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2. OBSTETRIC AND GYNECOLOGIC
MEDICAL FACULTY
CHRISTIAN UNIVERSITY OF INDONESIA
DECEMBER, 3RD 2012 –FEBRUARY,2ND 2013
Menorrhagia, Pain, and Constipation in Uterine Myoma
Tigor P. Simanjuntak,1 Katarina Maria2
1 Obstetric and Gynecology DepartmentChristian University of Indonesia
2 College Student Medical Faculty Christian University of Indonesia
3. Abstract
Uterine myoma are benign neoplasms of uterine smooth muscle cells, that typically
originate from the myometrium. It also known as myomas or fibroids. The insidence in
Indonesia was 2,39-11,7 %, happened between 36 and 49 years old women. 20% of all
women of reproductive age. The highest proportion was 5-10 cm (67,5%). Multipara parity
women 45,2% .Intramural myoma 41,9%, Prolonged menstruation 37,3%. Heavy menstrual
bleeding 59,8%. Chronic pelvic pain was 14.5%. 28,8% pressure symptom cause intestinal
obstruction. Pain during menstrual period 59,7%. Uterine myoma still become one of the
problem in Gynecology. This paper will report the menorrhagia, pain, and constipation in
P3A1woman.
Keyword : Uterine Myoma, menorrhagia, pain, constipation
Introduction
Uterine myomas are benign neoplasms of uterine smooth muscle cells, that typically
originate from the myometrium. It also known as leiomyomas or fibroids, are by far the most
common benign uterine tumors.The uterine leiomyomas are the most common pelvic tumors
in women of reproductive age.(1-10)
The etiology of this common tumor is not known.(1)However, the relative
contributions of estrogen vs. progesterone and their functions in the pathogenesis of uterine
leiomyomas are still controversial.(9)Leiomyomas develop during the reproductive years and
regress in size and incidence after menopause.(3)So that, Leiomyomas are not detectable
before puberty and being hormonally responsive, normally grow only during the reproductive
years.(1)
4. There are some conditions associatedwith increased estrogen production that
encourage leiomyoma formation. For example, the increased years of estrogen exposure
found with early menarche and with an increased body mass index (BMI). Obese woman
who poduce more estrogens from increased adipose conversion of androgens to estrogen are
each linked with a greater risk of leiomyomas. Because the pregnancy is a progesterone
dominant state,it should provide an interlude from chorionic estrogen exposure, and
intuitively at least, should discourage leiomyoma development.(3)
While the role of progesterone in leiomyoma growth is less clear, and indeed both
stimulatory and inhibitory effects have been reported. For example, exogenous progestins
have been shown to limit leiomyoma growth. For example, antiprogestin induces athrophy in
most leiomyomas.(3)
Beside the hormone, the etiology of leiomyomas are related to the cytogenetic
abberation. Although most of uterine leiomyomas have a normal karyotype, there have been
reports suggesting that 50% of these tumors bear specific chromosomal abberations including
chromosome 3,6,7 trisomy 12, reciprocal translocation and monosomy 22. Such
chromosomal rearrangements may be responsible for initiatin as well as the growth of these
tumors with a significant relationship between clonal cytogenetic abnormalities and myoma
size. (5)
Duringthe reproductive years, the incidence of Leiomyomas increases with age.(3)
They are
estimatedto be present in at least 20% of all women of reproductive age, may be discovered
incidentally during routine annual examination.(2)
In the studies at 2011, the uterine
myomahappened between 36 and 49 years old women.(7)
The cumulative incidence by age 50 years
