Fibroid

Ans. is a, b, c  i.e. Fibroid uterus; Endometriosis; Adenomyosis; and PID

Before going into the details of the causes of Infertility, lets first have a look at the prevalence of various causes.

    Etiology of Inlertility

Male W                              25%

Ovulatory                         27%

Tubal / Uterine                 22%

Others                              9%

Unexplained                     17%

Common causes of female Infertility are :

a.     Decreased ovarian reserve

b.     Ovarian Factor It is the most easily diagnosed and most treatable cause of infertility°. It includes :

Anovulation / Dysovulation

• Like in case of hypothalamic dysfunction°, Kaltman syndrome
• Hyperprolactinemia (due to drugs, pituitary adenoma°)
• Primary hypothyroidism°

•  
• Sub clinical adrenal failure
• Diabetes mellitus

Luteinized unruptured follicle Luteal phase defect

c. Tubal Factors : Partial or Complete Bilateral tubal obstruction resulting from previous salpingitis / PID. It could be : — Postabortal°

—  Gonococcal°

—  Chlamydial°

—  Tuberculous°

• Tubal inflammation related to endometriosis
• Following Inflammatory bowel disease
• Following surgical trauma

d.   Peritoneal Factors : — Pelvic adhesions — Endometriosis

e.   Uterine Factors :

• Uterine absence, atrophy
• Congenital malformations (Among all congenital uterine abnormalities, septate uterus is the M/C and most highly associated with reproductive failure and obstetrics complications).
• Intrauterine adhesions (Asherman’s syndrome)°
• Endometrial polyps
• Leiomyomas (most common with sub mucous variety)°
• Chronic endometritis (TB)°
• Exposure to DES in utero

f. Cervical Factors :

• Impenetrable cervical mucus or poorly penetrable cervical mucus due to presence of local sperm antibodies.
• Loss of mucus due to amputation of cervix, cone biopsy or over enthusiastic cervical diathermy.
• Faulty direction of cervix as seen in retroversion or severe prolapse.
• Cervical stenosis.

g. Others : Anxiety / apprehension use of contraceptives; anorexia nervosa.

As such adenomyosis is not given as a cause of infertility but if you go through the chapter of adenomyosis: (In chapter on Adenomyosis) : “The patient may also complain of infertility”. So, I am including it in the correct options

Ans. is a i.e. Interstitial                         

• Fibroids are the commonest benign solid tumours in females.°
• It is the most common pelvic tumour.°
• Most common age group affected = 35 – 45 years°

Extra Edge :

• Fibroid with maximum symptoms – submucous fibroid.
• Wandering or parasitic fibroid-subserous fibroid.
• Lantern on dome of St. Paul – Cervical fibroid.
• Pseudo cervical fibroid- fibroid polyp.
• Most common fibroid to undergo calcerous degeneration – subserous fibroid.
• Fibroids are most commonly seen in Nulliparous female.°
• It is an Estrogen dependent tumour. °
• Fibroid is monoclonal in origin.
• Multiple chromosomal abnormalities are detected in 50% of all fibroids most common being translocation between long arms of Chromosomes 12 to 14, followed by deletion of long arm of chromosome Y.

Ans. is a i.e. Amenorrhea          

Symptoms of Fibroid

Most common symptom – Menstrual disturbances°

1. Most common Menstrual Disturbance – Progressive Menorrhagia° (seen in 30% cases ).

Causes :     a. Increased surface area°

1. Increased vascularity of uterus°
   1. Associated endometrial hyperplasia°
   2. Hyperestrogenism°
   3. Congestion of Venous plexus°
   4.  Abnormal uterine contractility° Other Menstrual Symptoms :

Metrorrhagia° – (Continuous and irregular bleeding)° Causes :        a. Ulceration of submucous fibroid or polyp.°

1. Sarcomatous change in Leiomyoma.°
2. Coincidental pregnancy state.°
3. Coincidental Ca endometrium or Endometrial Polyp.°

2. Pressure Symptoms

^1! Feeling of presence         Veins & Lymphatics       Alimentary tract          Nerves of sacral              Bladder

of mass                                                                                                                 plexus or obturator

Oedema & varicosity° Dyspepsia°                      (v rare)                               Diurnal frequency

Rarely Constipation l              anterior cervical Pain in pelvic region° fibroid° can cause

Urinary retention

• Dysmenorrhea – congestive° as well as spasmodic° type seen.

