Report on Myoma Uteri: Signs and Symptoms, dg, DD, Management. Myoma = fibroids = fibromyo Def: M are proliferative, well circumscribed, pseudocapsulated benign T° composed of sm mm and fibrous connective tissue. Incidence: Most common Neoplasm found in female pelvis and the most common uterine mass. Present in 20-25% of females in Reproductive age 3-9 x in black α in 5th decade → 50% of black women will have M. Etilogy: is unknown. M are monocolonal T° which arise from a single sm mm cell. Possible theories: (1) genetic role – due to somatic mutations and chromosomal obnormalities of chr. 12. * Estrogen is needed for the expression of this mutation. Factors affecting growth of myoma: (1) Estrogen: * M are rarely found b/f puberty * Stops growing a/f menopause * New myomas rarely appear a/f menopause * Rapid growth of M. during pregnancy (2) Peptide growth factors (3) Human Placental Lactogen (4) Local factors – blood supply adjacency to other T° accounts for variations in T° degenerative changes volume and rate of growth Pathology: M are pseudo encapsulated (is not a true capsule, formed from compression of fibrous and muscular tissue on the surface of the T°) M is solid and well demarcated from the surrounding myometrium. pale and more fibrous than the myometrium. Most active growth is at the periphery. Very few bl. Vess and lymphatics transverse the pseudo capsule. ∴ the central part of the T° is more susceptible to degenerative changes. Degeneration of M→ Reasons for degeneration: (1) II° to alterations in circulation (2) Post menopausal atrophy (3) Infection (in pedunculated M which 1st becomes necrotic and II° infected) (4) Malignant transformation Types:
Sarcomatous degeneration ↓ Sarcoma (1/1000) → spindle cell type → round cell type
Non-sarcomatous degeneration ↓ (1) Atrophy (in post menopausal period) (2) Red/carneous → during pregnancies due to hemorages into the M.
(3) Myxmatous degeneration (4) Mucoid degeneration (soft and gelatinous) (5) Hyatia degeneration (most common) (6) Cystic degeneration (7) Fatty degeneration (rare) (8) Calcification (a/f menopause) (9) Neorotic degeneration (due to infection / loss of bl. supply) Classification: (1) According to histology: - Leiomyoma (softer, from sm mm) - Rhabdomyoma (from skeletal mm) - Fibromyoma (hard, from conn. tiss) (2) According to location: - submucosal, pedunculated submucosal /leiomyomatous polyps T° grow into the Uterine cavity, causes abnormality of the overlying endometrium, resulting in a disturbed bleeding pattern - Subserous/pedunculated subserous-grow out toward the peritoneal cavity - intramural / Interstitial (most common type) toward the peritoneal cavity they can distort the uterine cavity or the external surface of the uterus. (3) According to the number: - single - multiple (4) → diffuse localised (5) → tubes corpus (90%) cervix (5%) – can damage ureters intra ligamentous – when in lig. Latum Uteri very difficult to differentiate from ovarian T. * Parasitic M- subserous pedunculated M, may migrate further and become attached to the omentum or the bowel mesentery and loose their connection with the serosal surface of the uterus, develop an omental or mesenteric blood supply and thus become parasitic M. Symptoms: * Most women w/M are asymptomatic * Symptoms occur in only 10-40% of affected women (1) Abnormal Uterine bleeding – 30% of symptomatic women • Menorrhagia (Hypermenorrhea) – more than 7 days of bleeding / more than 80ml of blood loss with regular intervals. The increase in flow usually occurs gradually. Usually associated w/ intramural M • Metrorragia – Irregular uterine bleeding not related to menstruation. Usually associated with submucous myomas ulcerating through the endometrial lyning. Reasons for ab. U. bleeding → (1) necrosis of the surface endometrium overlying a submucous myoma. (2) Disturbed hemostatic contraction of normal mm bundles when there is extensive intramural myomatous growth. (3) an increase in surface area of the endometrial cavity. (4) Alteration in endometrial microvasculature. (5) Smt, polyps and endometrial hyperplasia may produce the ab bl pattern.