was nearly70% inCaucasiansand over80% in African- Americanwomen.(9)
So that,Leiomyomas are
more common in African-American women compared with Caucasian, Asian, or Hispanic
women.(3)
Proportion uterine myoma in Indonesia 2,39-11,7% from all hospitalized benign
gynecology.(12)
Family and twin studies have shown the risk of leiomyoma formation to be
approximatelytwotimesgreaterinwomenwithaffectedfirst- degree relatives.(3)
Thus far, the only
known genetic factor conferring a high risk for developing uterine leiomyomas are the germline
mutationsinthe fumareatehydratase (FH) gene, an enzyme of the tricarboxylic acid cycle.(4)
For the
womenwhosmoke generallyhave alowerriskforleiomyomaformationbecause the smoking alters
estrogenmetabolismandlowersphysiologicallyactive serumestrogenlevels.(3)
The studyat Pirngadi
Hospital reported that based on the parity the highest proportion was multipara parity women
45,2% and the lowest was primi parity with 13,4%. (12)
Leiomyomas contain estrogen receptors in higher consentrations than the surrounding
myometrium. Progesterone increases the mitotic activity of myomas in youngwomen,
progesterone may also allow for tumor enlargement by downregulating apoptosis in the
tumor. Leiomyomas are usually multiple, discrete, and either spherical or irregularly
lobulated. Leiomyomas have a false capsular covering, and they are clearly demarcated from
surrounding myometrium. Which allows easy enucleation at the same time of surgery. There
5. is usually one major blood vessel suplying each tumor. The cut surface is characteristically
whorled. (2)
They are usually less than 15 cm in size.(1)The study at RS Pirngadi Medan reported,
based on the size, the highest proportion was 5-10 cm (67,5%) and the lowest was > 10cm
(11,1%).(12)The appearance of leiomyomas may vary when normal nuscle tissue is replaced
with various degenerative substances following hemorrhage and necrosis. This proces is
termed degeneration and these gross changes should be recognised as normal variants.
Degeneration in leiomyoma because of the limited blood supply within these tumors.
Leiomyomas have a lower arterial density compared with the surrounding normal
myometrium. (3)
Uterine leiomyomas are classified by anatomic location. Submucous leiomyomas lie
just beneath the endometrium and tend to compress it as they grow toward the uterine lumen.
Their impact on the endometrium and its blood supply most often leads to irreguler uterine
bleeding. Intramural or interstitial leiomyomas lie within the uterine wall, giving it a variable
consistency. Subserous leiomyoma may also become pedunculated. If such a tumor acquires
an extrauterine blood supply from omental vessels, its pedicle may athrophy and
resorb.(2)Based on anatomic location, the most was intramural myoma 41,9%, submucous 37,2%,
and subserouswas32,6%.(12)
Symptoms are present in only 35-50% of patients with leiomyomas. Thus, most
leiomyoma do not produce symptoms, and even very large ones may remain undetected,
particularly in obese patient. Symptoms from leiomyomas depend on their location size, state
of preservations, and whether or not the patient is pregnant. Abnormal uterine bleeding is the
most common and mostimportant clinical manifestation of leiomyomas, being present in up
30% of patients.(1)The bleeding related to dilatation of venules.Bulky tumors are thought to
exert pressure and impinge on the uterine venous system, which causes venular dilatation
within the myometrium and endometrium. Accordingly, intramural and subserous tumors
have been shown to have the same propenstiy to cause menorrhagia as mucous ones.
Dysregulation of local vasoactive growth factors are also thought to promote vasodilatation.