3. Infertility :

As a sole cause fibroid is responsible for < 3% cases of infertiliy. Causes :

1. a.     Fibroid hinders the ascent of the sperm.°
2. b.     Interferes with implantation of fertilised ovum.°
3. c.     Can cause associated disturbance in ovulation°

4. Pain :

A fibroid usually does not cause pain.

Causes : • Malignancy°

• It is being extruded from body as a polyp°
• Associated Endometriosis°
• Torsion of a pedunculated fibroma.°
• Degeneration°

Mnemonic :My PET Dog.

A woman with leiomyomas never has amenorrhoea.

Every woman suffering from fibroid who has continuous bleeding or irregular bleeding should be subjected to endometrial aspiration before her treatment is planned.

Ans. is b i.e. Squamous metaplasia

Fibromyoma can have following complications and r⁴—-^,:ative changes.

• Most common degeneration : Hyaline degeneration.°
• Degeneration starts from the central part.°
• Calcification starts in periphery (Womb stone).°
• Most uncommon (Rarest) change in fibroid is malignant change / sarcomatous change.° It occurs in 0.5%° cases of fibroid.

Ans. is b i.e. Intramural          

Well friends, we will have to rely on logic and the little text available in Shaw Gynae for this answer. I have searched in all books including Novak’s Gynecology and Devita – Tumours but without any success. Only Shaw’s throws some light on this issue.

“Intramural and submucous tumours have a higher potential for Sarcomatous change than Subserous tumour.” … Shaw 14/e. p 319 Since percentage of intramural tumours is much higher than submucous, so we take Intramural as the correct option. But finally it is upto you to decide.

Also know :

• Sarcomatous change is seen in only 0.2 – 0.5% of cases.
• The malignant process begins from the centre.°

Diagnosis is made by histological examination of the removed myoma.°

Changes seen in Myoma are :

– Sarcomatous Myoma is ^yellowish gre^y in colour (Normally pinkish white), with soft and friable consistency (Instead of firm consistency).

Non encapsulation of the tumour. (Normally fibroid is surrounded by a pseudo capsule made of connective tissue).

Sarcomas with malignant behavior have 10 or more Mitosis per high power field.

• becomes painful, tender, grows rapidly and produces systematic upset and pyrexia.

Ans. is c I.e. Red degeneration of fibroid

Friends, the answer is quite obvious but let’s see how other options can be ruled out. Option “a-Preterm labour

Points in favour                                                                          Points against

Patient has fibroid (Though no mention has                • Torsion is not associated with fever

been made whether it is pedunculated                          and leucocytosis.

or not, Remember torsion is seen in

subserous pedunculated Myomas)°

• Patient is complaining of acute

pain in abdomen.

Option “d”        Infection of fibroid

Points in favour                                          Points against

• Presence of fibroid                   • Acute pain in abdomen

(Remember : Infection is common        (Infection of fibroid will not cause acute pain in abdomen).

in submucous fibroids)°                      • Infection of fibroid occurs following abortion or labour

• Fever                                       (Here patient is pregnant but there is no history of

Option “c”    Red degeneration of fibroid

Red degeneration of fibroid : also called as Cameous degeneration.

• It is seen mostly during pregnancy mid pregnancy° (But can occur at other times as well and in non

pregnant females also).°

• It is an aseptic condition.°
• The myoma suddenly becomes acutely painful°, enlarged° and tender°.

• Patient presents with :                  Acute abdominal pain° Vomitting°

Malaise°

–                              Slight fever°

Lab investigations :                          – Moderate leucocytosis°
Raised esr°

Pathological changes in the tumour :

• Fibroid becomes soft. necrotic or homogenous especially in its centre.
• It is stained Salmon pink°, or red (due to Diffusion of blood pigments from the thrombosed vessels).
• It has fishy odour° (due to secondary infection with coliform organisms)
• Histologically : There is evidence of thrombosis in some vessels.°
• Pathogenesis : There is subacute necrosis of the myoma caused by an interference in blood supply (aseptic infarction).°

Management :

• Conservative management°
• Patient is advised rest°
• Analgesics are given to relieve the pain.°
• The acute symptoms subside in 3-10 days° and pregnancy proceeds uneventfully.

