UTERINE LEIOMYOMA 2015 - 2016
UTERINE FIBROIDSLEIOMYOMA
What is a leiomyoma? It is a benign neoplasm of the muscular wall of the uterus composed primarily of smooth muscle . Although they can grow to huge size their malignant potential is minimal. Incidence: They are the most common pelvic tumors It is found in 25% of white women & 50% of black Women. More than 45% of women have leiomyomas by the fifth decade of life. They are primary indication for about 200000 Hysterectomies in united state each yearETIOLOGY
UnknownEach individual myoma is unicellular in origin Estogens no evidence that it is a causative factor , it has been implicated in growth of myomasMyomas contain estrogen receptors in higher concentration than surrounding myometriumMyomas may increase in size with estrogen therapy & in pregnancy & decrease after menopauseThey are not detectable before pubertyProgestrone increase mitotic activity & reduce apoptosis in sizeThere may be genetic predispositionRisk factors
Nultiparity and infertility. Increasing age . Ethinicity(two fold in african american compared with white women. Increased BMI. Family history. Reduced incidence with COCP and DMPA user.PATHOLOGY
Frequently multiple May reach 15 cm in size or larger Firm Spherical or irregularly lobulated Have a false capsule Can be easily enucleated from surrounding myometriumCLASSIFICATION
Submucous leiomyoma Pedunculated submucous Intramural or interstitial Subserous or subperitoneal Pedunculated abdominal Parasitic Intraligmentary CervicalMICROSCOPIC STRUCTURE
Whorled appearance nonstriated muscle fibers arranged in bundles running in different directionsIndividual cells are spindle shaped uniformVarying amount of connective tissue are interlaced between muscle fibersPseudocapsule of areolar tissue & compressed myometriumArteries are less dense than myometrium & do not have a regular pattern of distribution1-2 major vesseles are found at the base or pedicle
SECONDARY CHANGES
1-BENIGN DEGENERATIONAtrophic.Hyaline yellow, soft gelatinous areas Cystic liquefaction follows extreme hyalinizationCalcific circulatory deprivation precipitation of ca carbonate & phosphateSeptic circulatory deprivation necrosis inectionMyxomatous (fatty) uncommon, follows hyaline or cystic degenration
1-BENIGN DEGENRATION (cont’d) Red (carneous) degenerationCommonly occurs during pregnancy Edema & hypertrophy impede blood supply aseptic degenration & infarction with venous thrombosis & hemorrhagePainful but self-limitingMay result in preterm labor & rarely DIC2-MALIGNANT TRANSFORMATION is rare:Transformation to leiomyosarcomas occurs in 0.1-0.5%
CLINICAL FINDINGS
1-SYMPTOMSSymptomatic in only 35-50% of Patient.Symptoms depend on location, size, changes & pregnancy status1-Abnormal uterine bleedingThe most common 30%Heavy / prolonged bleeding (menorrhagia) iron deficiency anemia
1-Abnormal uterine bleeding (cont’d) Submucous myoma produce the most pronounced symptoms of menorrhagia, pre & post-menstrual spottingBleeding is due to interruption of blood supply to the endometrium, distortion & congestion of surrounding vessels or ulceration of the overlying endometriumPedunculated submucous areas of venous thrombosis & necrosis on the surface intermenstrtual bleeding
2-PAIN
Vascular occlusion necrosis, infectionTorsion of a pedunculated fibroid acute painMyometrial contractions to expel the myomaRed degenration acute painHeaviness fullness in the pelvic area Feeling a massIf the tumor gets impacted in the pelvis pressure on nerves back pain radiating to the lower extremitiesDysparunea if it is protruding to vagina3-PRESSURE EFFECTS
