Uterine Leiomyomas
Kindu Y
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Introduction
o Uterine Leiomyomas are benign smooth-muscle neoplasms that
typically originate from the myometrium.
o Their prevalence among women is generally cited as 10 to 20 percent,
but is as high as 70 to 80 percent in sonographic studies
o uterine Leiomyomas are estrogen and progesterone-sensitive tumors
o Progesterone is considered the critical mitogen for uterine
leiomyoma growth and development
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Introduction
o Are the most common pelvic tumor in women
o Myoma’s are rare in adolescence, but rates rise with age during the
reproductive years.
o However, once in the menopause, myoma incidence becomes lower.
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Classification
Fibroids are often described according to their location in the uterus.
o Sub-serosal leiomyomas: originate from myocytes adjacent to the
uterine serosa.
o Parasitic Leiomyomas attach themselves to nearby pelvic structures
from which they derive vascular support.
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Leiomyomas categorized by FIGO system
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o Intramural leiomyomas are those with growth centered within the
uterine walls
o Sub-mucous leiomyomas are proximate to the endometrium and grow
toward and bulge into the endometrial cavity.
o Delivered myoma
o Cervical myoma
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Risk factors
o Obesity
o PCOS
o Age
o Early menarche
o Prenatal exposure to diethylstilbestrol
o Family history
o Late menopause
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Degenerative changes
The very poor vascularity of fibroids encourages the
degenerative changes that are common in big myoma's.
o Hyaline degeneration
The most common of all secondary changes
Asymptomatic
Yellowish, soft and often gelatinous area is seen
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Cystic degeneration
o Formation of multiple small cystic spaces,
giving a sponge-like appearance
and soft consistency to the tumor
o Some times mimic cystic ovarian tumor
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Calcific Degeneration
o Occurs when there is some circulatory disturbance
o Final stage of degeneration
o Can be seen using X- Ray
Necrotic degeneration
o May occur in any tumor
o This is commonly due to impairement of the blood supply or
severe infection
e.g. torsion of a pedunculated myoma.
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Carneous (red degeneration)
o Commonly seen during pregnancy
o Venous thrombosis and congestion with interstitial hemorrhage
are responsible for the color of the myoma undergoing red
degeneration.
o The process is usually associated with extreme pain but is always
self limited.
o Its exact mechanism is not known
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Sarcomatous degeneration
o Even if malignanat transformation is quite rare, some times it may be
changed to malignant condition.
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Clinical features
o Heavy or prolonged menstrual bleeding
o Bulk-related symptoms, such as pelvic pressure and pain
o Reproductive dysfunction (i.e. infertility or obstetric complications)
o Increase abdominal size
o Urinary symptoms
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Physical examination, laboratory and imaging
o Leiomyomas are often detected by pelvic examination with
findings of
uterine enlargement
irregular contour, or both
o Sonography is done to define pelvic anatomy
o Urine or serum human chorionic gonadotropin (hCG) to
exclude pregnancy
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Diagnosis
o History
o Physical examination
o Imaging
o Laboratory ????
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Differential diagnosis
Pregnancy (normal, GTD)
Ovarian tumor
Adenomyosis
Full blader
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Management of myoma
Managements of myoma depend on
o Age
o Fertility goal
o Symptoms
o Availability of options
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Cont…
o Relief of symptoms (e.g. AUB, pain, pressure) is the major goal in
management of women with significant symptoms.
o The type and timing of any intervention should be individualized,
based upon factors such as :
Type and severity of symptoms
Size of the myoma
Location of the myoma
Patient age
Reproductive plans and obstetrical history
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Expectant management
o Leiomyomas in general are slow-growing
o Thus, regardless of their size, asymptomatic leiomyomas usually be
observed and surveilled with an annual pelvic examination.
o Also, because these tumors typically ~ postmenopausal, some women
choose medical treatment to relieve symptoms as a bridge to
menopause.
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o Sex Steroid Hormones
Either COCs, continuous oral progestin's, or DMPA can be used to
induce endometrial atrophy and to decrease prostaglandin production.
o GnRH Receptor Agents
GnRH can function at the GnRH receptor as either agonists or
antagonists.
Despite their differing actions at the receptor, both groups
ultimately incite profound systemic drops in estrogen and
progesterone levels.
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Surgical management
Indications:
Infertility or recurrent pregnancy loss
AUB unresponsive to medical therapy
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Surgical Managements options
o Hysterectomy
o Myomectomy
o Endometrial Ablation
o Uterine artery embolization
o Myolysis
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Pregnancy and myoma
o What is the potential effect of pregnancy on myoma?
o What is the potential effect of myoma on pregnancy?
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