When engorged venules are disrupted at the time of menstrual sloughing, bleeding from the
markedly dilated venules overwhelms usual hemostatic mechanisms.(3)
The abnormal bleeding commonly produces iron deficiency anemia, which may not
be uncontrollable even with iron therapy if the bleeding is heavy and protracted. Most
commonly, the patients has prolonged,menorrhagia, premenstual spotting, or prolonged light
staining following menses; however, any type of abnormal bleeding is posible.Metrorrhagia
may be assosiated with a tumor that has areas of endometrial venous thrombosis and necrosis
on its surface, particularly if it is pedunculated and partially extruded through the cervical
canal.(1) 37,3% of women with diagnosed uterine myoma reported a significantly longer
duration of period (5.6 ± 3.1 days, n = 1,245) than women without a diagnosis of uterine
myoma. Shortened duration of menstrual bleeding 13,1%.Heavy menstrual bleeding 59,8% ,
irregularperiods36,3%, Frequentperiods (periodsoccurmore often than just every 24 days) 28.4%,
Infrequent periods (periods occur less often than every 38 days) 16,7%.(11)
6. A sufficiently enlarged uterus can cause pressure sensation, urinary frequency,
incontinance, and constipation. Rarely, leiomyomas extend laterally to compress the ureter
and lead to obstruction and hydronephrosis.(3)
Pressure on the bladder or inside the abdomen
32,6%. (11)
Pressure symptom happened in 28,8% women with uterine myoma. (12)Pressure
effects may cause intestinal obstruction if they are large or involved omentum or
bowel.Although dysmenorrhea is common, in a population based cross sectional study,
Lippman and co-workers reported thatwomen with leiomyomas more frequently had
dyspareunia or noncyclical pelvic pain than dysmenorrhea.(3)
Leiomyomas may cause pain when vascular compromise occurs. Thus, pain may
result from degeneration associated with vascular occlusion, infection, torsion of a
pedunculated tumor, or myometrial contraction to expel a subserous myoma from the uterine
cavity. The pain associated with infarction from torsion or red degeneration can be
excruciating and produce a clinical picture consistent with acute abdomen.Large tumor may
produce sensation of heaviness or fullnes in the pelvic area, a feeling of a mass in the pelvis,
or a feeling of a mass palpable through the abdominal wall. Tumors that become impacted
within the bony pelvis may presson nerves and create pain radiating to the back or lower
extremities.(1)The incidence of chronic pelvic pain was 14.5%. Pain during menstrual
bleeding or period was 59,7%.Cramping during menstrual period was 50.2%.Pain after
menstrual periodwas 16,7% while painful sexual intercoursewas 23,5%.(11)
Although the mechanism are not clear, leiomyomas can be associated with infertility.
It is estimated that 2to 3 % of infertility cases due sorely to leiomyomas. Their putative
effects include occlusion of tubal ostia and disruption of the normal uterine contractions that
properl sperm or ovum. Distortion of the endometrial cavity may diminish implantation and
sperm transport. Importantly, leiomyomas are associated with endometrial inflammation and
vascular changes that may disruptimplantation.(3)
Thereis a stronger associationof subfertility with submucous leiomyomas than with
tumors located elsewhere. Improved pregnancy rates following hysteroscopic resection have
provided most of the indirect evidance for this link. In one study, Garcia and Tureck reported
pregnancy rates approaching 50% following myomectomy in women with submucos
leiomyomas as their sole source of infertility.(3)
The incidence of spontaneous abortion secondary to leiomyoma is unknown but is
possibly 2 times the incidence in normal pregnant women. For example, the incidence of
spontaneous abortion prior to myomectomy is approximately 20%.(1)
Most myomas arediscovered by routine bimanual examination of the uterus or
sometimes by palpation of the lower abdomen. Uterine retroflexion and retroversion may
obscure the physical examination diagnosis of even moderetly large myoma. When the cervix
is pulled up behind the symphisis, large fibroids are usually implicated. The diagnosis is
obvious when the normal uterine contour is distorted by one or more smooth, spherical, firm
masses, but often it is difficult to be absolutley certain that such masses are part of the
uterus.(1)
7. As noted earlier, anemia is a common consequence of leiomyomas due to excessive
uterine bleeding and depletion of iron reserves. However, occasional patients display
erythrocytosis. The hematocrit returns to normal levels following removal of the uterus, and
elevated erythropoietin levels have been reported in such cases.Moreover, the recognized
association of polycythemia and renal disease has led to speculation that leiomyomas may
compress the ureters to cause ureteral back pressure and thus induce real erythropoietin
production. Leukocytosis, fever, and an elevated sedimentation rate may be present with
acute degeneration or infection.
Pelvic ultrasound examination are useful in confirming the diagnosis of leiomyomas.