(2) Pain – M usually do not produce pain. • Acute severe pain → red degeneration during pregnancy, torsion of a pedunculated myoma • Crampy pain → when submucous M acts as a foreign body inside the uterine cavity. • Secondary dysmenorrhea → in pt’s w/ intramural M. • Pressure pains in lower abdomen and pelvis → if myomatous uterus becomes incarcerated within the pelvis. • Dyspareunia (3) Lower abdominal mass → if it protrudes above, the symphysis pubis (4) Pressure effects – (1) Feeling of pelvic heaviness, bloating or pelvic pressure. (2) Urinary symptoms → Urinary frequency – M exerting P on bladder Urinary retension – P on ureterovesicular angle Hyronephrosis – intraligamentous M. or by Hydroureters – laterally extending M. (3) Constipation and difficult defication – by large posterior. M. (4) Dyspareunia → if myomatous uterus becomes incarcerated within the pelvis. (5) Varicosities or edema of the lower extremities: compression of pelvic vasculature by the M. (6) Pain may radiate to back / lower extrimities → pressure on nn. (5) Anemia, weakness, dyspnea, congestive heart failure → if significant blood loss. (6) High fever and foul discharge→ if infection of M. Degeneration of M. (7) Reproductive disorders → Secondary infertility (8) Pregnancy related disorders → • Spon. abortion • Red degeneration • Torsion of a pedunculated fibroid • Premature labour • Malpresentation (pelvic presentation / citus transverses) • Mechanical obstruction • Uterine dystocia • Prematrue labour • IUGR • Abruptio placenta • Placenta previa • Post partum bleeding due to atonic uterus • C-section (if descent of presenting part is prevented by large M of lower uterine segement). Signs: (1) very large fibroids can be palpated abdominally (those smaller than 12-14 ges. Wk. are usually confined to the pelvis) - palpated as irregular, nodular firm T°, protruding against the anterior ab. wall. - Softness, tenderness → suggests presence of edema ,sarcoma, degenerative changes. (2) Bruits – similar to uterine soufflé of pregnancy may be heard and felt over large myomas. (3) Bimanual vaginal examination: • Enlarged uterus • Shape → asymmetric and irregular in outline (in submucous M → usually symmetric enlargement)
• Consistency → firm • Visible T° which has extended into the cervical canal – in cervical myomas,in pedunculated submucous M. (Occasionally asubmucous myoma may be visible at the cervical os or at introitus). Diagnosis (1) Labs – Blood – Anemia Leukocytosis (in degeneration / infection) ESR ↑ Erythropoetin level (2) US → • in case of morbid obesity • When adnexal pathology cannot be excluded on physical examination alone (in case of laterally placed myomas) • To detect hydroureter, hydronephrosis in P’t s with marked uterin enlargement • Intra uterine infusion of sterile saline at the time of ultrasound can identify the presence of pedunculated submucous M and endomentrial polyps. (3) Endometrical biopsy - in Pt’s w/ abnormal uterine bleeding who is thought to be anovalutory or at risk far endo metrial hyperplasia or endometrial cancer (4) X-ray - large M appear as soft tissue masses on X-ray - calcification of myoma can be seen (5) Hysterosalpingography – for Pt’s w/uterine M and infertility or repetitive pregnancy loss.submucous myomas can be seen as filling defects of uterine cavity. (6) Hysteroscopy – for dg and removal of pedunculated submucous M. (7) i/v urography – reveals ureteral compression or deviation and identifies urinary anomalies. (8) MRI – rarely used used for detection of Nomber, size and location of M.
Differential Diagnosis → (1) Ovarian neoplasia (2) Tubo – ovarian inflammatory mass (3) Diverticular inflammatory mass of colon (4) Pregnancy (5) Endometriosis (specially adenomyosis) (6) Congenital anomalies (7) Endometrial polyps Treatment: depends on Pt’s age, parity, pregnancy status desire for future pregnancies, health status, symptoms, size, location. Non-surgical → (1) → (2)
Expectant management Medical management
Surgical → (3) Myomectomy → (4) Hysterectomy
(1)
Expectant management Requirements for expectant management: 1) absence of symptoms (pain, abnormal bleeding, pressure symptoms) 2) absence of large M Consists of→ (1) Bimanual vaginal examination
(2)
- • every 3-6 months to determine uterine size and rate of growth • if slow growth/stable uterine size → annual follow up is carried out onwards
(2)
P’ts W/ ↑ menstruation - endometrial biopsy - regular check of Bl.counts - oral iron supplementation if required - NSAID’s on scheduled basis rather than as needed basis - Low dose oral contraceptives
(3)
NSAID’s → for treatment of pelvic discomfort or pressure.
Medical Management • W/ GnRH agonist Indications : (1) To control bleeding (2) Unsuitable surgical candidate (3) Shrinkage of T° to facilitate surgical management For 8-12 weeks { - Nafarelin nasal spray 200µg × 2 daily { - Lupron depot i/m injections 7.5 mg × 1 month action
: GnRH agonist suppress gonadotropin secreation ↓ Create hypoestrogenic state ↓ ↓ the size of myoma (result of ↓ Bl. supply and cell size)
S.E. → brings the effects of artificial menopause. (4)
Surgical treatment : Indications for surgical treatment: (1) Abnormal uterine bleeding causing anemia (2) Severe pelvic pain or Ii y dysmenorrhea (3) Inability to evaluate adnexa (b/c fibroid is>= 12 wks gestational size) (4) Urinary tract symptoms (frequeny or urinary retention) progressive hydronephrosis and impaired renal function tests (5) growth of myoma following menopause (6) infertility (all excluding other causes) (7) rapid ↑ in size (more than 2-3 ges wks per year) (8) submucous myomas (specially pedunculated sub-mucous leiomyomas which protrude through cervix) (9) reproductive process complicated by repetitive pregnancy loss (a/f excluding other etiologies)
type of surgical procedure depends on → (1) Reproductive desire → young patients and desire for future pregnancy → Myomectomy old patients, no desire for future pregnancy → Hysterectomy (2) On location → subserous / submucous → most often myomectomy is done Myomectomy – involves the removal of single or multiple myomas while preservating the uterus. Hysteroscopic resection → if pedunculated submucous myomas Laparotomic – for intramural, submucous, subserous, or pedunculated subserous * if uterine cavity is opened → is an indication for c-section in future pregnancies. Laparoscopic – if pedunculated subserous Enucleation – if pedunculated submucosal M and protruding through cervix, then can rotate and separate the node. Hysterectomy Curettage of the endometrial cavity is essential before hysterectomy to rule out endometrial Neoplasia. the absence of cervical malignancy is ascertained before surgery. Ovaries should be retained in women younger than 40 – 45 years. Vaginal hysterectomy – Myoma size <12-14 ges wk> Transabdominal – Myoma >12-14 ges wk total hysterectomy → subtal hysterectomy →
put the clamp paralleled to the Uterus and clamp uterine aa put the clamp perpendicular to the Uterus and clamp the rumus ascendence of Uterine aa
* Indications for emergency surgery → (1) Acute torsion (2) Infected leiomyoma (3) Intestinal obstruction by parasitic myoma * Newest method for Myomas tr. Embotlsation of bl. Ves. Which supplied the myoma (USA, UK)
Report on Myoma Uteri: Signs and Symptoms, dg, DD, Management Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom. 2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia. 3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu