Uterus Leiomyoma

1. Identity
Note Uterine leiomyomas are the most common neoplasms of the
female genital tract.
They are benign tumors composed of smooth muscle and fibrous
connective tissue. On the basis of the symptomatology, they are
estimated to occur in 20 to 30% of women in the reproductive age,
but a study of serial sections of uteri raises the estime up to 77%.
They are frequent in women older than 30 years of age, very rare in
woman below the age of 18, and tend to regress after menopause.
Rarely, if ever, progress to malignant leiomvosarcoma. Multiple
nodules have be found in approximately 25% of women, with an
average of 6.5 tumors per uterus. They are one of the most frequent
indication for major surgery during the reproductive period.
Distribution of estrogen receptors is similar to that of adjoining
miometrium, whereas the concentration of progesteron receptors
seems to be lower.
Other names Uterine fibromyoma fibroma fibroleiomyomafibroid
myoma
see WebPath leiomyoma , leiomyomata , and degeneration

3. Note Classification of leiomyomas can be based on : location and
uterine layer affected.
Location
Cervical (2.6%): generally grows toward vagina, causing sinusiorragia and
infection. Isthmic (7.2%): more frequently causes pain and urinary problems.
Corporal (91.2%): this is the most common location, and frequently causes no
symptoms.
Uterine Layer
Subserous: located just beneath the serosal surface. They grow out toward the
peritoneal cavity, and can be sessile or pedunculated. The pedunculated ones
may attach themselves to adjacent structures like the bowel, omentum or
mesentery, and develop a secondary blood supply, loosing its primary uterine
blood supply (parasitic leiomyoma). Subserous leiomyomas may also extend
into the broad ligament (intraligamentary leiomyomas). Submucous: located
beneath the endometrium. They may be sessile or pedunculated. The
pedunculated nodules may protrude through the cervical os, and may undergo
torsion, infarction, and separation from the uterus. Submucous leiomyoma are
often associated with an abnormality of the endometrium, resulting in a
disturbed bleeding pattern. Intramural: occurring within the walls or the uterus,
they are the most common.

4. Epidemiology Leiomyomas are more frequent (from three to nine fold) in
women of African origin than women of other ethnic groups
Clinics The clinical presentation depends on the size, location and number
of the lesions. They may occur singly but often are multiple, with variations in
size. The most common signs and symptoms are pain, a sensation of
pressure, abnormal uterine bleeding, fetal wastage, infertility. Leiomyomas
may be cause of pregnancy complications, such as abortion, hemorragic
degeneration, disseminated intravascular coagulation, hemoperitoneum,
premature rupture of membranes, dystocia, inversion of the uterus,
postpartum hemorragia. They are steroid hormon dependent. Based on the
observation that nodules with abnormal karyotype fail in lowering DNA
content after GnRH agonist therapy, it has been proposed that karyotypically
abnormal nodules are less steroid hormon-dependent than nodules with a
normal karyotype. No specific association between cytogenetic subgroups
and histologic subtypes has been found.

5. Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. Pathology Leiomyomas are spherical, firm, and bulge above the
surraounding myometrium. The cut surfaces are white to tan in color, with worled
trabecular pattern. The appearence is often altered by degenerative changes.
Microscopically, they consist of whorled, anastomosing fascicles of uniform,
spindle-shaped, smooth muscle cells. Cells have indistinct borders and abundant
fibrillar, eosinophilic cytoplasm. The nuclei are elongated and have finely
dispersed chromatin. They may show areas of hemorragia, as well as cystic
degeneration and microcalcification in a minority of lesions. Despite the variety in
the histologic subtypes of leiomyomas, all are grossly similar. Beside ordinary
leiomyoma (composed of whorled anastomosing fascicles of uniform, fusiform
smooth muscle cells showing eosinophilic cytoplasm and elongated nuclei)
several specific subtypes are distinguished, some of which are very rare:
Cellular leiomyoma (composed of densely cellular fascicles of smooth muscle
with little intervening collagene). Atypical leiomyoma (containing atypical cells,
clustered or distributed through the lesion). Epithelioid leiomyoma (composed of
round or poligonal cells rather than spindle-shaped. This subtype includes
leiomyoblastoma, clear cell leiomyoma, plexyform leiomyoma). Myxoid
leiomyoma (containing abundant amorphous myxoid substance between the
smooth muscle cells). Vascular leiomyoma (containing dense proliferations of
large, caliber, thick-walled vessels). Lipoleiomyoma (consisting of a mixture of
mature adipocytes and smooth muscle cells). Leiomyoma with tubules
(containing tubular structures). Benign metastasizing leiomyoma (occurrence of
multiple smooth-muscle nodules, most often located in the lung after previous
hysterectomy). microscopic pathology: see WebPath leiomyoma

7. Some times hormone preparations like Depoprovera are
used to turn off periods and so give some relief from the
heavy periods There are also other treatments available
that cause fibroids to shrink. Women close to menopause
may opt to take drugs which induce a temporary false
menopause - they literally turn the ovaries oestrogen
production completely off while the woman takes the drug
and this tends to cause the fibroids to shrink. However the
drug can only be taken for 6 months because of potential
side effects like loss of bone density (osteroporosis) and
after this time the fibroids usually regrow anyway. However
this drug may be of benefit once a woman has decided to
have surgery and it may shrink the fibroid to make the
operation easier.

8. Curette - or a "D&C" as its known, can sometimes be
offered to women who don't want surgery to remove
the fibroids but want to see if a currette may help
reduce her menstural flow. The mechanism isn't
entirely clear but it seems to follow that if the
endometrium (the lining of the uterus the builds up
each month ) is removed under anaesthetic as you
might imagine removing the pulp from the inside of a
pumpkin ( the seeds don't fit the analogy here but it's
the best I can think of! ) these women seem to get
some temporary relief from heavy periods. This relief
doesn't usually last though.

9. For decades women had been told their only option was hysterectomy, and then
only via a sizeable surgical cut on their abdomen. Not so any more ! Now days
with the development of fibreoptic endoscopic surgical techniques ( laparoscopy )
not only has this reduced the discomfort and size of scar and also length of stay
in hospital but also highly skilled surgeons are offering women conservative
surgery where they have the fibroids removed but keep their uterus
( myomectomy) . This latter surgery has been especially welcomed by women
who still have troublesome fibroids yet have not completed their family and wish
to avoid hysterectomy.
Vaginal hysterectomy reduced the size of cut needed in the abdomen and use of
a laparoscope to assist this procedure reduces the cuts even further! In this
procedure a ring incicsion is made round the base of the uterus and it is passed
out through the vagina. The top of the vagina is then sewn over. These days
surgeons some surgeons leave the cervix and some don't. It is important to
discuss this with your surgeon because if you still have your cervix you will need
to continue have pap smears while it is suggested that following hysterectomy
you may stop having them if you have no cervix. Even methods of hysterectomy
are changing rapidly. These days laparoscopic techniques allow removal of
uterus and /or even quite large fibroids in many cases
Not all gynaecologists are skilled in laparoscopic techniques and it is very
important that a woman feel confident that if she has been recommended to have
a certain procedure that the recommendation has been based on her clinical
needs and not the skill level of the surgeon. Certainly here in Australia every
woman has a right to a second opinion before committing to surgery of this kind.

10. Uterine fibroids (also referred to as myoma, leiomyoma, leiomyomata, and
fibromyoma) are benign (non-cancerous) tumours that grow within the
muscle tissue of the uterus. Between 20-50% of women of childbearing
age have uterine fibroids. While many women do not experience any
problems, symptoms can be severe enough to require treatment.
Fibroids range in size from very small (coin sized) to larger than a
melon. A very large uterine fibroid can cause the uterus to expand to the
size of a six or seven-month pregnancy. There can either be one
dominant fibroid or a cluster of many small fibroids.
There are three primary types of uterine fibroids, classified primarily
according to location in the uterus:

11.  Very heavy and prolonged menstrual periods
 Pain in the back of the legs
 Pelvic pain or pressure
 Pain during sexual intercourse
 Pressure on the bladder which leads to a constant need to
urinate, incontinence, or the inability to empty the bladder
 Pressure on the bowel which can lead to constipation and/or
bloating
An enlarged abdomen which may be mistaken for weight gain
or pregnancy