While ultrasound should never be a substitute for a thorough pelvic examination, it can be
extremely helpful in identifying leiomyomas, detailing the cause of other pelvic masses, and
in the identification of pregnancy. Moreover, the ultrasonography is particularly useful in the
obese individual. (1)
The sonographic appearance of leiomyomas vary from hypo to hyperechoic,
depending on the ratio of smooth muscle to conective tissue and whether there is
degeneration. If menorrhagia, dysmenorrhea, or infertility accompanies a pelvic mass, then
the endometrial cavity should be evaluated for submucous leiomyomas, endometrial polyps,
congenital anomalies, or synechiae.Leiomyoma have characteristic vascular patterns that can
be identified by color flow Doppler. A peripheral rim of vascularityfrom which few vessels
arise to penetrate into the center of the tumor is traditionally seen. Doppler imaging can be
used to differentiate an extrauterine leiomyoma from other pelvic masses or submucous
leiomyoma from endometrial polyp or adenomyosis. (3)
In the diagnosis of myomas, MRI demonstrated sensitivity of 94,1 %, specificity of
68,7%,PPV pf 95,7%, and NPV of 61,1%. The Area Under the Curve (AUC) for the
diagnostic perfomance of MRI in the detection of mymoas was 0,81, respectively. MRI
exhibits a high AUC for the diagnosis of myomas. MRI seems to be a useful technique in
everyday clinical practice in the diagnosis approach of these common condition, enabling
clinicians to select the most appropriate management.(6)
Choice of treatment depends on the patient’s age, parity, pregnancy status, desire for
fture pregnancies, general heath, and symptoms, as well as the size, location, and state of
preservation of the leiomyomas.Blood transfusins ma be necessary to correct anemia.
Transfusion of packed red cells is preffered over whole blood. (1)
In some women with symptomatic leiomyomas, medicaltheraphy may be preffered.
Women with dysmeorrhea have higher endometrial levels of prostaglandins than
asymptomatic women. Accordingly, treatment of dysmenorrhea and menorrhea assosiated
with leiomyomas is based in the role of prostaglandins as mediators of these symptoms. A
number of NSAIDs have proved effective for dysmenorrhea, yet there is not one considered
to be superior. Prostaglandin are also associated with menorrhagia.(3)
The gonadotropin releasing hormone (GnRH) agonist have proven very useful for
limiting growth or to cause a temporary decrease in tumor size. GnRH induce hypogonadism
8. through pituitary desensitization, downregulation of receptors, and inhibition of
gonadotropins. (1)
Table 1 : Dosages of GnRH Agonists
Brand Name Generic Name Dosage
Decapeptyl Triptorelin 3,75mg depot IM monthly
Lupron Leuprolide acetate 3,75mg depot IM monthly
Zoladex Goserelin 3,6 mg depot SC monthly
Synarel Nararelin 200 mg taken twice daily as
1 spray
The progesterone receptor modulators make up an interesting group of compounds.
The almost pure antagonist of the progesterone receptors, such as mifepristone with 5 or 10
mg daily during 6 months had a similar efficacy in reducing the uterine myoma volume,
48,1% and 39,1%.(7)
Two randomised double-blind studies have shown the effectiveness of the
progesterone receptor modulator ulipristal acetate (UPA) in the preoperative treatment of
uterine fibroids and in the control of a concomitant hypermenorrhea. A dosage of 5 or 10 mg
UPA over three months has produced no significant sideeffects. A cessation of the
hypermenorrhea has been observed after only seven days, a volume reduction of the uterine
myoma by 40% within three months seemed to be visible even six months after stopping the
therapy.(10)
Some indication for surgery are abnormal uterine bleeding with resultant anemia,
unresponsive to hormonal management. Chronic pain with severe dsmenorrhea, dyspareunia,
or lower abdominal pressure or pain. Acute pain as in torsion of a pedunculated leiomyoma
or prolapsing submucosal fibroid, urinary symptoms or signs such as hydronephrosis after
complete evaluation. Infertility with leiomyomas as the only abnormal finding. Markedly
enlarged uterine size with compression symptoms or discomfort.(2)
Removal of the uterus is the definitive and most common surgical treatment for
leiomyomas. Hysterectomy for leiomyoma can be performed vaginally, abdominally, or
laparoscopically.(3)Uterine with small myomas may be removed by total vaginal
histerectomy, particularly if vaginal relaxation demands repair of cystocele, rectocele, or
enterocele. When numerous large tumors especially intraligamentary myomas are found,total
abdominal histerectomy is indicated. Other considerations prior to hysterectomy include
uterine size and preoperative hematocrit. In some cases,preoperative GnRH agonist may
provide advantages.(1)
Myomectomy should be planned for the symptomatic patient who wishes to preserve
fertility or conserve the uterus or for those who decline histerectomy, but one can never be
certain before operation that myomectomy can accomplished easily. Myomectomy is quite
9. succesful for control of chronic bleeding association with leiomyomas. Increasingly
myomectomy is being performed through the histeroscope in cases of submucous leiomyoma
and through the laparoscope of subserous leiomyoma.(1)
Myolysis is one of the procedures that is claimed to provide significant improvement
in myoma status without hysterectomy. Myolysis procedures have been generally performed
via laparoscopy, and there are limited data on transvaginal radiofrequency (RF) myolysis.
