Fibroids are uncommon in young women, but common in older ones. In the developing world a patient with fibroids usually presents with: (1) Infertility or subfertility. (2) Recurrent abortion. (3) Abnormal bleeding. (4) An abdominal swelling. (5) Lower abdominal pain. The severity of her symptoms depends less on the size of her fibroids, than where they are; a small submucous fibroid can cause severe bleeding, whereas a huge interstitial one may hardly be noticed. She commonly has PID also, and the pain it causes may be her presenting symptom.

Several operations are possible: (1) Hysterectomy, which should ideally be total, so that her cervix is removed, and with it any risk of cervical carcinoma. (2) Myomectomy, which is usually abdominal, but which can be vaginal. Surgery can be difficult because of associated subacute or chronic PID, her wish not to have a hysterectomy and to continue menstruating, and the technical difficulties of doing a myomectomy.

There is one particular presentation that you should be aware of:

A pedunculated submucous fibroid may prolapse and present as a mass in her vagina, or less commonly at her vulva, as in Fig. 20-4. She may also complain of bleeding, and present as if she had an abortion, with a lump hanging in her vagina. Her cervix dilates to allow it to pass, and remains partly dilated around it. The mass may be large, necrotic, infected, and smelly. Bleeding may have made her very anaemic. The risk in merely tying the pedicle and cutting it off, is that her peritoneal cavity may have come down with it, so that you may open this by mistake. She is also at risk from from infection and bleeding.

Fig. 20-4 FIBROIDS. A, the surgical pathology of fibroids. B, a submucous fibroid polyp has brought the fundus of the uterus down with it. C, the correct site for incision. First, incise the fibroid longitudinally (''Y') to find the level of its capsule. You can then cut and transfix or twist off the pedicle transversely just above this (''X'), with no danger of entering her peritoneal cavity. Don't incise at level ''Z'!

Fibroids can be: 1, intramural. 2, subserous, distorting the tube. 3, submucous. 4, subserous and pedunculated. They can also project into the uterine cavity (5), through the cervix (6), or into the parametrium (7).

FIBROIDS THE DIFFERENTIAL DIAGNOSIS is that of a pelvic mass: (1) Pregnancy. (2) A full bladder. (3) An ovarian cyst (20.7). (4) A chronic ectopic pregnancy (16.7). (5) PID with an inflammatory mass (6.6).

CAUTION ! (1) A centrally placed fundal fibroid may feel like a pregnant uterus, but is much harder. (2) Pregnancy can occur in a fibroid uterus.

INDICATIONS FOR SURGERY. The rate at which a fibroid grows varies greatly. If it causes no symptoms, consider leaving it unless it is the size of a 12-week pregnancy or larger. At this size it will probably cause symptoms, so if she has completed her family, suggest hysterectomy. The indications for removing a fibroid depend more on symptoms (bleeding, anaemia, and premenstrual pain), than on its size. If it is causing symptoms, you may have to remove it when it is quite small. Other reasons for removal include torsion and prolapse. Many patients don't need surgery.

If the patient's uterus and the mass seem fixed and tender, and especially if she has fever, she is more likely to have PID, with or without fibroids. Treat her medically at first. Admit her, give her an antibiotic, and reassess her in 3 or 4 weeks.

If her temperature does not settle after a reasonable time, and her uterus remains tender, examine her under anaesthesia. She may have: (1) A tubo-ovarian abscess which fluctuates and needs draining. If so, leave her fibroids until later. (2) Mobile degenerating fibroids that you can operate on. ''Red degeneration' can occur in a fibroid during pregnancy, and can cause pain and a tender mass, but not the degree of fever that is common with PID or a tubo-ovarian abscess.

If she is younger and wants children, consider doing a myomectomy or referring her for it. Make sure she understands that: (1) If it is found to be impracticable, she may have to have a hysterectomy, or to have her abdomen closed after nothing has been done. (2) She may grow more fibroids later, especially if she does not conceive.

If she is older and does not want children, consider doing a total hysterectomy (20.12).

MYOMECTOMY INDICATIONS. A patient with fibroids who wants children. Myomectomy is hazardous, and has more complications than hysterectomy. Most patients are better with a hysterectomy, or with no surgery at all. If you are inexperienced, don't attempt it unless she has: (1) A single fibroid [lt]10 cm in diameter. Or, (2) a fibroid which is subserous (pedunculated into her peritoneal cavity), or submucous (pedunculated into her uterine cavity, and usually coming through her cervix into her vagina).

