22.Leiomyoma Of The Uterus

2. Leiomyoma of the
uterus

3. Incidence
Most common solid pelvic tumors.
Uterine leiomyomas (ie, fibroids or myomas) are benign clonal
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

4. Synonyms
leiomyoma of uterus
leiomyomas
fibromyomas
myofibromas
fibroids
fibromas
myomas

5. Pathology
•Usually multiple, discrete, either
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.

6. Microscopic Appearance
1.Composition：smooth muscle,
connective tissue
2.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.

7. Classification
According 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%）

8. Classification
Subserosal uterine fibroids
These fibroids originate from the serosal
surface 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
develop 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

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

10. Secondary changes
Benign degeneration:
Atrophic
Hyaline degeneration
Cystic degeneration
Calcification
Red degeneration
Malignant Transformation
Sarcomatous change
Other degeneration
fat degeneration
the secondary infection
at menopause or after pregnancy, tumor size shrink, so the sign

11. Red Degeneration
Occasionally 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

12. Red Degeneration
Here is a very large
leiomyoma 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.

13. Sarcomatous Change
Rare：0.4%～ 0.8%
More common at 40～ 50 years old
Usually occur in intramural fibroids
grow quickly
vaginal bleeding

14. 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.

15. SYMPTOMS
menorrhagia and prolonged menstrual period ：
common
Pelvic pain：
occurs in pregnancy if undergoing degeneration or
torsion of a pedunculated myoma
Pelvic pressure：urinary frequency
bowel difficulty（constipation）
Spontaneous abortion
Infertility

16. 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.

17. SYMPTOMS
Pelvic pressure and pain — Fibroids can range in size from
microscopic 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.

18. 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.

19. Signs
A palpable abdominal tumour
Pelvic examination：
uterus — enlarged and irregular；
hard

20. 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

21. DIAGNOSIS
History
Bimanual examination
Ultrasonography
（B–ultrasound examination）
Hysteroscopy
Laparoscopy

22. Differential Diagnosis
Pregnancy
Ovarian tumor
Adenomyosis
Malignant tumors of uterus
sarcoma of uterus
endometrial carcinoma
cervical cancer

23. 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.

24. Observation and Follow
Up
Small，asymptomatic fibroids need not
be treated，especially near
menopause.
Interval：3～6 months

25. Medical treatment
Androgenic agents：testosterone
propionate
GnRH-a：
induce a hypoestrogenic
pseudomenopausal state
not recommended for longer than 6
months
“add-back” regimens

26. 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.

27. Surgical treatment
Indications：
greater than 10 weeks’ gestational size
menorrhagia，lead to anemia
have pressure symptoms
grows rapidly
failure of medical treatment

28. Method：
Myomectomy—conservative therapy
preserve fertility
significant risk of recurrence
Hysterectomy— radical therapy
Subtotal hysterectomy
Endometrial ablation
Uterine artery embolization
Only true “cure”
for leiomyomas

29. Approach：
trans-abdominal
trans-vaginal
laparoscopic or hysteroscopic

30. Surgical treatment
In most women, surgical treatment is used to provide
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.

31. 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.

32. 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.

33. It is important to
individualize the choice of
therapy.

34. Uterine Leiomyomas
Complicating Pregnancy
impact on pregnancy：abortion
impact on delivery： premature labour
fetal malpresentation
retained placenta
placenta previa
need for operative delivery
（birth canal
obstruction）
postpartum hemorrhage
Conservative treatment

35. Critical Points
May 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 types
Individualized treatment，include
observation、medical treatment and surgical
treatment.

36. Normal female reproductive
anatomy