12. By Victoria Carrington, M.D.
For the majority of women, there are no signs or symptoms to indicate that they
have a fibroid. Fewer than 50% of women will experience clinically significant
symptoms in their lifetime. Fibroids are almost never found before adolescence and
they typically become smaller after menopause. Women who are going to have
symptoms generally begin to experience them in their 20's and 30's. The most
common symptoms of fibroids are painful periods and heavy bleeding with periods.
Often this bleeding is associated with an increased number of blood clots. The
heavy bleeding, which causes abnormally large amounts of blood loss, can lead to
anemia and resulting fatigue. Other, much less common signs and symptoms of
uterine fibroids include:
It is important to remember that these signs and symptoms are nonspecific. They
could be a sign of many different reproductive tract illnesses and require investigation by
your physician.

13. You could have uterine fibroids and not even know it! In fact, most of the time,
fibroids are found incidentally during a routine gynecological examination. This
means that the practitioner was not looking for them and they may not be causing a
problem but they are just present. Fibroids are routinely found during gynecological
examinations, between 70% and 80% of women end up with fibroid tumors by their
50th birthday. During the routine gynecological examination, the patient will have the
uterus felt from the outside of her body when the practitioner presses on her
pelvic/abdominal area. Also, in what is know as a bimanual examination, the
practitioner checks the uterus from the vagina by inserting one hand inside the
vagina while pressing on the uterus from the outside on the abdomen. An
abnormally large or abnormally shaped uterus can be felt by either of these
methods. Such abnormalities of a uterus could be caused by fibroids. If on physical
examination, the diagnosis of fibroids is suspected and the fibroids are causing
symptoms, your healthcare practitioner may suggest further testing to confirm the
diagnosis, plan treatment and perhaps to remove the fibroids as they are found.
Further testing may include imaging studies, usually done in a radiology office.
Examples of imaging studies include:
•Ultrasound - similar to those done for pregnancy. Can be done relatively quickly and
inexpensively
•Magnetic Resonance Imaging (MRI) - typically requires patient to be immobilized in a
long tunnel-like apparatus for a period of time to generate the images.

14. Computerized tomography (CT) - faster and more patient-friendly than MRI.
Hysterosalpingography (HSG) - injects a dye during an X-ray to visualize the
inside of theuterus and the Fallopian tubes.
Depending on your symptoms, the location and size of the fibroid, your healthcare
practitioner may recommend one or a combination of these techniques to gain more
information about your fibroids. If it is decided that that your healthcare provider
would rather have direct visualization of your uterus to determine the diagnosis of
fibroids and perhaps remove them at the time of diagnosis, he or she may want to
use more invasive techniques that require the use of anesthesia.
Laparoscopy - a surgical procedure in which the OB/Gyn makes a small cut in the
abdomen and looks inside the incision using a special viewing instrument. Fibroids
can be seen and possibly even removed during this procedure.
Hysteroscopy - a procedure in which a very small camera is inserted through the
vagina into the uterus to see the fibroids. Fibroids can possibly be removed during
this procedure as well.
Properly diagnosing the cause of the symptoms that may be due to fibroids is very
important. Pelvic pain, heavy or irregular bleeding, although common symptoms of
fibroids, they may have other causes as well. In women over 40, special care should
be taken to determine whether or not a cancer of the uterus is present and causing
the symptoms. The list of other possible diagnoses causing symptoms of fibroids is
long but some possibilities include: thyroid disorders, bleeding disorders, liver or
kidney problems, pituitary gland malfunction, polyps, congenital malformations of
the reproductive tract, adhesions from prior surgeries, gastrointestinal illnesses or
infections.