Mean baseline volume of the dominant myomas was 304.6+229.1 cm3 and its volume at 3
months following RF myolysis decreased compared with the previous examination (P ¼
0.002). An improvement of menorrhagia occurred 1, 3, 6 and 12 months after operation (all P
, 0.001 versus baseline). Overall symptoms at 1, 3, 6 and 12 months after RF myolysis also
improved (all P , 0.001 versus baseline). No major complications were observed or reported.
After 12 months, three patients had successfully conceived and delivered and there were no
complications during labor or delivery. Transvaginal ultrasound-guided RF myolysis might
be a safe, effective and minimally invasive outpatient procedure for uterine myoma in terms
of size reduction, symptom improvement and safety.(8)
Leiomyosarcoma are reported to developed with a frequency of 0,1- 0,5% that of
diagnosed leiomyomas.(1,2)Disadvanageously, postoperative intra abdominal adhesions
leiomyoma recurrence are more common aftermyomectomy compared with hysterectomy.
Recurrence rates following myomectomy range from 40 to 50%. New leiomyoma
development, however,diminished in women who become pregnant following myomectomy,
perhaps because of protective effect of increasingparity.(3)While in the other study, reported a
rate of 2-3% per yearof symptomaticmyomas after myomectomy.(1). Myomectomy usually
improves pain, infeertility, or bleeding. Menorrhagia improves in approximately 70-80% of
patients.(3)Ureteral injury or ligation is a well- recognized complication of surgery for
leiomyomas, particularly cervical.(1)
Case Report
Patient Identity:
Name : Miss. Rohayati
MR : 01.03.04.00
Age : 42 Years 10 months
Address : Cawang 3 Jl. Usman Harun no 8 RT 01/05, Kebon Pala, Jakarta Timur.
Date of Entry : December, 17th 2012.
10. Main Complaint : Vaginal Bleeding.
Additional Complaint : Lower Abdominal Pain.
History of Present Illness :
The patient came to UKI hospital with complaints of vaginal bleeding since about 6
days before entering the hospital. The patient said that the blood was blackish red and she had
a prolonged menstruation, 6 days. Within a day, the patient changes the bandage around 3-4
times. The first day of the last menstruation was December,11th 2012. Sometimes, she
complained of pain when menstruation. In addition, the patient complained of pain in the
lower abdomen, such as knead. Besides, the patient said that she had a constipation but has
no complained about bladder.
Previous Disease History:
The patient once had a complaint of vaginal bleeding in March 2010. The blackish red blood
came out. Within a day, the patient can change the bandage about 4 times. Patients also
complained of lower abdominal pain. The patientwastreatedto Kartika Pulomas hospitalwith
adiagnosis ofuterine myoma. The Patientalsounderwentsurgery inApril 2010. None of her
family has the same complaint.
Menstrual History :
The first period of menstruation : 16 years old.
Menstrual Cycle :
Cycle : Regular( 30days).
Duration : 6 days
Quantity : 4x changes the bandage/ ± 200 cc.
Pain during menstruation : + take the medicine : -
Menstruation last 3 months
Table 2 : Menstruation last 3 months
Date Month Year Lenght Amount
11 12 2012 6 days ± 200 cc
11 11 2012 6 days ± 200 cc
11 10 2012 6 days ± 200 cc
11. History of Marriage
Marriage : one time
Last marriage old : 16 years.
