Uterine myoma........................ppt

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1. Uterine myoma and adenomyosis Yekatit 12 hospital medical college, June 28,2023

2. Uterine myoma Also called leiomyoma, Fibroids, fibromyoma Is a benign tumor from smooth muscle tissue that originate from the smooth muscle layer and fibroblast of myometrium of the uterus. Most common monoclonal benign tumors of the uterus.

3. incidence Most common---- 77% specimen of hysterectomy were having fibroids invariable number, size and site. Sonographic survey in 35-49% aged Africa-American women reported fibroid in 60% while 80% among the women > 50yrs of age.

4. causes Unknown Family history Genetic alteration Fibroids are monoclonal and about 40% have chromosomal abnormalities that include; Translocation between chromosome 12 and 14 Deletion of chromosome 7 Trisomy of chromosome 12 in large tumors 60% may have yet undetected mutation More than 100 genes were found to be up down regulated in fibroid cells. Many of them appear to regulate cell growth, proliferation, differentiation and mitogenesis.

5. Cause cont … Hormones Increased in number and responsiveness of receptors for estrogen and progesterone appears to promote fibroid growth Develop and increase during reproductive period of life and pregnancy Regress after menopause/ bilateral oophorectomy Found more in hyper estrogenic state Progesterone is most important pathogenesis of fibroid- highest mitotic count

6. Cause cont … Growth factor Tumor growth factors, fibroblasts, epidermal growth factor, platelet derived growth factor, insulin like growth factor, PRL, Vascular endothelial growth factors. Promote growth of fibroids

7. Risk factors Hereditary Race – black women 2.9x than white women Endogenous hormonal factors – early menarche, late menopause, hyper-estrogenic state Nulliparity Family history Obesity – increased by 21% with each 10 kg increase in body weight Diet – rich in beef, ham, red meat

8. Exercise ERT – more increase when progesterone were added Smoking – decrease by decrease conversion of androgen to estrogen(caused by inhibition of aromatase enzyme by nicotine) Pregnancy – increased parity associated with lower incidence OCP – no definite relationship.

9. types Body or corporeal fibroids Intramural or interstitial fibroids- 75% Subserosal fibroids – 10% Submucosal fibroids- 15% Cervical fibroids- <5% Ligamentary – broad ligament myoma

10. pathology Gross Typical- well circumscribed tumor with psedo -capsule. Cut surface- pinkish white and has a whorled appearance. Microscopic Bundles of plane cells Separated fibrous strand

11. Secondary changes in fibroid Degenerative changes Subserous fibroids – pedunculated- torsion –acute abdomen - detached- wandering fibroid- get attached to other peritoneal structure- parasite fibroid Hyaline degeneration Cystic degeneration Calcification Fatty degeneration Red degeneration Septic degeneration

12. Infection/ ulceration of pedunculated fibroid Atrophy Necrosis Vascular changes Sarcomatous changes

13. Clinical features 75% remain asymptomatic Menstrual abnormalities Menorrhagia(30%) Metrorrhagia or irregular bleeding Dysmenorrhea Due to microscopic or macroscopic abnormalities of the uterine vasculature, impaired endometrial hemostasis, increased surface area Infertility Pain lower abdominal Dysmenorrhea Degenerated Torsion of fibroid

14. Abdominal swealing Pressure symptom Frequency, nocturia, urgency Constipation Polycythemia Erythropoiten production

15. Abdominal examination Firm more hard may be cystic in cystic degeneration Margins are well defined except lower pole Nodular may be uniformly enlarged Mobility is restricted from above down ward but can be moved from side to side Percussion: swealing is dull Uterine souffle due to increased blood supply to uterus.

16. Pelvic examination Bimanual examination Uterus irregularly enlarged Uterus is not felt separate from the swelling and as such a groove is not felt between the uterus and the mass. Enlarged uterus and cervix move together

17. Diagnosis Ultrasound Pelvic Transvaginal Saline infusion USG – sensitivity 90% and specificity 89%. Endometrial biopsy Hysteroscopy sensitivity 82% and specificity 89% Hysterosalpingography MRI- 100% sensitivity and specificity -87 % laparoscopy

18. FIGO leiomyoma classification

19. Fertility and fibroid Submucosal myoma Subserous and intramural fibroid do not effect fertility but their removal may increase fertility depending on their location. Myomectomy risk has to be balanced Risk of anesthesia, surgery, infection, post-operative adhesion, increased risk of cs, ruptured myomectomy scar, expansion of time of surgery and recovery. So until submucosal or intramural fibroid is a cause of infertility and repeated abortion, myomectomy??