15. Estrogen dominance causes the uterus to grow, and without the monthly balancing effect of
progesterone it doesn't have the proper signals to stop growing. This can result in an enlarged
uterus that presses on other organs, such as the bladder, and the digestive system, and generally
causes discomfort and heavy menstrual bleeding. In many women an estrogen imbalance results
in fibroids. A study released in 2004 provides further evidence of the role of estrogen dominance in
the existence of uterine fibroids. The study found that gene therapy in mice that blocked the
estrogen receptors of fibroids caused the fibroids to shrink, suggesting the importance of estrogen
in maintaining fibroids. Using natural "bioidentical" progesterone cream to balance the effects of
too much estrogen can offset these imbalances and relieve symptoms of uterine fibroids.
Progesterone is known to have many important effects in the body. Some studies have shown the
following effects of natural progesterone:
Dr. John Lee, an expert on natural hormone therapy, recommends natural "bioidentical"
progesterone hormone therapy for uterine fibroid tumors. Natural (bioidentical) hormones are
synthesized from natural, plant-based hormones to exactly match the hormones found in the human
body. By matching the body's hormones, experts such as Dr. Lee believe that the body will be able to
better tolerate natural hormones with few, if any side effects. Consult the Hera Essence Progesterone
Cream page for more information.

16. Hera Enzyme Therapy is also recommended for uterine fibroid tumors, it
contains several enzymes, including serrapeptase that have been found to
help reduce uterine fibroid tumors by removal of fiber buildup and abnormal
cell growth.
Supplementation of enzymes with Hera Enzyme Therapy, along with
proper diet and exercise, can help to maintain your normal enzyme levels,
balancing your body's own repair mechanisms and increasing your health
and wellness.
•Eat "organic" foods, to reduce xenoestrogens and pollutants in your diet
•Reduce consumption of animal fats, to reduce xenoestrogens
•Reduce or remove caffeine, refined sugar and salt
•Take supplemental magnesium (400 mg), manganese (6 mg), B vitamins, and calcium
(1,000 mg)
•Increase whole grains, vegetables, and fruit.
Hera Women's Multivitamin, Hera Cal Mag for Women and Hera Antioxidant are
designed to work in concert, to offer a complete solution to a women's unique vitamin
and mineral needs.
As with many medical conditions, it is vitally important to eat a balanced diet, exercise
and assure that your body gets all the vitamins and minerals the body needs.

17. Symptomatic treatments of fibroids will usually only reduce
symptoms, sometimes for short-term relief only, without
actually reducing the size or number of the fibroids. If mild
symptoms are present, over-the-counter or prescription anti-
inflammatory medications to manage the pain may be all that
is required. Warm castor oil packs or ginger compresses to
the abdomen may provide temporary relief from discomfort as
well. Exercises, increasing fiber intake, healthy emotional
expression and acupuncture have all been reported to help
mild cases of fibroids.

18. The use of oral contraceptives has been hotly
debated and the research findings have not been
consistent. Some believe that the increased exposure
to estrogen causes growth of the fibroids. Others
believe that although oral contraceptives do not shrink
fibroids, they can be used to stop a woman's natural
periods therefore decreasing the pain and bleeding
that may accompany fibroids.

19. Medications can be used either to shrink fibroids before surgery or as a treatment on their
own. Two major drawbacks to these treatments are the potential side effects of the
medications and the return of the fibroids once the medication is no longer being taken.
Gonadotropin-releasing hormone (GnRH) agonists work by decreasing the pituitary
output of GnRH which causes decreased estrogen production. Because there is less
estrogen present, the fibroids shrink to one-third or one-half of their original size after 2-3
months. GnRH should not be taken more than 6 months due to the risk of osteoporosis.
Mifepristone (also known as RU-486) is an abortifacient pill at high doses that is used at
lower doses to shrink fibroids. A 2003 study showed that Mifepristone can shrink fibroids to
up to one-half their previous size. Mifepristone is used to shrink the fibroid enough to allow
a woman to become pregnant, prior to surgery to remove the fibroids to make surgery
easier, and to avoid hysterectomy in an older woman approaching menopause (since the
fibroids will usually shrink on their own in menopause).
Lupron (leuprolide) is an injection that suppresses the hormone production of the ovaries
leading to decreased estrogen that puts the body into temporary menopause. Fibroids
treated with Lupron may shrink as much as 50%. Unfortunately, many women and women's
health advocates have expressed concerns over the severity of side effects that may be
seen with Lupron injections. These side effects may include memory problems,
osteoporosis or heart problems.
Selective progesterone receptor modulators (SPRMs) are a new class of drugs under
investigation for the treatment of fibroids. Selective progesterone receptor modulators
(SPRMs), have both agonist and antagonist activities depending upon the site of action.
Studies are being planned now to evaluate these drugs in large clinical trials.

