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Benign tumours of the uterus primarily composed of smooth muscle & fibroids connective tissue
leiomyomata (monoclonal).
- Benign monoclonal growth of myometrium
o Contains collagen
o Surrounded by pseudo-capsule

Occurs in 20 50% of women >30y.o.
o YOUNGER PATIENTS (Polyps = older patients)
Most common solid tumour of the female pelvis
In ~85% of cases, fibroids occur in multiples

Risk factors/Aetiology
Advanced maternal age
Black ethnicity
Exposure to sex hormones (e.g. contraceptive, HRT)
High intake of beef/red meat

Arise from the myometrial layer of the uterine corpus (intramural)
o Protrudes outward = subserosal
o Protrudes inward = submucous
Symptoms associated with distortion of endometrial lining more common in submucous
Growth accelerates during pregnancy (due to elevated hormones)
Involutes at menopause (decrease in size)
Hormone sensitive
o More hormone = grow faster
Increases in size with pregnancy
o Decreases in size after menoapuse

Classification (by where they appear)

1. Intra-uterine
o Subserosal pedunculated severity depends on location
o Intramural (most common)
o Submucosal/submural (least common) ?can affect backwards
2. Extra-uterine
o Cervical within the cervix
o Broad ligament located between 2 layers of the ligament
o Parasitic (likely pedunculated subserosal leiomyoma that twists off and latches on to
adjacent structures, with neo-vascularisation)
3. Diffuse uterine leiomyomatosis
Subserosal and intramural cause bleeding

- Fibroids may undergo atrophy, internal haemorrhage, fibrosis and calcification.
o This is bad it will be painful!
Types of degeneration:
1. Red degeneration**
Sudden cut of blood supply
Presents with acute abdo pain + localised tenderness over uterus
Risk factors
o Pregnancy
o Hormone supplement (e.g. OCP, HRT)
Due to haemorrhagic infarction

2. Hyaline degeneration (~60%)

Focal or generalised hyalinisation outgrown the blood supply
Outgrow blood supply cystic degeneration

3. Cystic degeneration (~5%)

Fibroid outgrows vascular supply necrosis oedema calcification

4. Myxoid degeneration
Filled with gelatinous material
Appear as complex cystic masses
Can mimic malignant leiomyosarcoma

Signs & symptoms

Commonly asymptomatic
Irregular firm, central pelvic mass

Abnormal uterine bleed/Abnormal PV bleed (due to distortion of endometrial lining most

common with submucous fibroids)
Heavy periods (menorrhagia)
Intermenstrual bleeding
Dyspareunia (if on cervix)

Recurrent 2nd trimester loss (submucosal)

Obstructed labour
Deep dysmenorrhoea (obstruction of menstrual flow)

Pelvic pressure
Urinary frequency/urgency
Urinary & faecal incontinence
Pedunculated submucous fibroids can dilate cervix prolapse into vagina risk of infection

Acute or chronic pain 2 degeneration


Abnormal PV bleed

Bimanual examination
Cobble-stone uterus irregular, hard, palpable mass on the uterus

Test Findings
Bimanual examination Round firm irregular vagina
BUZZWORD: Cobblestone uterus
Abdominal U/S 1st line Heterogenous hypoechoic masses +/- cystic areas
- Rule out ovarian mass
Calcification (cystic degeneration)
Hysteroscopy Direct visualisation of space-occupying lesions

Laparoscopy + histology Visualisation of irregular protrusion from uterine surface

MRI gold standard For evaluation of atypical cases of pelvic/abdo masses

- Differentiate types of fibroids + exclude other causes

Gross pathology: firm, round, well-circumscribed nodules located either:

o Subserosal (under the uterine serosa)
o Intramural (within myometrium)
o Submucosal (just below the endometrium)
Micropathology: spindle-shaped cells with no mitotic activity or remarkable nuclear atypia

Management (look at growth rate)

Conservative: if fibroids are asymptomatic and not causing any complications, simply monitor for any
Medical (pre-operative adjunct)

Nafarelin (Synarel) (GnRH antagonist) to reduce size of fibroids

o Stops ovulating and shrink fibroids
o High SE: Non-reversible androgenising
Mirena if small fibroids. Not for big fibroids as Mirena wont be retained
1st line: hysteroscopic myomectomy/endometrial resection (hysteroscopic or manually)

The only surgical procedure that preserves fertility uterus preserving

o Risk of future fibroids
o Haemorrhage
o May require hysterectomy
Give GnRH (goserelin) to reduce size of fibroid before surgery
Alternative: UAE (uterine artery embolization)
Gold standard: Hysterectomy


Recurrent uterine fibroid growth

o Affects fertility (intra and submucosal types)
o Increased rates of miscarriage
o (Subserosal tends to be okay?)
o Inter-menstrual bleeding
o Pain
Pain on intercourse
o Mass effect if tumour too bigspace occupying
o Urinary and bowel obstruction
o May affect babys growth
Labour & delivery complications
o Malpresentation
o Small fibroids can cause preterm laboru
o Fibroids can block birth canal
Acute torsion
Significant haemorrhage
Degenerative changes