Diagnosis is by ultrasound.

D/D

• Appendicitis°, Twisted ovarian cyst°, Pyelitis° and Accidental haemorrhage°.
• So amongst above options – Red degeneration is the correct answer.

Ans. is a i.e. Second trimester 

Friends, answer to this question was quite obvious as each one of us have mugged it up; but finding an appropriate reference was a difficult task.

Read for yourself whatDutta Obs. 6/e, p 309 has to say‑

“Red Degeneration; It predominantly occurs in a large fibroid durin^g the second half of pregnancy or puerperium.”

From the above statement answer could be second trimester, third trimester or puerperium.

“Red degeneration; manifests typically about midpregnancy when the leiomyoma suddenly become acutely painful, enlarged and tender.”

This clears the doubts and confirms our answer i.e Red degeneration is most common during second trimester (midpregnancy).

Friends you should also keep in mind the following important points regarding – Fibroids and pregnancy.

Effects of Fibroid on pregnancy :

• Infertility

– Leiomyomas are a sole cause of infertility in less than 3⁰/0 of cases.°

–  It causes infertility by :

1. Hindering the ascent of the spermatozoa by distorting the uterus and tubes.
2. By disturbances in ovulation and
3. By interfering with implantation of the fertilized ovum.

–  Pregnancy rate following myomectomy = 40%°

• Abortion°, Placental abruption° and Premature labour°.

Occurs when fibroid interferes with enlargement of uterus, initiates abnormal uterine contractions or prevents efficient placentation,

• Ma!position° and Malpresentation° of Fetus : occur as fibroid can prevent engagement of head.
• Obstructed labour : It can be caused by cervical° and broad ligament tumours° which are fixed in the pelvis and by pedunculated subserous leiomyomas which become trapped in the pouch of Douglas.
• During labour

– If fibroid is situated above the presenting part – uneventful vaginal delivery.

– If fibroid is situated below the presenting part spontaneous vaginal delivery may occur; otherwise caesarean section is done. Thus chances of cesarean section are increased.°

• Post Partum Hemorrhage° /Delayed Involution° can occur if placenta is implanted° over the leiomyoma.

Uterine inertia – Inertia due to fibroid is not supported

Management of Red degeneration of fibroid.

• Patient is managed conservatively.°
• Patient is put to bed rest and given analgesics° (to relieve the pain), sedatives° and if required antibiotics.°
• If because of mistaken diagnosis iaparotomy is done, abdomen is closed without doing anything.
• Myomectomy should never be contemplated during caesarean section as vascularity of fibroid is increased
  during pregnancy (due to increased estrogen) leading to increased blood loss during cesarean section.°

For more information about Red degeneration, refer answer 8

Ans. is b i.e. Malignancy                    

Sarcomatous change / malignancy in a fibroid is extremely rare (0.2-0.5%).

• Most common Fibroid to undergo malignant change is intramural followed by submucous.°
• Seen in postmenopausal or permenopausal females of 40 years of age.
• Features suggestive of malignancy :

– Sudden increase in size of fibroid

– Fibroid becomes tender and painful

– Post menopausal bleeding

–  Systemic upset and pyrexia may be present

Extra Edge : Specific features of different types of fibroid —

Ans. is a, b and c i.e. Hysteroscopy; Hysterosalpingography; and USG (Transabdominal)  

USG • Ultrasound is the main diagnostic tool in case of fibroid.° It checks the number°, location° and size° of fibroids and helps to reduce overlooking small fibroids during surgery (which might lead to persistence or recurrence of symptoms).

USG findings in case of Fibroid

• Enlarged and distorted uterine contour
• Depending on connective tissue amount — fibroid may have varying echogenecity (hypoechoic or hyperechoic.
• Vascularisation is seen at periphery.

Uterine Curettage : It can also help in diagnosis of submucous fibroid by feeling of a bump during curettage.° Laparoscopy : is helpful if uterine size is less than 12 weeks, for detection of a subserous fibroid. It can also differentiate a pedunculated fibroid from an ovarian tumour not revealed by clinical examination and ultrasound. Investigation which can be done is MRI.°

Role of Doppler in diagnosis of Fibroid :

Leiomyomas have characteristic vascular patterns which can be identified by color flow doppler. A peripheral rim of vascularity from which a few vessels arise and penetrate into the centre is seen. Doppler imaging can be used to differentiate an extrauterine leiomyoma from other pelvic masses or a submucous leiomyoma from an endometrial polyp or adenomyosis.

