Uterine fibroids

Medical management of fibroidsFibroid growth is hormone dependent Medical treatments mainly involve hormonal Manipulations AIM : to control Menorrhagia , Improve Haemoglobin before surgeryIron Therapy for anaemiaDrugs used to control Menorrhagia :-Anti fibrinolytic agentsGnRH therapyDanazol Clomiphene CitrateMirena IUCD NSAIDs

The objectives of medical treatment are-To improve menorrhagia and to correct anemia before surgery . To minimize the size and vascularity of the tumor in order to facilitate surgery . In selected cases of infertility to facilitate hysteroscopic or laparoscopic surgery . As an alternative to surgery in perimenopausal women or woman with high-risk factors for surgery .

DRUGS USED TO MINIMISE BLOOD LOSSLEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM (LNG-IUS)

ANTIPROGESTERONE Mifepristone (RU486) is very effective to reduce fibroid size and also menorrhagia. It may produce amenorrhea. A daily dose of 25-30 mg is recommended for 3 months . Long term therapy is avoided as it causes Endometrial hyperplasia. Asoprisnil is used with success,it is a selective progesterone receptor modulator & it does not cause endometrial hyperplasia.

DANAZOLIt administered daily in divided doses ranging from 200-400 mg for 3 months minimizes blood loss or even produce amenorrhea by its antigonadotropin & androgen agonist actions.

GnRH AGONISTSDrugs commonly used are- goserelin , luporelin , buserelin or nafarelin . Mechanism of action is sustained pituitary down regulation and suppression of ovarian function. Optimal duration of therapy is 3 months.

GnRH ANTAGONISTSCetrorelix or ganirelix causes immediate suppression of pituitary and the ovaries .onset of amenorrhea is rapid.

Advantage of GnRH Analogue

Disadvantage of GnRH Analogue

PROSTAGLANDIN SYNTHETASE INHIBITORSThese are used to relieve pain due to associated endometriosis or degeneration of the fibroid. They cannot improve menorrhagia due to fibroids.

LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM (LNG-IUS)It reduces blood loss and uterine size. However, this is not recommended when the uterine size is >12 weeks or there is distortion of uterine cavity.

Benefits of medical t/tPfannenstiels incision can be given during total hystrectomyVaginal hystrectomy can be doneHysteroscopic guided resection can be done

Demerits of medical t/tExpensiveRegrowth after stopping therapyDifficulty in establishing the surgical plane between fibroid and surrounding tissue due to thinning of capsuleMenopausal signs and symptoms

Desire future fertilityMyomectomy Laparotomy larger fibroidsLaparoscopic pedunculated or subserosal fibroidsHysteroscopic submucosal fibroids, >50% in cavity

Desire uterine preservation but not fertilityEndometrial ablationUterine artery emboloization (UAE)

No desire for uterine preservation or fertilityHysterectomy (definitive)Laparotomy (TAH) larger fibroidsLaparascopic (TVH, TLH) smaller fibroids

Surgical Management

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MYOMECTOMYRemoval of fibroids leaving behind the uterusIndicationsInfertile womanWoman desirous of child bearingSolitary or few fibroids

Pre operative requisitesHb should be restoredConsent for Hysterectomy in difficult unforeseen circumstancesEndometrial cancer ruled out by d & cPerform in preoovulatory menstrual cycle to reduce blood loss

INDICATION OF MYOMECTOMY1

PRE-REQUISITES TO MYOMECTOMY

CONTRAINDICATIONS OF MYOMECTOMY

TechniqueIncision - Pfannelstiel incision (uterus 40 yearsMultiparousMalignancyUncontrolled haemorrhage during myomectomyTypesAbdominalVaginalLaproscopic

Abdominal HysterectomyRadical Hysterectomy (Complete Removal of Uterus , cervix , upper vagina and parametrium)

Total Hysterectomy (removal of uterus and cervix without oopherectomy)Subtotal Hysterectomy (removal of uterus leaving cervix in situ)

Pan Hysterectomy (when ovaries are also removed)

Extended and Wertheims Hysterectomy

Partial HysterectomyRemoves 2/3 of uterus

Total HysterectomyRemoves uterus and cervix

Radical HysterecomtyRemoves uterus, cervix, and vagina

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Vaginal HysterectomyDone in