History of Pregnancy and Childbirth Ago
Previous Pregnancies : P 3 A 1
The number of children alive : 2 children
General examination
Vital Signs
General State : Looks Moderate Illness
Awareness : Composmentis
Blood Pressure : 160/ 70 mmHg
Pulse : 80x / menit
Temperature : 36,5 C
Respiration Rate : 20 x / minute
Body Weight : 70 kg
Eyes : Conjunctiva was not pale, no jaundice sclera, tear +
Ears : Normotia, spacious ear canal, serumen -/-
Nose : Spacious nose canal, sekret -/-, septum deviasi (-),
Mouth : Lips mucosa moist
Tonsil : T1 – T1, Calm
Faring : Not hiperemis
Neck : Trachea in the middle, no palpable lymph glands enlarge
Toraks
inspection : Movement of the chest wall left and right symmetric
Intercostal retraction (-)
Palpation : Vocal fremitus left and right
12. Percussion : Percussion comparison of left and right symmetric resonant
Auscultation : Basic breath sounds vesicular
Ronkhi -/-, Wheezing -/-
Heart sounds I and II normal, murmurs (-), gallop (-)
Abdomen
Inspection : Abdomen looks flat
Auscultation : Bowel sounds (+) normal: 4x/minute
Palpation : Supple stomach, liver and spleen not palpable enlarged. Turgor enough
Percussion : Tympani
Extremities : Warm Acral + / +, capillary refill <2 seconds, good movement in all
directions, muscle tone normotonus.
Ginecology Examination
Face : looks symetric
Breast : Retraction (-), tenderness (-).
External Genitalia
Distribution of pubic hair : prevalent
Fluksus : (+) not active
Fluor : (+)
Vulva : Bump (-)
Pain (-)
Internal Examination
V-U-V :Calm, mass (-), portio springy, bouncy pain (-).
The uterus of an adult fist, tenderness (-).
Adnexal mass - / -, tenderness - / -, not prominent cavum of Douglas.
Diagnosis: Uterine myoma + Menorrhagia.
Working Diagnosis: Uterine myoma +Myomectomy history 1x + DM type II + Hypertension.
Prognose : Ad vitam : Ad bonam
13. Ad Functionum : Dubia ad malam
Ad Sanationam : Dubia ad malam
Therapy : 1. hospitalization
2. Observation of general condition, vital signs, abdominal pain, and bleeding.
3. Complete blood lab tests, SGOT, SGPT, MP3, urea, creatinine,
Electrolytes, Present blood sugar, HBsAg, complete urine, plano test, chest X-ray, ECG.
4. Pro USG
5. Diet: Regular
6. IVFD: RL
7. mm/ : Ciprofloxacin 2 x 500 mg.
Kalnex 3 x 1 ampul.
Mefenamic Acid 3 x 500 mg.
8. Total hysterectomy with General Anesthesi planning : January, 2nd 2013.
Uterusof the fist with adhesions. The left tuba, left ovary, and portio was
left.
Table 3: Daily Follow Up
Date SOAP
December, 18th 2012 S: Lower abdominal pain
Blood of the pubic
O: GC: Look Moderate Illness (LMI)
Awareness : composmentis
Blood Pressure : 100/ 60 mmHg
Pulse : 80x/ minute
Temperature : 37, 1 oC
RR : 16 x/ minute
Eyes : Anemis -/-, Jaundice -/-.
Extremity : Warm, CRT < 2”.
Abdomen: Abdomen looks flat, flexible,
palpable mass of an adult fist, Tender (-),
timpani, word of pain (-).
Noisy intestine (+)
Genital: fluorine (-), fluksus (+) is not active.
Hb : 13,6 g/ dL
14. Leukocyt : 22 thousand/uL
Hematocryt: 40,5 %
Trombocyt : 284 thousand/uL
Bleeding time :1.3 minutes
Clotting time : 12 minutes
Protrombin time : 12 seconds
GOD - POD : 145 mg/dL
HbA1c : 7,8 %
USG: Uterus : 12 x 9 x 9.5 cm
Myoma : 7,01 x 5,9 cm
Impression: Uterine myoma
A: Uterine myoma + myomectomy history+
DM type II + Hypertension
P: Pro Gynecology USG
Diet : Reguler
IVFD : I RL
Mm/ : Ciprofloxacin 2 x 50 mg.