If large may distort or obstruct other organs like ureters, bladder or rectum urinary symptoms, hydroureter, constipation, pelvic venous congestion & LL edemaRarely a posterior fundal tumor extreme retroflexion of the uterus distorting the bladder base urinary retention Parasitic tumor may cause bowel obstructionCervical tumors serosanguineous vaginal discharge, bleeding, dyspareunia or infertility
4-INFERTILITY
The relationship is uncertain 27-40% of women with multiple fibroids are infertile but other causes of infertility are presentEndocavitary tumors affect fertility more5- SPONTANEOUS ABORTIONS~2X N incidence before myomectomy 40% after myomectomy 20%More with intracavitary tumorsEXAMINTION
Most myoma are discovered on routine bimanual pelvic exam or abdominal examinationRetroflexed retroverted uterus obscure the palpation of myomas LABORATORY FINDINGSAnemiaDepletion of iron reserveRarely erythrocytosis pressure on the ureters back pressure on the kidneys erythropoietin Acute degeneration & infection ESR, leucocytosis, & feverIMAGING
Pelvic U/S is very helpful in confirming the Dx & excluding pregnancy / Particularly in obese .Saline hysterosonography can identify submucous myoma that may be missed on U/SHSG will show intrauterine leiomyomaMRI highly accurate in delineating the size, location & no. of myomas , but not always necessaryIVP will show ureteral dilatation or deviation & urinary anomaliesHYSTROSCOPY for identification & removal of submucous myomasDIFFERENTIAL DIAGNOSIS
Usually easily diagnosed Exclude pregnancy Exclude other pelvic masses -Ovarian Ca -Tubo-ovarian abscess -Endometriosis -Adenexa, omentum or bowel adherent to the uterus Exclude other causes of uterine enlargement: -Adenomyosis -Myometrial hypertrophy -Congenital anomalies -Endometrial CaDIFFERENTIAL DIAGNOSIS
Exclude other causes of abnormal bleeding Endometrial hyperplasia Endometrial or tubal Ca Uterine sarcoma Ovarian Ca Polyps Adenomyosis DUB Endometriosis Exogenouse estrogens Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial CaCOMPLICATIONS
1-COMPLICATIONS IN PREGNANCY
≥ 2/3 of women with fibroids & unexplained infertility conceive after myomectomyRed degeneration In the 2nd or 3rd trimester of pregnancy rapid in size vascular deprivation degeneration Causes pain & tendernessMay initiate preterm laborManaged conservatively with bedrest & narcotics + tocolytics if indicatedAfter the acute phase pregnancy will continue to termCOMPLICATIONS IN PREGNANCY
DURING LABORUterine inertiaMalpresentationObstruction of the birth canalCervical or isthmeic myoma necessitate CSPPHCOMPLICATIONS IN NONPREGNANT WOMEN
Heavy bleeding with anemia is the most commonUrinary or bowel obstruction from large parasitic myoma is much less commonMalignant transformation is rareUreteral injury or ligation is a recognized complication of surgery for Cx myomaNo evidence that COCP the size of myomasPostmenopausal women on HRT must be followed up with pelvic exam or U/S every 6 MTREATMENT
TREATMENTDEPENDS ON: Age Parity Pregnancy status Desire for future pregnancy General health Symptoms Size Location
Management of uterine fibroid
No treatment is required for asymptomatic small fibroid ,unless if cause 12 week uterine enlargement or is the cause of infertility. For excessive heavy cycle: Progesterone only therapy: Oral Injected MPA. Progesterone only pills. LNG releasing IUD.COCP:used cyclically to reduce menstrual blood loss or continueously to eliminate the cycle Dysmenorrhoea is also improved
GNRH AGONISTS
RX results in: 1- size of the myomas 50% maximum 2- This shrinkage is achieved in 3months of RX 3-Amenorrhea & hypoestrogenic side-effects occur 4-Osteopososis may occur if Rx last > 6MIt is indicated for 1- bleeding from myoma except for the polypoid submucous type 2-Preoperative to size allow for vaginal hysterectomy myomectomy laparoscopic myomectomy