Also know :

• Best investigation for submucous fibroid – Hysteroscopy°
• Best investigation to detect fibroid (in general)°

—       USG (P^t choicer

—       MRI (2^f‘^d choicer

Ans. is b i.e. Radiofrequency ablation

Emblotherapy :

• Uterine artery embolization is done using polyvinyl° alcohol or gel foam°, in patients not suited for or not desirous of surgical therapy.
• Uterine blood flow is obstructed producing ischemia and necrosis.
• It shrinks the fibroid by 40-50% in selective young women.°
• Results : These patients experience

1. lowered fertility rate°
2. risk of placental insufficiency and°
3. uterine rupture in subsequent pregnancy° because of interference with the blood supply and embolotherapy induced necrosis of the leiomyoma.

Due to lack of long term outcome data women who desire future childbearing are not currently considered candiates for uterine artery embolisation

Post op Complications : • Pain°

• Fever°
• Pulmonary embolism°
• Complete amenorrhea° Extra Edge

Indications for operating an Asymptomatic fibroid° :

• Fibroids larger than 12-14 weeks pregnancy.°
• Rapidly growing fibroids.°
• Subserous and pedunculated fibroid prone to torsion.°
• If it is likely to complicate a future pregnancy°
• If there is doubt about its nature°

• Unexplained infertility and unexplained recurrent abortion.° 
• Uncertain diagnosis.°

Indications of Medical management° :

• To treat anemia and recover Hb levels before surgery.°
• To reduce the size of large fibroid and facilitate surgery.°
• Treatment of women approaching menopause to avoid surgery.°
• In women with medical contraindication to surgery or those who are postponing surgery.°
• For Preservation of fertility in women with large myomas before conservative surgery like myomectomy.°

Indications of surgical management° : Fibroids causing symptoms like

• Menorrhagia°

• Pressure symptoms° : Urinary Retention (by a cervical or broad ligament fibroid)
• Chronic pelvic pain with° severe dysmenorhea
• Acute pelvic pain as in° torsion of a pedunculated fibroid or prolapsing Sub-mucosal fibroid
• Infertility caused by cornual fibroid
• Recurrent abortions due to submucous fibroid.

Ans. is a, b, and c i.e. GnRH analogues; Danazol; and Mifeprestone

As I have already explained in previous question, the drugs used to decrease blood loss / vascularity of fibroid during surgery are :

Ans. is a  i.e. Danazol; and GnRH analogues

Ans. is d i.e. Red degeneration       

From the given options the answer is quite obvious as red degeneration of fibroid is managed conservatively not by any surgery.

But here I would like to discuss in detail the surgical management of fibroid and its indications, especially myomectomy (which is being done more frequently these days).

Indications of surgical management of fibroid :

• Fibroid causing symptoms : – Menorrhagia°

–  Chronic / Acute, Pelvic pain°

–  Pressure symptoms like urinary retention.°

• Fibroid like cornual fibroid causing infertility.°
• Sub mucous fibroid causing infertility (Other causes of infertility should be ruled out before surgery).°

Surgical options can be :

•  Myomectomy
• Hysterectomy

Indication of myomectomy : Myomectomy is specifically indicated in an infertile woman or woman desirous of bearing child and wishing to retain the uterus. Indications being the same as for surgery.°

Some specific indications for Hysterectomy :

• In patients > 40 years of age.°
• Multiparous women.°
• If fibroid is associated with malignancy.°
• During myomectomy if their is uncontrolled hemorrhage or other surgical difficulty.°
• If the size of uterus is < 12 weeks vaginal hysterectomy can be done.°

• Myomectomy is the enucleation of myomata from the uterus leaving behind a potentially functioning organ capable of future reproduction.°
• Prerequisites : Anemia should be corrected.°

–  All other causes of infertility should be excluded.°

– Male factor infertility should be ruled out.°

– Diagnostic D and C should be performed in case of irregular cycles, to detect any polyp and to rule out endometrial cancer.°

– Hysteroscopy or HSG : To detect a fibroid encroaching the uterine cavity or a polyp or tubal block.°

• Myomectomy is specifically indicated in an infertile woman or woman desirous of bearing child and wishing to retain the uterus.°

