A Text-book of Diseases of Women

by Charles B. Penrose

The intra-ligamentous fibroid grows from the side of the uterus or from the supra-vaginal cervix. It pushes apart the peritoneal folds of the broad ligament, and grows between them or beneath them. The tumor is thus outside of the peritoneum. It may fill the whole pelvis with a dense unyielding mass, pushing the uterus to the pelvic wall, destroying anatomical relations, and exerting most disastrous pressure upon blood-vessels, nerves, ureters, and other pelvic structures.

Sometimes, as these tumors enlarge in an upward direction, they carry with them overlying pelvic organs; thus the ureter may be found passing over the top of a tumor which, beginning as an intra-ligamentous pelvic growth, has become abdominal.

In some cases the fibroid grows from the posterior aspect of the supra-vaginal cervix, passes beneath the bottom of Douglas’s pouch, pushes the peritoneum above it, and becomes a retro-peritoneal tumor.

Again, it may grow from the anterior aspect of the cervix in the vesico-uterine space, and as it extends upward may push the vesico-uterine fold of peritoneum above it and drag up the bladder, so that this viscus is sometimes found spread out upon the anterior face of the tumor and extending as high as the umbilicus.

As has already been said, fibroid tumors are usually multiple, and if one of the terms designating the position of the tumor as subperitoneal or intra-ligamentous is used to describe any case, we understand that the chief tumor-mass is of this character.

The fibroid polyp is more likely to be single than any of the other varieties. In fact, the fibroid polyp is usually single; that is, no other fibroid tumor can be detected in the body of the uterus. This is not always the case, however, and sometimes the repeated expulsion of successive fibroid polypi from the same woman renders it probable that several nodules were simultaneously present in the uterine wall.

As a rule, fibroid tumors of the uterus are of slow growth. In some cases five, ten, or fifteen years may elapse before the tumor attains the size of the fetal or the adult head. Sometimes the tumor appears to be of limited growth, and early attains its maximum size, or it may not increase at all in size after its first discovery by the woman; in other cases the tumor slowly but steadily grows until, after a lapse of ten or twenty years, it fills the whole of the abdominal cavity and renders the woman helpless from weight and pressure; and, finally, in some instances the tumor grows unlimitedly with the rapidity characteristic of an ovarian cyst, and in one or two years may crowd the woman out of existence. This rapid unlimited growth is characteristic of tumors of the fibro-cystic variety.

A fibroid tumor causes very marked changes in the body of the uterus—the muscular coat and the endometrium. The whole uterus becomes enlarged. The cavity is increased in length, and the muscular wall becomes often very much hypertrophied. This hypertrophy resembles that occurring in pregnancy. Even small fibroid tumors may produce this condition, which seems to depend more upon the position than upon the size of the growth. The interstitial and the submucous tumors are accompanied by a greater degree of uterine hypertrophy than accompanies the subperitoneal growths. In some cases the uterus may be of normal size if the subperitoneal growth has become pedunculated. The uterus may appear to be uniformly enlarged to the size of the fourth or fifth month of pregnancy, and when incised it will be found to contain one or more interstitial or subperitoneal tumors that have become encapsulated by it. When such a case is subjected to celiotomy the resemblance of the uterus to pregnancy is very striking. Between such a smooth, uniformly enlarged uterus on the one hand, and the irregular, distorted mass of subperitoneal fibroids on the other, there are an infinite number of varieties. A great increase in the vascular supply accompanies the hypertrophy of the uterus. The ovarian and uterine arteries and their branches become very much hypertrophied, while the veins in the broad ligaments and the sinuses in the capsule of the tumor become enormous.

The endometrium shares in the changes that take place in the uterus. It is, of course, increased in area with the increase of the uterine cavity. There may be atrophic changes from pressure upon or tension of this membrane, or various forms of endometritis may be present, most usually the interstitial and the glandular. The glandular form of the disease is said to occur most frequently when the tumor is remote from the cavity of the uterus, as in the subperitoneal variety; while interstitial endometritis occurs with the submucous and the interstitial tumors.

In the Fallopian tubes and the ovaries pathological changes occur as the result of uterine fibroids. The tubes may present any of the forms of cystic change—hydrosalpinx, pyosalpinx, or hematosalpinx—that are caused by salpingitis. It is probable that these diseases are often caused by extension of endometritis. The tubes and ovaries may be much distorted and displaced from the normal position. In some cases the ovary is drawn out into a long cord five inches in length; in other cases it is spread out upon the face of the tumor.