerebral or cardio-renal vascular disease or accidents.
Submucous polyp visible through the external
os was removed by twisting its pedicle (vaginal
polypectomy) with good results; but when attempts
were made to remove other submucous and even
some interstitial tumors, through anterior vaginal
hysterotomy, so many cases succumbed from sepsis
and sapremia that this method was soon abandoned.
Since it had been observed that fibroids ceased
growing at the menopause, Hegar advocated bilateral oophorectomy to bring about an early menopause; obvious was the fate of such a treatment on
the child-bearing period. Apostoli, a physician during the Crimean War, employed electrolysis for
the treatment of fibroids, but, with very few exceptions, this method was disappointing.
To Heath and Charles Clay of Manchester, England, credit is given for performing the first coeliotomies for fibroid tumors, one in 1843 and one
in 1844, with a mortality of 100 per cent. An
American, by name, Burnham, performed the first
successful coeliotomy operation for fibroids in
1853. Thomas Keith, Koeberle, Pean followed by
Winter, Price and others, fortified by the epochmaking innovations by Lister (surgical antisepsis)
and Pasteur (germ theory of disease) placed coeliotomy on a basis firm and enduring.
It is worthwhile to remember that the mere
presence of an uterine fibroid(s) is not necessarily responsible for the abnormal bleeding.
Hence, an endometrial diagnostic curettage should

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

precede every decision for abdominal surgical intervention, in order to rule out other possible causative or contributing factors, such as endometrial
hyperplasia, polyps, tuberculosis or malignancy
which, if found, would modify the therapeutic
procedure.
Moreover, if an organic lesion or other circumstance would constitute an unpredictable hazard to
surgery, wisdom or necessity should suggest the
use of organo-or irradiation therapy, instead, to
check the bleeding and the tumor growth as well.
It is to be remembered, however, that by election,
age under forty years, the tumor larger than a
four-month pregnant uterus, signs of adnexitis,
certain tumor degenerations, severe anemia or
rapid growth contraindicates x-ray or radium therapy for fibroids.
Surgical intervention then having been decided
upon because of the abnormal bleeding or other
indications, there are two methods of approach:
myomectomy and hysterectomy. It should be borne
in mind, a priori, that the uterine fibroid(s) is a
benign condition; and the coordinated functions
of the uterus and ovaries are just as essential for
reproduction as are the brain or bowel for human
preservation. One would dare not extricate the
brain or bowel because it happened to be the sight
of a benign tumor. Why remove the uterus thus
affected ?
The rational procedure, therefore, should be
myomectomy, even multiple, which can be and is
done in our service, regardless of the size, number
or location of the fibroid, especially during the
child-bearing period, with increasingly gratifying
results.
Time is not too remote when myomectomy for
the submucous fibroid was tantamount to signing
a death warrant for the patient, because of the
resulting sepsis and sapremia, and hysterectomy be-

JANUARY, 1955

came the inevitable procedure of choice.

Fortunately, hysterectomy, a devastating operation
with its unpredictable consequences, for the removal of submucous fibroids, is passe in our service
and has been superseded by myomectomy, a physiology-preserving procedure.
This has been brought about, largely, through
the routine preoperative, operative and postoperative preparation, technique and care of the patient,
respectively.' To which should be added: maintenance of the proper electrolyte and fluid balance,
plasma proteins to at least 6 per cent (4 per cent
of which being the albumen fraction), indicated
blood transfusions, better anesthesiology and the
indicated use of the Wangensteen suction apparatus
or the Miller-Abbott tube.
These have placed myomectomy on a sound, safe
and satisfactory basis to which one hundred and
five known healthy babies, following myomectomy
in our service during the past five years, are a
living testimonial.
Deviation from the beaten path of hysterectomy
taxed our ingenuity, but it did enhance the ultimate
success of our undertaking. Broad anatomic knowledge and experience enabled us to avoid many pitfalls. The cervix uteri is carefully evaluated, in
the parous woman, before decision for myomectomy.
And what is of no less importance, to many
other such women, is the fact that, after myomectomy, reproductive possibility is preserved, and
they remain unimpaired biologically, sociologically
and psychologically, to which every woman is
innately entitled.
LITERATURE CITED

1. Ross, J. W. Surgery in the Uterine Fibroid, A Plea

for Myomectomy. Am. J. Obst. and Gynec. v. 53,
266-270, 1947.

PREVENTION OF MENTAL DEFICIENCY BY STERILIZATION

Sterilization laws have been operative in thirty states. In three, Alabama, New York and Washington, they
have been found unconstitutional because of technical defects in wording. Gamble made comprehensive studies of
the mentally deficient sterilized in New Hampshire and estimated that each 100 sterilizations of females and each
200 of males will prevent the birth of ninety feebleminded children. Since the passage of sterilization laws,
25,903 mentally deficient persons have been protected from parenthood in 29 states. Gamble estimated that these
sterilizations would prevent the birth of 19,000 mentally deficient children. At least 98 per cent of the eugenic
sterilizations reported in 1949 were with the consent of the patient or his family.
See, Clarence J. Gamble, The Prevention of Mentally Deficiency by Sterilization, 1949. Am. J. of Mental
Def., v. 56, pp. 192-197, 1951.