Time of myomectomy :

• It should be performed in preovulatory menstrual phase to reduce blood loss during surgery.°
• It should not be performed during pregnancy and at the time of cesarean section.°

Contraindications :

• Big broad ligament fibroid : (as many large vessels are present which can cause uncontrollable bleeding and thus the need to abandon myomectomy and do hysterectomy.°
• Multiple tiny fibroids scattered through the uterine wall.°

Instrument used to decrease blood loss during myomectomy : bonney’s myomectomy clamp.°

• Myomectomy operation should always be followed by shortening of round ligament to prevent retroversion.°
• Bonney’s hood technique : is done in interstitial fibroid on the fundal posterior wall.°

Results (Important) :

• Pregnancy rate following myomectomy : 40%°
• Abortion rates if woman conceive : 25%°

Myomectomy :

• Low grade postoperative pyrexia is a rule and should not be treated by antibiotics (pyrexia is d/t slight extravasation of blood in uterine wall or peritoneal cavity and settles spontaneously in 7-14 days).
• Recurrence rate : 5-10%°
• Persisting menorrhagia 1-5%°
• Reason for persisting menorrhagia is either myoma was not responsible for the complain or an intrauterine polyp or fibroid was overlooked during surgery.
• 20 – 25% women subjected to myomectomy : ultimately come for hysterectomy.

Ans. is a i.e. Myomectomy  

First lets see whether we would like to go for medical management or surgical intervention. The patient is presenting with :

•  Severe menorrhagia°
• Chronic lower abdomen pain°
• Size of fihroici = 14 weekca

These 3 indications are strong enough for surgical intervention. Other indications for surgical Management are :

• Acute pain in abdomen as in Torsion of pedunculated fibroid or prolapsing submucosal fibroid°
• Pressure symptoms like constipation°
• Dysuria°
• Infertilty (when other causes of infertility have been ruled out) and habitual abortion caused by submucous fibroid.°

Now comes the question – whether Myomectomy or hysterectomy should be done.

Indication of Myomectomy : Myomectomy is specifically indicated in an infertiie woman or woman desirous of bearing child and wishing to retain her uterus.

Since, our patient, Sucheta is just 29 years and Nulliparous – Myomectomy should be done.

Ans. is a i.e. Estrogen dependant tumour; and Danazol is used in treatment 

Now friends after knowing so much about fibroids by means of all previous question. I don’t think you need an explanation for this one.

You already know Fibroids are estrogen dependant tumours° and don’t have a true capsule but a pseudo capsule°.

• Red degeneration occurs in pregnancy but does not require surgical Management, rather it is managed conservatively.
• Danazol is used in Medical Management of fibroid to both decrease its Vascularity as well as its size.

Remember :

Fibroid are associated with :

— Follicular cyst of ovary° Endometrosis°

— Endometrial hyperplasia°

— Endometrial cancer°

Blood supply of a fibroid is present in its pseudo capsule therefore most vascular area of fibroid is its periphery (hence calcification begins in periphery).

Whereas least vascular part of fibroid is its centre (hence degeneration begin in centre).

Ans. is b i.e. Subserous        Ref. Dutta Gynae 4/e, p 256

Calcareous degeneration usually involves the subserous fibroids with small peduncle or myomas of postmenopausal women. It is usually preceded by fatty degeneration. There is precipitate of calcium carbonate or calcium phosphate within the tumour, when whole of the tumour is converted into a calcified mass it is termed as ‘womb stone’.

Also Know :

0.5%

Estrogen

All Correct

Subserous

Intramural

TAH

Sarcomatous changes

Thrombosis of the veins

Is aseptic infarcation

Usually malignant

Second trimester

Ans. is d i.e. Endometriosis; and Fibroid (Most probably)

Well friends, here we will have to weigh each option one by one.

Option “a”  DUB              

• Especially metropathia hemorrhagica is seen in age group 40 – 45 years which coincides with the age of the patient given in the question.
• But in DUB (as 80% cases are due to anovulatory bleeding) pain is characteristically absent. Bleeding is always painless and acyclical and continues for 2 – 8 days. In about half the cases it is preceded by a short period of amenorrhea (Metropathia Haemorrhagica).

So, option “a” is ruled out.

