UTERINE FIBROIDS
Uterine fibroids, also known as leiomyomas or myomas, are benign (non-cancerous) tumors that develop in the smooth muscle of the uterus. They are among the most common gynecological conditions affecting women, particularly those in their reproductive years. Fibroids can vary greatly in size, number, and location, and many women with fibroids experience no symptoms, while others may have heavy menstrual bleeding, pelvic pain, or other related issues.

Types of Uterine Fibroids
Fibroids are categorized based on their location within the uterus:
1. Submucosal: These fibroids develop just under the inner lining of the uterus (the endometrium). They can distort the uterine cavity and often cause heavy menstrual bleeding and infertility.
2. Intramural: These are the most common type and grow within the muscular wall of the uterus (myometrium). They can cause pain, heavy periods, and infertility.
3. Subserosal: These fibroids grow on the outer surface of the uterus. They may not cause symptoms unless they become large enough to press on nearby organs, such as the bladder or rectum.
4. Pedunculated: These fibroids are attached to the uterus by a stalk, either inside the uterine cavity (submucosal) or on the outer surface (subserosal). If they twist or outgrow their blood supply, they can cause severe pain.

Etiology and Risk Factors
While the exact cause of fibroids is not fully understood, several factors contribute to their development:
• Genetic predisposition: Family history of fibroids can increase the risk.
• Hormonal factors: Estrogen and progesterone are thought to stimulate fibroid growth. Fibroids often shrink after menopause when hormone levels decrease.
• Age: Women in their 30s and 40s are more likely to develop fibroids.
• Ethnicity: African American women are more likely to develop fibroids and tend to have more severe symptoms.
• Obesity: Higher body fat may increase the risk due to the production of estrogen.
• Diet: High-fat diets may increase the risk, while diets high in fruits and vegetables may reduce the risk.
• Reproductive history: Women who have never been pregnant are at higher risk of developing fibroids.

Clinical Symptoms
Many women with fibroids do not experience symptoms, but when symptoms occur, they may include:
• Heavy menstrual bleeding (menorrhagia), which can lead to anemia.
• Pelvic pain or pressure, especially with large fibroids.
• Frequent urination (if the fibroid presses on the bladder)

• Pain during intercourse (dyspareunia).
• Infertility or pregnancy complications, especially with submucosal fibroids.
In some cases, fibroids may not cause any symptoms but are found incidentally during routine pelvic exams or imaging studies.
Gross Appearance
On gross inspection, fibroids appear as well-defined, solid, white to grayish masses that may be round or oval in shape. Their size can vary greatly, ranging from tiny lesions to large masses that can distort the shape of the uterus. The fibroids are often surrounded by normal myometrial tissue, though their location within the uterus can affect their presentation. The surfaces of the fibroids may be smooth or lobulated.
• Submucosal fibroids: These may cause the uterine lining to bulge, and in some cases, they may protrude into the uterine cavity.
• Intramural fibroids: These are typically found within the uterine wall and can cause the uterus to become enlarged and asymmetric.
• Subserosal fibroids: These may be pedunculated (attached by a stalk) and can appear as bulging masses on the outer surface of the uterus.
• Pedunculated fibroids: When these fibroids grow on a stalk, they may twist, causing severe pain (torsion), and may have a pedicle that’s easy to visualize on examination.

Microscopic Appearance
Under the microscope, uterine fibroids are composed of smooth muscle cells (myocytes) arranged in whorled or haphazard patterns, along with varying amounts of fibrous connective tissue. The key features are:
1. Smooth Muscle Cells: The smooth muscle cells within fibroids appear larger and more elongated than normal uterine muscle cells. They have a dense eosinophilic (pinkish) cytoplasm due to the high amount of actin and myosin fibers.
2. Whorled Arrangement: The smooth muscle cells in fibroids are arranged in a characteristic whorled pattern (spirals or bundles), which is one of the distinguishing features of fibroids. The muscle fibers often intermingle with fibrous tissue, leading to a firm texture.
3. Fibrosis: Some fibroids have extensive fibrous tissue (collagen), which makes them feel hard on palpation. The amount of collagen can vary from one fibroid to another.

4. Necrosis and Calcification: In larger fibroids, areas of necrosis (dead tissue) can be present, which may appear as areas of irregularly shaped cells or cystic spaces. In some fibroids, especially older ones, calcification may occur, appearing as areas of dense, basophilic (blue) material on histologic slides.
5. Blood Vessels: Fibroids can have blood vessels, particularly around the edges. These vessels can sometimes become engorged in larger fibroids. In some cases, these vessels can be a site for infarction (tissue death due to lack of blood supply).
6. Cystic Changes: In some fibroids, cystic degeneration may occur, leading to the formation of small fluid-filled spaces within the fibroid. These spaces may become filled with mucus or hemorrhagic fluid.

Diagnosis
Fibroids are often diagnosed through:
• Pelvic examination: A healthcare provider may feel an enlarged or irregularly shaped uterus.
• Ultrasound: This is the most common imaging method to detect fibroids, helping to identify their size, location, and number.
• Magnetic Resonance Imaging (MRI): MRI can provide detailed images of fibroids and help differentiate them from other conditions.
• Hysteroscopy: This allows for direct visualization of fibroids in the uterine cavity, particularly useful for submucosal fibroids.
• Hysterosalpingography (HSG): An X-ray procedure that uses contrast dye to visualize the inside of the uterus and fallopian tubes. It can help identify fibroids obstructing the uterine cavity or fallopian tubes.

Treatment
Treatment options depend on the severity of symptoms, size and location of the fibroids, and the patient's desire for fertility preservation:
1. Medications:
o Gonadotropin-releasing hormone (GnRH) agonists: These drugs reduce estrogen production and can shrink fibroids temporarily, making surgery easier. However, they are usually used for short periods because of side effects.
o Progestin-releasing intrauterine device (IUD): This can help control bleeding associated with fibroids.
o Tranexamic acid: To reduce heavy menstrual bleeding.
o Anti-inflammatory drugs: For pain relief.

2. Minimally Invasive Procedures:
o Uterine artery embolization (UAE): A procedure where blood vessels feeding the fibroids are blocked, leading to fibroid shrinkage.
o Myomectomy: Surgical removal of fibroids while preserving the uterus. It can be done through the abdomen, laparoscopically, or hysteroscopically (via the cervix).
o Endometrial ablation: Removal or destruction of the uterine lining to reduce bleeding, often used in women with submucosal fibroids.
3. Hysterectomy:
o The surgical removal of the uterus is considered the definitive treatment for women who no longer wish to preserve fertility or who have very large or symptomatic fibroids.
Prognosis
Most fibroids do not lead to serious health issues, but they can significantly impact a woman's quality of life. Treatment usually resolves symptoms, though fibroids can recur after surgery, especially if they are not completely removed.