20. For severe symptoms, your doctor may consider surgery. Surgeries involve
serious risks with potential complications and extended recovery times but
may be the best option for some women.
Myomectomy involves removal of the fibroids without removing the uterus.
It may be done as a traditional abdominal surgery or laparascopically through
a smaller incision in the abdomen. Recovery time may be up to 4-8 weeks.
Aside from the risk factors associated with the use of anesthesia, there is also
a risk of heavy bleeding that could require a transfusion. Fibroids frequently re-
grow after surgical removal.
Hysterectomy involves the removal of a woman's uterus and/or ovaries.
Removing the place of growth of the fibroids, the uterus, is the only proven
way to get rid of fibroids once and for all. Hysterectomy ends a woman's ability
to reproduce and is typically only used after a woman is nearing menopause
or is sure that she will not want to have any children. Out of approximately
600,000 hysterectomies performed in the United States each year, 200,000 of
these are performed for the treatment of fibroids. The uterus can be removed
through the vagina or through a cut made in the abdomen depending on the
size and location of the fibroids. Recovery time may be up to 6-8 weeks.
Removal of the ovaries at the time of hysterectomy will put a woman into
menopause.

21. There are alternatives to major surgery or medications in the treatment of
fibroids. These treatments are less invasive than surgery but more invasive than
medications.
Most recently, on October 22, 2004, the FDA approved a device called the
ExAblate 2000 for the treatment of fibroid tumors in women who do not desire to
preserve their fertility. The device uses magnetic resonance imaging to visualize
and monitor the uterus after heating the fibroid with a focused, high-energy
ultrasound beam to destroy the fibroid tissue. The procedure takes up to 3 hours in
the MRI machine and involves repeated targeting and heating of the fibroid until it
is destroyed. Studies found that fibroid symptoms were reduced in 71% of the
women studied. No more than 2 treatments should be performed in a 2-week
period.
Endometrial ablation is used to destroy the lining of the uterus to control very
heavy bleeding. There are several different methods that can be used to achieve
this goal. It can only be used in women who do not want to have any more
children.
Myolysis is the destruction of uterine tissue by heat or freezing to cause the
fibroids to degenerate. Major complications may include adhesions or growths in
the abdomen. This method is not recommended for women who want to have
children.

22. Uterine artery embolization (UAE) also known as uterine fibroid
embolization (UFE) is a minimally invasive technique that is quickly gaining
popularity as an alternative to hysterectomy or myomectomy. Performed by
interventional radiologists in the radiology suite, UAE eliminates the risks of
surgery and anesthesia and minimizes recovery time. The 1 - to 2- hour
procedure involves threading a small catheter up through the leg to the uterine
blood supply. The uterine arteries are blocked with particles, causing the death
of the fibroids. Studies have shown that nine out of ten women get complete
relief for their symptoms after UAE.
Originally in use since the 1970's to control acute pelvic hemorrhage, UAE
was shown in 1989 to shrink fibroids. Given the apparent success rate and
history of UAE, questions have been raised about why so man women still
undergo hysterectomies for the treatment of fibroids instead of the less
invasive technique of UAE. Recent press reports are calling into question why
more women are not taking advantage of UAE. A cover story in the August
2004 issue of The Wall Street Journal questioned whether or not patients were
being properly referred to be considered for UAE by their gynecologists. The
article quoted sources as stating that gynecologists may not let their patients
know about UAE so that they can perform a surgical treatment on the patients
and thereby generate more income. The American College of Obstetrics and
Gynecology (ACOG) wrote a rebuttal letter to the newspaper shortly thereafter.
However, the fact remains that many more women undergo hysterectomies
than UAEs each year for fibroids.