Option “b” : Endometriosis

Dysmenorrhea (Secondary and Progressive in nature) and menstrual irregularities including menorrhagia are specifically seen in endometriosis.    

As far as age is concerned.

“Active endometriosis is seen most commonly between the ages of 30 and 40 years. It can however occur at any time between the menarche and the menopause, even before the age of 20 years.”

Option “c”         Fibroid

• Age group : Seen in women of child bearing age group. Seen in 40% of women above the age of 40 years.
• Fibroids most commonly cause symptoms between the ages of 35 and 45 years. (So age is consistent with the patients age).
• Fibroid uterus causes menorrhagia and dysmenorrhea so, the possibility of fibroid is high. 

Option “d” : Endometrial carcinoma

• It is not a case of endometrial Ca because, endometrial Ca is common in 55 – 60 years 
• Patient presents with irregular and heavy cycles.

The lower abdominal pain in advanced stage is due to parametrial involvement. (Not dysmenorrhea) .

Fibroid

Submucous fibroid

Submucus fibroid

All of the above

Ans. is c i.e. impacted cervical fibroid

The patient in the question :

• Was being treated for infertility.
• Now H/0 a 6 weeks of amenorrhea.
• Presents with urinary retention. The first diagnosis which comes in our mind is Retroverted gravio uterus.

Points which favour the diagnosis are : The woman is pregnant and has complain of urinary retention.

But friends, here it is important to understand that retroverted gravid uterus causes urinary retention at 14 – 15 weeks of gestation (not 6 weeks). Jeffcoate 7/e. p 299 So Option -a^–. is ruled out

Option “b^“ Pelvic hematocele

“Pelvic hematocele is formed in a patient complaining of 6 weeks amenorrhea in case of ectopic pregnancy.”

Though pelvic hematocele causes urine retention but then other symptoms (pain) and signs of ectopic pregnancy should be present.

Option “c^“ Impacted cervical fibroid

“A cervical fibroid impacted in pouch of Douglas can cause retention of urine. The onset of retention is acute and usually occurs immediately before menstruation, when the uterus is further enlarged by congestion or during early pregnancy.”                                                                                                                                                   

Fibroid is associated with infertility.

Thus an impacted cervical fibroid can explain all features seen this woman and is our option of choice.

Ans. is a, b, and c i.e. Cervical fibroid; Retroverted Gravid uterus; and Severe UTI

Important gynaecological causes of acute retention :

Acute retention          Other symptoms                           Diagnosis

Retention                    Primary amenorrhea                   Hematccaiposcopy

Retention                    Secondary amenorrhea             Retroverted gravid uterus

Retention                    Menorrhagia                                 Uterine leiomyoma (cervical fibroid)

Retention                    No menstrual upset                     Ovarian or broad ligament tumor

Retention                    Irregular bleeding                       Threatened abortion from a retroverted gravid uterus or pelvic haematocoele or pelvic abscess

Besides the above causes gives an exhaustive list of other causes of urinary retention-in which urethritis causing spasm of voluntary external urethral sphincter and acute urinary retention is given.

Ans. is a, d and c i.e. Tuberculosis; Endometriosis; and Subserous fibroid

Dysmenorrhea means painful menstruation of sufficient magnitude so as to incapacitate day to day activities.

Primary (Spasmodic)

• There is no identifiable pelvic pathology
• Spasmodic dysmenorrhea manifests as cramping pain most pronounced on the first and second day of menstruation.
• It rarely lasts for more than 12 hours°
• Pain is felt mainly in the hypogastrium°
  and is referred to inner and front of

thigh (it never extends below the level of knee and back of leg).

• Area supplied by iliohypogastric and ilioinguinal nerves (T12, Ll and L2)

are affected.

• Mainly seen in girls between 18 – 24 years° and begins to decline beyond 30 yrs. of age
• It is nearly always cured by pregnancy

Secondary (Congestive)

• Pain occurring in presence of pelvic pathology
• Congestive dysmenorrhea manifests as diffuse dullache in the pelvis, accompanied by backache.
• It is thought to be the result of increasing tension in the pelvic tissue associated with inflammation exacerbated by premenstrual engorgement.
• The pain is at its height during the 2 or 3 days proceeding menstruation and slowly relieved as congestion is reduced with the onset of menstruation.
• Causes :

–  Uterine or vaginal anomalies with obstruction of menstrual flow

– imperforate hymen°

– transverse vaginal septum°

–   Congenital malformations

– bicornuate uterus°

– sepatate uterus°

–  Asherman’s syndrome°

Endometrial polyp°

–   Uterine fibroicf2

–  IUCD°

–  Chronic PIO°

–  Pelvic congestion syndrome°

–   Broad ligament varicocoele°

–   Endometriosis°

Adenomyosis°

In the question cause of secondary dysmenorrhea in a young female is asked

– Adenomyosis is observed frequently in elderly woman (ruling out Options ‘b’)          

–  Fibroid are seen in approximately 20% of women over 20 years of age.                                   

