Uterine leiomyomas

1. Dr. Yusri Arif Sapaee
Supervised by Dr. Amy Suzanna Annuar

2.  Benign tumours of the uterine smooth
muscle (the myometrium)
 Also called myomas, fibromyomas
and fibroids
 Most common benign tumours of
female genital organs
 Major contributor for hyterectomy in
Malaysia ~ 47.8%

4.  Exact etiology is UNKNOWN
 Possible etiological factors include:
 HYPERESTRENISM
 GROWTH FACTORS
 GENETIC FACTORS

5.  Evidenced by the following
 Appear only in childbearing period
 Commonly associated with endometrial
hyperplasia and/or endometriosis
 Increase in size during pregnancy and
during estrogen hormonal therapy
 Decrease in size and undergoes atrophy
after menopause with hormonal
depletion or with GnRH agonist therapy

6.  Parity
 More common in nulliparous and low parity
women
 Hereditary
 More common in women with positive
family history (mother and sister)
 Obesity
 More common in obese women
 Conversion of circulating androgens to
estrone (E1) by excess adipose tissue

9.  Understanding their differences,
how they grow and how they develop
 Can help to decide the best treatment
option
 To evaluate degree of difficulty during
operation

10.  proximate to the endometrium and
grow toward and bulge into the
endometrial cavity
 Increase surface area of endometrial
lining
 Heavy menstrual bleeding  anemia 
multiple blood transfusion
 Large submucosal fibroid tumors
 May block fallopian tubes  infertility

11.  The growth centered within the
uterine walls
 Tends to make uterus feels larger
than normal  bulk symptoms
 Prolonged heavy menses
 Pelvic pain
 Pressure on surrounding organs
 Inhibit muscle contraction
  cramping pain during menses

12.  originate from myocytes adjacent to
the uterine serosa, and their growth
is directed outward
 Usually cause pelvic pain and
compression symptoms
 May extend to lie within the broad
ligaments  difficult to remove
during surgery

13.  Attached only by a stalk to their
progenitor myometrium
 Pedunculated submucosal myoma
 Pedunculated subserosal myoma
 It can be twisted on their stalk
  acute pelvic pain

15.  Mostly asymptomatic
 Usually accidentally discovered during
routine bimanual examination or on
performing pelvic ultrasound

16.  Mostly with submucosal and large
multiple interstitial myomas
 Increased surface area of the
endometrium
 Mechanical interference with uterine
contraction
 Associated endometrial hyperplasia
 Increased myometrial vascularity due to
venous congestion

17. At any level within the myometrium, submucous, subserosal, and
intramural leiomyomas can compress adjacent veins and thereby
cause dilatation of distal endometrial venules.

18.  Usually painless unless complicated
 Dull aching pain: hyaline degeneration,
infection of submucosal fibroid polyp
 Acute pain: red degeneration and torsion
of pedunculated myoma
 Colicky pelvic pain: extrusion of
pedunculated submucosal myoma
through the cervix
 Loin pain: ureteric compression
 Congestive or spasmodic dysmenorrhea

19.  Urinary bladder  frequency, incontinence
 Ureter  hydronephrosis
 Rectum  constipation
 Cervix  dyspareunia
 Major veins  edema of lower limb(s)
 Pelvic nerve  back pain and thigh pain

20.  Interference with implantation and
distortion of uterine cavity
 Tubal obstruction
 Interference with ascent of sperm
and fertilization

21.  Recurrent miscarriage
 Preterm labour
 Pre-labour rupture of membrane
 Malpresentations
 Obstructed labour
 Post partum haemorrhage
 Abruptio placenta

23.  Hyaline degeneration
 Occurs in the centre due to poor
vascularity
 Becomes larger and softer
 Red degeneration
 More frequent in pregnancy
 Thrombosis of capsular vessels
 Rapid uterine growth  outgrowth its
blood supply

