Sunday, November 07, 2010

Fibroids of the uterus (leiomyoma):

Fibroids are the commonest tumors of the uterus and have a reported incidence of at least 25 to 30 % in the female population. Uterine fibroids are benign tumors (lumps) of the uterine musculature (called smooth muscles) and have varying prognosis from slowly growing tumors to those that may actually regress (become smaller). A small percentage of fibroids of the uterus may actually undergo malignant transformation (become cancerous); these cancerous tumors are called leiomyosarcoma. Another aspect about a fibroid is that this uterine tumor may be single or it may be multiple.
What are the symptoms of a uterine fibroid?
The earliest symptoms of a fibroid can be pain the lower abdomen (the pelvis) of the woman (usually after the age of 30). The other symptoms of uterine fibroids include dysmenorrhea (pain during menses), increased frequency or amount of bleeding during menses (polymenorrhea or menorrhagia) and other menstrual abnormalities. Other symptoms include those produced by pressure of the fibroids of the uterus on the adjacent organs in the female pelvis including the urinary bladder (increased frequency of urination and obstructed urination). Pressure on the rectum may cause constipation in women where the uterine mass (tumor/ fibroid) arises from the posterior (back) of the uterus. Fibroids are also a common cause of infertility in women.
 So how does one diagnose fibroid of the uterus?
If a woman has one or more of the symptoms mentioned above, she should consult the doctor/ gynecologist immediately. Per abdominal examination (palpation) of the pelvis can sometimes help detect a relatively larger fibroid. In addition, a per vaginal examination may also help to detect a lump of the uterus. In any case, the safest and best method to diagnose a fibroid of the uterus is ultrasound examination. The sonologist or radiologist conducts a transabdominal examination of the pelvis (on a full bladder) to visualize the uterine mass. The uterine tumor is seen from various angles to determine its size, number, location and pressure effects on the adjacent bladder or rectum.
Here is some examples of what a uterine fibroid looks like on ultrasound imaging:
There are commonly three types of fibroid based on ultrasound imaging:
a) Intramural- the fibroid is within the wall of the uterus.
b) Subserosal- the fibroid is just below the outer covering serosa of the uterus.
c) Sub mucous- the fibroid is just below the inner lining of the uterus (the endometrium).
This ultrasound image shows a fibroid extending from the subserous to the intramural location of the uterus-













What does the sonologist or radiologist see in this ultrasound image of the subserosal fibroid? The uterine fibroid is pressing upon the anteriorly (front) located urinary bladder. The mass or tumor is located to the right side of the uterus and extends from the intramural to the subserosal location of the upper part of the uterus (called the fundus).
See another ultrasound picture of the same case:
 












The uterine fibroid also appears to compress upon the inner lining of the uterus (EM= endometrium).(FIB= fibroid; BL= bladder; UT= uterus). Thus this patient is likely to have a number of complaints- from bladder compression to irritation of the inner lining (endometrium) of the uterus with resultant menstrual problems.
Broad ligament fibroid:
In rare cases the uterine fibroids may be located to either side of the uterus- the so called broad ligament fibroids- see the ultrasound pictures/ ultrasound video clips of one such case of broad ligament fibroid:
The uterine tumor in this case is seen in the left broad ligament of the uterus. Such a broad ligament fibroid may interfere with the function of the left fallopian tube (the duct that transmits the ovum from the left ovary to the uterine cavity). Hence such a patient might have problems conceiving or may be infertile.
See this ultrasound video clip of the same case (left broad ligament fibroid):
video

Pedunculated fibroid:
The next case we shall discuss is another relatively rare entity called the pedunculated fibroid of the uterus. Here, the fibroid in the uterus is connected to the uterus by a short or sometimes long pedicle or stalk. See the ultrasound images of one such case of pedunculated fibroid of the uterus:

In this patient, the uterine fibroid is seen extending just above the fundus (top) of the uterus and is connected to it by a short stalk. It is almost like a floating tumor suspended from the main body - the uterus by a stalk or cord. Such pedunculated uterine fibroids can cause severe pain due to torsion of the uterine tumor mass (twisting of the stalk) resulting in cutting off of the blood supply to the tumor from the uterus.
Have a look at these ultrasound video clips of the pedunculated fibroid described above:

video
Such an event resulting in twisting of the stalk of the pedunculated fibroid can be a medical emergency and urgent surgery might be required to remove the mass immediately.

video
This color Doppler ultrasound video clip shows the stalk is very vascular (ie: a number of blood vessels are seen between the pedunculated uterine fibroid and the fundus of the uterus. For more details of the various other types of fibroids of the uterus and ultrasound images of each case, visit:

Case-2 (pedunculated fibroid of uterus):
This is another example of a large fibroid with a stalk connecting the tumor (6 x 7 cms.) to the fundus of uterus via a stalk or peduncle. The peduncle measures about 2 cms. in thickness. I managed to visualize the peduncle by applying pressure onto the area between the fibroid and the fundus of the uterus. See the ultrasound video below:
video

video 
Color Doppler video clip (above) shows multiple blood vessels within the short and relatively thick pedicle connecting the fundus to the fibroid.
This is how the mass (fibroid) and pedicle appeared on still images (see below):
















 Observe the presence of a second fibroid within the lower part of body of the uterus in these sagittal sections of the uterus. This fibroid appears intramural in location.
It is beyond the scope of this article to describe in detail the other methods of diagnosing tumors of the uterus. However, it must be added that CT (CAT) scan imaging and MR imaging can also offer additional information on  fibroids of the uterus, in certain cases.
For information on treatment of fibroid of the uterus visit:
Degenerative changes in fibroid:
This case of a large fibroid with a most unusual appearance:
  video 
This is a sagittal section of the huge mass in the uterus. Note the markedly inhomogenous appearance of the mass. The ultrasound video clip below shows a transverse section of the mass:

video

Now, the color doppler video of the tumor (fibroid) of the uterus:

video
For more images and details of this case see:
http://www.ultrasound-images.com/uterus.htm#Degenerative_changes_in_fibroid
Multiple fibroids:
Uterine fibroids can very often be multiple. This middle aged lady has 3 fibroids seen in this sagittal section ultrasound video clip of the uterus:
video
Of these, the one labeled as (1)- towards the fundus, shows degenerative changes- it is hypoechoic, inhomogenous, suggesting possible cystic changes within it.
Another video clip shows the presence of all 3 fibroids in this uterus:
video

3 comments:

  1. Fibroid breast tumors are prone to very quick growth in pregnant women, in whom estrogen levels are high.
    uterine fibroid treatment

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  2. dr nusrat7:54 PM

    excellent guide !!

    ReplyDelete
  3. Anonymous7:15 AM

    nice

    ReplyDelete