Endometriosis is most commonly seen between the ages of 30 and 40 years. It can however occur at any time between menarche and menopause. even before 20 years.

–  Tuberculosis : A virgin having symptom and signs of chronic pelvic infection, should be assumed to have tuberculosis unless it is proved to the contrary.                                                                                                                  

Extra Edge

Causes of unilateral spasmodic dysmenorrhea :

• One horn of malformed uterus.
• Endometrosis with unilateral distribution.

Small fibroid at the utero tubal junction.

Submucus fibroid

Fibroid

Laparoscopic myomectomy is  best treatment for  such  young infertile patients, but  it  requires subserosal pedunculated fibroids and surgical expertise.

Hysterectomy is advisable in patients who had completed their family.

Myolysis is myoma coagulation with laparoscopic lasers. (Nd- YAG) or bipolar needle & used in perimenopausal patients.

UAE is newer intervention for fibroid management in surgically unfit high risk patients, but it causes decreased fertility & carries risk of placental insufficiency and uterus rupture in subsequent pregnancy.

• Primary with no organic cause
• Secondary due to pathologic cause
• Membranous in which cast of endometrial cavity is shed as a single entity.

• Hyaline change: It is present in two third of the fibroids and is very rarely symptomatic.
• Cystic change
• Oedema
• Red degeneration
• Calcification
• Fatty change

In a pregnant female with red degeneration of fibroid, management is essentially conservative treatment with analgesia and rest.

Menstrual abnormalities associated with fibroids are menorrhagia, metorrhagia and dysmenorrhea.

It does not cause amenorrhea. Subserous, broad ligament or cervical fibroids are unassociated with menstrual abnormalities.

Other features associated with fibroids are lower abdominal pain, pressure symptoms, infertility, abortion, preterm labor, and IUGR.

Ref: Textbook of gynecology by D C Dutta 4th edition  Page 255 – 8; Johns Hopkins Manual of Gynecology and Obstetrics, 3rd Edition, chapter 33 – Uterine Leiomyomas.

• Mature or “old” leiomyomas are white but contain yellow, soft, and often gelatinous areas of hyaline change. These tumors are usually asymptomatic.
• Leiomyomata may cause pain when vascular compromise occurs. 
• Thus, pain may result from degeneration associated with vascular occlusion, infection, torsion of a pedunculated tumor, or myometrial contractions to expel a subserous myoma from the uterine cavity. 
• The pain associated with infarction from torsion or red degeneration can be excruciating and produce a clinical picture consistent with acute abdomen.

Resection of tumors is an option for symptomatic women who desire future childbearing or for those who decline hysterectomy.

This can be performed laparoscopically, hysteroscopically, or via laparotomy incision, and each is described in detail in the surgical atlas.

Myomectomy usually improves pain, infertility, or bleeding.

Menorrhagia improves in approximately 70 to 80 percent of patients following tumor removal.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

In a pregnant female with red degeneration of fibroid, management is essentially conservative treatment with analgesia and rest.

Lower segment fibroid

Fibroid uterus

Ans. is d i.e. None

Effects of Fibroid on Preononcv

Infertility : It is other the cause or the effect of the fibroid.

• Leiomyomas are a sole cause of infertility in less than 3% of cases.°
• It causes infertility by :

1. Hindering the ascent of the spermatozoa by distorting the uterus and tubes.
2. By disturbances in ovulation and
3. By interfering with implantation of the fertilized ovum.

• Pregnancy rate following myomectomy is 40%°

During Pregnancy :

• Abortion°, Placental abruption° and Premature labour°.

Occurs when fibroid interferes with enlargement of uterus. initiates abnormal uterine contractions or prevents efficient placentation.