CONTRAINDICATIONS. (1) Multiple fibroids ([mt]3) (2) Active sepsis. (2) Dense adhesions of both tubes which make pregnancy impossible. (3) If she has a large posterior fibroid in her pouch of Douglas, leave it unless you are an expert. Removing this without damaging her bladder or ureters is difficult, and can be bloody.

If you are inexperienced, refer her. If you cannot refer her proceed as follows.

MYOMECTOMY FOR INTRAMURAL FIBROIDS. Bleeding is the great danger. Cross-match 2 units of blood, with due consideration for HIV.

Use tourniquets to prevent bleeding. Make small openings at the base of her broad ligaments. Take three rubber catheters. Pass one round her cervix and the other two round each of her ovarian pedicles. Pull them tight and hold them with clamps to occlude the vessels temporarily. Alternatively, pass a catheter round her cervix and clamp her ovarian vessels with rubber covered bowel clamps. Special vascular clamps are better if you have them. If her anatomy makes applying catheters or clamps difficult, consider abandoning the operation.

Make an incision over the fibroid which exceeds its diameter by 2 or 3 cm. The correct plane to remove it in may not be easy to find. Cut into the fibroid and you should see it. Shell it out. If necessary, remove some of the wall of her uterus to reduce the size of the dead space. Repair her uterus with at least 2 rows of mattress sutures of ''1' or ''2' chromic catgut.

Remove the catheters. If her uterine incisions bleed, insert more mattress sutures. If bleeding continues, decide whether to do a hysterectomy, or to tie her internal iliac arteries.

Close her abdomen in layers without drainage. Make sure she knows what you have removed, and understands that she must always be delivered in hospital in future.

Fig. 20-5 THREE WAYS OF REMOVING MUCOSAL POLYPI. A, by twisting. B, by ligation. C, by section. These mucosal polypi are much more common and are more easily removed than fibroid polyps. Don't try to remove pedunculated fibroids this way. Kindly contributed by Jack Lange.

MYOMECTOMY FOR A SUBMUCOUS FIBROID POLYP. She may have only a single vaginal fibroid. If she has others, they can be removed later by myomectomy or hysterectomy. Bleeding is usually mild, but however you remove a fibroid, it can occasionally bleed so severely that you have to tie her internal iliac arteries (3.5), or to do a hysterectomy (2.12). If necessary, give her an antibiotic and a blood transfusion.

If the pedicle of the polyp is thick and is attached well within the cavity of her uterus, be careful. Incise it longitudinally to find the level of the capsule of the fibroid first, as in Fig. 20-4. You can then cut and tie the pedicle just above this, with no danger of entering her abdomen. Transfix the pedicle as far distally as you can, and divide it distal to the ligature, so that you minimize the risk of opening her peritoneal cavity. If you don't remove it completely, it will recur.

If she has a large submucous polyp presenting at her cervix, but not protruding through it, treatment is difficult. It is sure to be partly necrotic, so that a hysterectomy carries the risk of sepsis. You can: (1) Define it as well as you can with your fingers first and then twist it off vaginally (risky). If she continues to bleed (unusual) see above. (2) Improve her general condition, transfuse her, give her antibiotics, and then do a hysterectomy.

CAUTION ! Don't try to twist off a fibroid polyp, it is usually impossible. The only kind of cervical polyp to twist off is a mucosal one, as in Fig. 20-5.

DIFFICULTIES [s7]WITH FIBROIDS If her FIBROID IS PAINFUL, either spontaneously or on palpation, with perhaps a low fever, this is due to aseptic necrosis (red degeneration), or associated torsion of a pedunculated fibroid.

If you discover a SMALL SUBMUCOUS FIBROID when you are doing a ''D and C' for abnormal vaginal bleeding, you may be able to remove it with the curette.

If she has a MUCOSAL POLYP, it may come from her cervix or endometrium and cause menorrhagia, or intermenstrual bleeding, or both. If it comes through her cervix, you can see it with a speculum and twist it off, as in Fig. 20-5. You will only see an endometrial polyp when you do a ''D and C'.

If she is PREGNANT, don't remove a fibroid, unless it it is pedunculated and very easy to remove. See Section 18.7.