25.  Calcification
 Deposition of calcium phosphate and
carbonate along blood vessels in long
standing myomas
 Peripheral  egg-shell appearance
 Diffuse  womb stone
 Common after menopause

26. Transvaginal sonogram of an intramural leiomyoma
with calcified border

27.  Infection
 Most frequent at the tip of a submucosal
myoma polyp
 Torsion
 Pedunculated subserous myoma
 Rarely torsion of the whole uterus
 Malignant transformation
 Very rare
 No more than 0.2 – 0.5% of myomas

29.  Gold standard in diagnosis
 Saline-infusion sonography
 Injection of saline to delineate the
endometrial cavity
 Improve sensitivity of TVS in diagnosing
submucosal myoma
 Also very helpful to exclude
associated pelvic pathology
e.g. Ovarian cyst

36. Submucous fibroid clearly outlined by saline-infusion
sonography and identified by long white arrows.

37.  These tools allow more accurate
assessment of leiomyomas, which
may help identify appropriate patients
for alternatives to hysterectomy
 Hysteroscope
 Hysterosalpingography (HSG)
 Magnetic resonance imaging (MRI)

39.  Structural factors
 uterine size
 size, number and location of the myomas
 Desire for fertility
 Definitive versus uterus-conserving treatment
 General medical health
 Age, BMI, co-morbidities, previous treatment,
previous surgery
 Preference
 Focal versus global uterine treatment

40.  NSAIDs
 Inhibit prostaglandin synthesis
 Reduce menstrual flow (25-35%)
 Relieve dysmenorrhea
 Progestogens
 Given for 21 days
 Significant reduction in menstrual blood
loss

41.  Danazol
 Synthetic steroid
 suppress estrogen and progesterone
receptor in endometrium
 thinning of lining of endometrium
 reduction of blood loss
 Disadvantage: masculinizing effect

42.  Tranexamic acid
 Antifibrinolytic agent
 Synthetic derivative of amino acid lysine
 Reversible blockage on plasminogen
 50% reduction of menstrual blood loss
 Levonorgestrel intrauterine system
 Reduces blood loss by 80%
 Not applicable to all type of fibroid

43.  GnRH agonist
 Induce a reversible hypoestrogenic state
 Reduce uterine volume
 Pre-operative use
 3-4 months course prior surgery
 Reduce fibroid size and uterine volume
 Midline vertical laparotomy incision  lower
transverse abdominal incision
 Improve pre-operative haemoglobin level
 Reduce perioperative blood loss and
transfusion requirement

44. 1. Myomectomy
1. Abdominal myomectomy
2. Vaginal myomectomy
3. Hysteroscopic myomectomy
4. Laparoscopic myomectomy
2. Hysterectomy
3. Uterine artery embolization

45.  Benefits
 80% improvement in abnormal
menstrual bleeding
 Removal of intracavitary fibroid improves
fertility
 Disadvantage
 Need another treatment after
myomectomy
 20% over 2-5 years

46.  Removal of small submucosal myoma
<5cm in diameter which protrude
>50% into uterine cavity
 Better preceded by GnRH agonist
preparation to decrease vascularity
and diminish the size of myomas
 Advantage:
 Significantly less pain
 Shorter recovery period

47.  Indications
 Postmenopausal women with symptomatic
fibroids
 Multiple or very large myoma
 Future fertility not desired
 Patient’s preference
 Advantages
 Sure relief of symptoms with no recurrence
 Less blood loss during surgery
 Lower post-operative morbidity

48.  Angiographic interventional procedure that
delivers polyvinyl alcohol (PVA)
microspheres or other particulate emboli
into both uterine arteries.
 Uterine blood flow is therefore obstructed,
producing ischemia and necrosis
 These microspheres are preferentially
directed to the tumors, sparing the
surrounding myometrium

50. Source:
1. William’s Gynaecology Textbook
2. RCOG website
3. Kasr El-Ainy School of Medicine Textbook