• Malposition° and Malpresentation° of Fetus : occur as fibroid can prevent engagement of head.
• Obstructed labour : It can be caused by cervical° and broad ligament tumours° which are fixed in the pelvis and by pedunculated subserous leiomyomas which become trapped in the pouch of Douglas.

During labour :

• If fibroid is situated above the presenting part – uneventful vaginal delivery.
• If fibroid is situated below the presenting part-Trial for vaginal delivery should be given. Thus chances of cesarean section are increased.°
• Post Partum Hemorrhage° /Delayed Involution° can occur if placenta is implanted° over the leiomyoma.

Should not be removed

Ans. A: Metastasis

• Pain
• Breech presentation
• Malposition
• Higher incidence of cesarean delivery
• Preterm birth
• Premature rupture of the membranes
• Postpartum hemorrhage
• Placental abruption Submucosal, fibroids located beneath the placenta, and fibroids 7 to 8 cm in diameter had the highest risk for abruption.

Ans: C i.e. Tourniquet use administration

Haemorrhage should be controlled with the myomectomy clamp. If the myomectomy clamp cannot be applied as in cervical fibroid, a rubber tourniquet will serve the purpose.

Ans. A i.e. Dysmenorrhea

Fibroid

• Red degeneration of fibroid:

–  Seen in 2^nd half of pregnancy or puerperium,

– Due to thrombosis of large veins of the tumour,

– Infection has no role (this process is an aseptic one),

• Management is conservative (analgesics and sedatives)
• Fibroids are associated with:

– Follicular ovarian cysts,

– Endometriosis,

– Endometrial hyperplasia,

– Endometrial Ca

• MC type of fibroid: Intramural/ interstitial
• MC type of degeneration: Hyaline (starts from the centre)
• MC to undergo malignant change: Intramural
• MC to undergo calcareous degeneration: Subserous
• Most fibroid starts as: Interstitial fibroids

Ans. Pulmonary edema, hysterectomy, mitral stenosis

Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, non-cancerous tumors arising from the myometrium (smooth muscle layer) of the uterus. In addition to smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, proteoglycan, fibronectin). Other names for these tumors include fibromyomas, fibromas, myofibromas, and myomas.

Subserosal leiomyomas are located just under the uterine serosa and may be pedunculated (attached to the corpus by a narrow stalk) or sessile(broad-based).

Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, non-cancerous tumors arising from the myometrium (smooth muscle layer) of the uterus. In addition to smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, proteoglycan, fibronectin). Other names for these tumors include fibromyomas, fibromas, myofibromas, and myomas.

Intramural leiomyomas are found predominantly within the thick myometrium but may distort the uterine cavity or cause an irregular external uterine contour.

Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, non-cancerous tumors arising from the myometrium (smooth muscle layer) of the uterus. In addition to smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, proteoglycan, fibronectin). Other names for these tumors include fibromyomas, fibromas, myofibromas, and myomas.

Submucous leiomyomas are located just under the uterine mucosa (endometrium) and, like subserosal leiomyomas, may be either pedunculated or sessile.

Ans. b. Sarcomatous change .

• The risk of sarcoma developing in a fibroid uterus is approximately 0.5% (Least common secondary change).

Secondary Changes in Fibroid

• Hyaline degeneration:
• MC change, more common in central portion^Q
• Cystic degeneration (after menopause)
• Fatty degeneration (after menopause)
• Calcareous degeneration (after menopause)
• Atrophy° (after menopause)
• Red degeneration° (2′ half of pregnancy)
• Sarcomatous change:
• Least common change^Q
• Incidence 0.5% of all fibroids
• More common in intramural and submucous fibroids

Ans:D.)Uterine Fibroid.

Image shows:KUB shows a large calcified mass in the pelvis (arrows), which is typical for a large calcified fibroid.

UTERINE FIBROID

• Uterine leiomyoma, also known as uterine fibroid, is benign and the most common gynaecological neoplasm.
• When they are symptomatic, their usual presentations include: suprapubic mass, pain or menorrhagia.
• A leiomyoma may undergo calcification as it degenerates, and become visible on plain radiograph.
• The diagnosis is usually made on ultrasound . On USG, it appears as a well-defined hypoechoic mass in the myometrium of the uterus.

Other differentials of pelvic calcification in a female include dermoid , bladder stones  and phleboliths.