20. Pregnancy and fibroid 18% based on first TM USG. Most fibroids do not increase significantly in pregnancy. Red degeneration in 5% of the cases Myoma effect on pregnancy Malpresentation and malposition IUGR PROM Preterm labor Labor abnormality Obstructed labor APH PPH Inversion of uterus Sub involution Rupture of myomectomy scar

21. treatment expectant Medication surgical Ultrasound fibroid destruction Surgically aided methods to reduce blood supply of fibroids Myomectomy or radio frequency ablation Hysterectomy Uterine artery embolization

22. expectant Asymptomatic or mild to moderate discomfort. A women approaching menopause Size < 12 weeks

23. medications Oral contraceptive pills – for symptoms of HMB Progestin releasing IUDS Antihormonal drugs RU-486(MIFEPRISTONE). 48% of reduction in size for 6 month therapy 28% develop endometrial hyperplasia Antifibrinolytics(tranexamic acid). Nonsteroidal anti-inflammatory agents. Found to have minimal or no effect in controlling menorrhagia.

24. GNRH agonist. Decrease uterine size, fibroid volume and bleeding. Monthly GNRH agonist for 6 month reduce uterine volume by 35% and fibroid volume by 30% After discontinuation all return within 4-8 weeks. 95% of women develop side effect of hypo estrogen – add back therapy In premenopausal with heavy bleeding GNRH agonist dosage Triptorelin 3.75mg im monthly Leuprolide acetate 3.75mg im monthly Goserelin 3.6 mg SC monthly Nararelin 200mg 2x/ daiy into one nostril exchanging

25. GNRH antagonist; imidiate suppression of endogenious GNRH Reduction of volume within 3 weeks Hypo estrogen symptom Ganirelix, linzagolix , relugolix , elagolix For medical treatment prior to surgery Often formulated with low dose steroids add-back to limit side effect

26. surgery Myomectomy For young and want to preserve fertility Indication Pedunculated fibroid likely to undergo torsion Fibroid > 12 weeks Broad ligament fibroid pressing ureter Symptomatic Rapidly growing fibroid in post menopausal Complication Hemorrhage Trauma to urinary tract Infection Adhesion Intestinal obstruction recurrence

27. Uterine artery embolization; to reduce blood supply to fibroid reduction in fibroid size(50%), further growth, bleeding(by 80%), pressure (40-70%) at the end of three month Contra indications Pedunculated sub serous Sub mucosal Very big myoma Poly vinyl alcohol gel injected to bilateral uterine artery through percutaneous femoral catheterization Complication Fever and infection Vaginal discharge and bleeding Unbearable ischemic pain Pulmonary embolism Premature ovarian failure- accidental occlusion of ovarian vessels

28. Hysterectomy Women over 40 years of age and multiparous Complicated fibroid Unforeseen difficulties during surgery Types of hysterectomy Abdominal total and subtotal and Wertheim’s hysterectomy Vaginal hysterectomy

29. Uterine artery ligation Radio frequency ablation Endometrial ablation

30. complication Menorrhagia Abdominal pains Premature birth, labor problems, miscarriages infertility

31. Complication cont …. Leiomyosarcoma Twisting of the fibroid Anemia Urinary tract infections Cesarean section PPH

32. adenomyosis

33. definition Is a benign disease of the uterus characterized by ectopic endometrial gland and stroma within the myometrium Is associated with myometrial hypertrophy focal or diffuse. Over 23% of patients requiring hysterectomy for control of severe pelvic pain had adenomyosis and half of these women had had tubal ligation performed.

34. pathogenesis Not known Theories Endometrial invagination of endometrium De novo from Mullerian remenant Microtrauma to endometrial/myometrial interface

35. symptoms Pelvic pain Dysmenorrhea Menorrhagia unresponsive to hormonal therapy or uterine curettage Subfertility and pregnancy termination Classic presentation cyclic and crampy uterine pain beginning later in reproductive life(>35yrs) and often associated with prolonged and heavy menses. Often coexist with other uterine disease particularly myoma and endometriosis Poor pregnancy outcome(infertility, abortion, SGA)

36. Pelvic exam There may be uterine enlargement upto 6-10 weeks pregnancy size. Uterus can feel soft and boggy May be also associated with leiomyoma Repeted bimanual examination before and after mensturation to detect fluctuating change in contour, size and consistency of uterus

37. diagnosis Diagnosis can only be proven by pathologists A good gynecologist may suspect adenomyosis based on the clinical factors, but final diagnosis usually has to wait until hysterectomy is performed.

38. DIAGNOSIS CONT… Hysterography The presence of ill defined areas of contrast intravasation extending perpendicularly from uterine cavity into myometrium True adenomyomas(encapsulated) are uncommon Ultrasound Ill defined hypoechoic areas Heterogeneous myometrial echotexture Small anechoic lakes Asymmetrical uterine enlargement Indistinct endometrial- myometrial border Subendometrial halo thickening

39. Histopathology Presence of heterotopic endometrial glands and stroma in the myometrium with adjusent smooth muscle hyperplasia MRI Superior to TVS in diagnosing adenomyosis

40. managment The only definitive treatment for adenomyosis is total hysterectomy with or without ovarian conservation. Conservative surgery in adenomyosis- adenomymectomy Young and want to preserve their reproductive capacity Though the pregnancy rate of conservative surgery for diffuse adenomyosis was low, it still has therapeutic value. GNRH agonist Uterine artery embolization All clinical symptoms relieved Safe and effective method But recurrence rate????

41. THANK YOU