Leiomyoma of the uterus

Incidence

Most common solid pelvic tumors. Uterine leiomyomas (ie, fibroids or myomas) are benign clon

al tumors arising from the smooth muscle cells of the uterus and containing an increased amount of extracellular matrix proteins (collagen and elastin). They are surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers.

Myomas are clinically apparent in approximately 25 percent of reproductive aged women and noted on pathological examination in approximately 80 percent of surgically excised uteri( UpToDate professional-level topic review )

3-9 times more frequent in black than in white women

Synonyms

leiomyoma of uterusleiomyomas fibromyomasmyofibromasfibroidsfibromasmyomas

Pathology• Usually multiple, discrete, eith

er spherical or irregularly lobulated;

• Have a false capsular covering, and clearly demarcated from the surrounding myometrium;

• The consistency is usually firm or even hard except when degeneration or hemorrhage has occurred;

• color ： light gray or pinkish white;

• cut section ： an intertwining pattern or a whorl-like arrangement ； bulgy.

Microscopic Appearance1. Composition ： smooth muscl

e, connective tissue2. The nonstriated muscle fibers

are arranged in bundles of various sizes that run in multiple directions.

Individual cells are spindle shaped, have elongated nuclei, and are uniform in size. varying amounts of connective tissue are intermixed with the smooth muscle bundles.

ClassificationAccording to growth location ： Myomas on the body of uterus （ 90% ） Myomas on the cervix of uterus （ 10% ） According to the relation to uterine muscle ： Submucous leiomyomas （ 10 ～ 15% ） Intramural leiomyomas （ 60 ～ 70% ） Subserosal leiomyomas （ 20% ）

Classification Subserosal uterine fibroids These fibroids originate from the serosal surfa

ce of the uterus. They can have a broad or pedunculated base and may be intraligamentary (ie, extending between the folds of the broad ligament).

Intramural uterine fibroids The most common type of fibroid. These devel

op within the uterine wall and expand making the uterus feel larger than normal (which may cause "bulk symptoms"). They may enlarge sufficiently to distort the uterine cavity or serosal surface. Some fibroids can be transmural and extend from the serosal to the mucosal surface.

Submucosal uterine fibroids These fibroids develop just under the lining of

the uterine cavity. These neoplasms often protrude into the uterine cavity. These are the fibroids that have the most effect on heavy menstrual bleeding and the ones that can cause problems with infertility and miscarriage.

•There are three primary types of uterine fibroids, classified primarily according to location in the uterus

Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.

Secondary changes

Benign degeneration:AtrophicHyaline degenerationCystic degenerationCalcificationRed degeneration

Malignant TransformationSarcomatous change

Other degeneration fat degeneration

the secondary infection

at menopause or after pregnancy, tumor size shrink, so the sign

Red DegenerationOccasionally seen as a complication of pregnancy（ during pregnancy or immediate postpartum period ）

The pathogenesis is unknown ， may be the result of the accumulation of blood in the tumour because of venous obstruction.The cut surface resembles raw meat.Clinical features ： a cause of pain （ acute ）

fever rapid growth ， tender

Red Degeneration Here is a very large leio

myoma of the uterus that has undergone degenerative change and is red (so-called "red degeneration"). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors.

Sarcomatous ChangeRare ： 0.4% ～ 0.8%More common at 40 ～ 50 years oldUsually occur in intramural fibroidsgrow quickly

vaginal bleeding

SYMPTOMS

The majority of fibroids are small and do not cause any symptoms at all. However, many women with fibroids have significant bleeding and/or pain that interfere with some aspect of their lives.

The severity of symptoms is related to the number, size, and location of the fibroids, and fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. The symptoms tend to decrease at the time of menopause, although women who take hormone replacement may not see this effect.

SYMPTOMSmenorrhagia and prolonged menstrual period ： commonPelvic pain ：

occurs in pregnancy if undergoing degeneration or torsion of a pedunculated myomaPelvic pressure ： urinary frequency

bowel difficulty （ constipation ）Spontaneous abortionInfertility

SYMPTOMS Increased uterine bleeding — Fibroids

can cause an increase in the amount of blood flow and length of a woman's menstrual period. The presence and amount of uterine bleeding is determined mainly by the location and size of the fibroid. Women with fibroids that protrude into the uterus are more likely to have significant increases in bleeding, although women with all types of fibroids can have this problem. If the bleeding is very heavy, anemia can occur.

SYMPTOMS Pelvic pressure and pain — Fibroids can range in size from microsc

opic to the size of a grapefruit or even larger. Larger fibroids may cause a sense of pressure and fullness in the abdomen, similar to that caused by pregnancy. Fibroids of variable sizes can cause other symptoms, depending upon where they are located within the uterus. As an example, if the fibroid is pressing on the bladder, frequent urination or difficulty emptying the bladder can occur. A fibroid near the rectum may cause constipation, and cervical fibroids can cause pain during sexual intercourse.

In rare cases, fibroids can cause sudden and severe pain if the fibroid begins to break down (degenerate) or twist. Pain of this type may be associated with a mild fever, tenderness in the abdomen, and elevation in the white blood cell count. The pain usually resolves in a few days to weeks. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, can be used to treat the discomfort.

SYMPTOMS Problems with pregnancy and fertility — Some studies have suggested a slightly increased risk of problems during

pregnancy in women with very large fibroids, including breech presentation, premature rupture of membranes, premature labor, and placental abruption (a condition in which the placenta separates prematurely from the uterine wall). In addition, women with very large fibroids are at a high risk of cesarean delivery. These problems are more likely if the placenta is implanted over the area of the large fibroid. Nevertheless, nearly all women with fibroids have completely normal pregnancies without complications.

The risk of miscarriage and infertility is associated with a type of fibroid that protrudes into the uterine cavity. Typically these fibroids can be easily removed using a hysteroscope (a small telescope-like device inserted through the cervix into the uterus), which reduces this risk.

However, it is not completely clear what role that fibroids play in infertility. An infertile woman who has large or numerous fibroids may want to talk with her doctor about having the fibroids removed, although all other causes of infertility should first be eliminated.

Signs

A palpable abdominal tumour

Pelvic examination ： uterus — enlarged and irregular ； hard

DIAGNOSIS

Fibroids are often diagnosed during a routine pelvic exam. A clinician may feel the enlarged, irregular outline of the uterus through the abdomen. In certain cases, the clinician may wish to confirm the diagnosis of fibroids and exclude other types of masses. Ultrasound is generally preferred, and uses sound waves to visualize the uterus

DIAGNOSIS

HistoryBimanual examinationUltrasonography

（ B–ultrasound examination ）

HysteroscopyLaparoscopy

Differential Diagnosis

PregnancyOvarian tumorAdenomyosisMalignant tumors of uterus

sarcoma of uterus endometrial carcinoma cervical cancer

TREATMENT

In women who have no symptoms from their fibroids, treatment is usually not required. In women with significant symptoms, treatment may be medical or surgical.

Observation and Follow Up

Small ， asymptomatic fibroids need not be treated ， especially near menopause.

Interval ： 3 ～ 6 months

Medical treatment

Androgenic agents ： testosterone propionate

GnRH-a ： induce a hypoestrogenic pseudomen

opausal state not recommended for longer than 6 m

onths “add-back” regimens

Medical treatment Medical treatment includes the use of medications to treat the symptoms of

fibroid-related bleeding and pain. Gonadotropin-releasing hormone (GnRH) agonists are the most common medical treatment for fibroids. Most women who use GnRH agonists temporarily stop having menstrual periods and have a significant reduction in the size of their fibroid(s). Reducing or eliminating menstrual bleeding can improve anemia.

However, fibroids rapidly enlarge after GnRH agonists are discontinued. In addition, there are some significant side effects after long-term use, including bone loss leading to osteoporosis. GnRH medications are usually given as a temporary measure (usually no longer than six months), such as while a woman is preparing for surgical treatment. In some cases, using a small dose of estrogen can minimize the side effects of GnRH agonists.

Danazol is an androgenic steroid, and may be used to stop menstrual bleeding. Danazol may be used when it is not necessary to shrink the size of the uterus or for women who cannot take GnRH-agonists. Use of Danazol is generally limited due to bothersome side effects, including weight gain and mood changes.

Surgical treatment

Indications ：greater than 10 weeks’ gestational sizemenorrhagia ， lead to anemiahave pressure symptomsgrows rapidlyfailure of medical treatment

Method ：Myomectomy—conservative therapy

preserve fertility significant risk of recurrence

Hysterectomy— radical therapySubtotal hysterectomyEndometrial ablationUterine artery embolization

Only true “cure” for leiomyomas

Approach ： trans-abdominal trans-vaginal laparoscopic or hysteroscopic

Surgical treatment In most women, surgical treatment is used to provi

de relief from fibroid symptoms. In other cases, surgical procedures are done in an attempt to treat infertility. A number of surgical treatments are available.

Hysterectomy — Hysterectomy is surgical removal of the uterus through the abdomen or vagina. It may be the treatment of choice for some women who have completed childbearing, are not interested in other surgical treatments, and who have severe symptoms. Removal of the ovaries and cervix is not necessary for symptom relief.

Surgical treatment Myomectomy is surgical removal of a fibroid. preserves the chance

of future childbearing and may provide short-term relief of heavy bleeding, but is associated with a significant risk of recurrence. Between 10 and 25 percent of women who have myomectomy will require a second surgery. In addition, abdominal and laparoscopic myomectomy slightly increase the risk of uterine rupture during pregnancy or labor; the risk for most women is small.

Endometrial ablation — In this procedure, the lining of the uterus is destroyed with heat by a scope inserted into the vagina through the cervix and into the uterus. It can be done alone, or in combination with other treatments such as hysteroscopic myomectomy or myolysis (explained below). Normal pregnancy is possible, though not recommended after endometrial ablation; contraception is strongly recommended since a woman continues to ovulate. Endometrial ablation decreases bleeding without affecting uterine size.

Uterine artery embolization — In uterine artery embolization (UAE or UFE), a small catheter is inserted in a large blood vessel and threaded up to blood vessels near a fibroid. Tiny particles are injected into the blood vessel, which stops blood flow to the fibroid. This causes the fibroid to rapidly decrease in size within days to weeks after UAE.

•Diagram showing superselective catheter position in the right uterine artery via left femoral arterial approach.

Diagram showing embolic particles being released from the catheter and into the uterine arterial branches supplying the fibroid.

It is important to individualize the choice of therapy.

Uterine Leiomyomas Complicating Pregnancy

impact on pregnancy ： abortionimpact on delivery ： premature labour

fetal malpresentation retained placenta placenta previa need for operative delivery （ birth canal obstruction ） postpartum hemorrhage

Conservative treatment

Critical PointsMay be related to superabundant estrogen.Well-circumscribed,have a pseudocapsule.Can be classified into submucosal,intramural and subserosal types.Different types have different features.Menorrhagia is common.Four degeneration typesIndividualized treatment ， include observation 、medical treatment and surgical treatment.

Normal female reproductive anatomy