Tranexamat Acid 3 x 1 ampul
Mefenamic Acid 3 x 500 mg
Norelut 3 x 1
Captopril 2 x 2,5 mg (stop)
19 December 2012 S: Blood of genitals reduced
O: GC : Looks Mild illness
Awareness: CM
Eyes : anemis -/-, Jaundice -/-
Extremities : warm, CRT <2”
Mammae : tenderness -, retraction -, mass-
Abdomen: Abdomen looks flat, supple,
muscular defense (-), timpani, tenderness (+),
palpable mass (+) flat surface, smooth,
mobile, assertive, bowel (+) 3x / min.
Genitals: Fluor (-), fluksus (+) slightly.
Natrium : 154 mmol/L
Kalium : 3,5 mmol/L
Chloride: 112 mmol/L
Total protein 7,19 g/dL
Albumin : 3, 06 g/dL
Globulin : 3, 33g/dL
SGPT : 25 U/L
SGOT : 31 U/L
Total Cholesterol : 343 mg/ dL
Trigleseride : 123 mg/dL
HDL Cholesterol 52 mg/dL
LDL Cholesterol 174 mg/dL
A: Uterine myoma + post miomektomy +
DM + Hypertension
P: Diet : DM
IVFD : RL ( 20 drop/minute)
Mm/ : Ciprofloxacin 2 x 500 mg (III)
Tranexamat Acid 3 x 500 mg
15. Mefenamic Acid 3 x 500 mg
Norelut 3 x 10 mg
Examination : Elektrolit, Hb, HbA1C.
December,20th 2012 S: difficult defecation
O: GC: Looks Mild Illness
Awareness: CM
Blood Pressure: 140/90 mmHg
Pulse : 84x/ minute
Temperature : 36, 5 oC
RR : 22x /minute
Eyes : anemis -/-, Jaundice -/-
Ekstremities : Warm, CRT <2”
Edema -/-/+/+.
Mammae : tenderness -, retraction -, mass-
Abdomen: Abdomen looks flat, supple,
muscular defense (-), tenderness (-), palpable
mass (+), bowel sounds (+) 3x / min.
Genitals: fluorine (-), fluksus (-).
GOD – POD :124 g/dL
A: Uterine myoma + post miomektomy +
DM + Hypertension.
P: Diet : DM + papaya extra.
IVFD: RL ( 20 drop/minute) + KCl 50 meq
Mm/: Ciprofloxacin 2 x 500 mg
Tranexamat Acid 3 x 500 mg
Mefenamic Acid 3 x 500 mg
Norelut 3 x 10 mg
Metformin 2 x 500mg
Discussion
In the studies at 2011, the uterine myoma happened between 36 and 49 years old
women, while the patient is 42 years old.(7).The patient complaints of vaginal bleeding since
about 6 days.This complaintsdue to the symptoms based on the theory thatabnormal uterine
bleeding is the most common and most important clinical manifestation of leiomyomas,
being present in up 30% of patients.(1)The bleeding related to dilatation of venules.Bulky
tumors are thought to exert pressure and impinge on the uterine venous system, which causes
venular dilatation within the myometrium and endometrium. Accordingly, intramural and
subserous tumors have been shown to have the same propenstiy to cause menorrhagia as
mucous ones.(3)The patients also had a prolonged menstruation,it was reported that 37,3% of
women with diagnosed uterine myoma had a significantly longer duration of menstruation
period (5.6 ± 3.1 days, n = 1,245). (11)
The patient complained of pain in the lower abdomen. It’s suitable with the symptom
that Leiomyomas may cause pain when vascular compromise occurs. Thus, pain may result
16. from degeneration associated with vascular occlusion, infection, torsion of a pedunculated
tumor, or myometrial contraction to expel a subserous myoma from the uterine cavity. The
pain associated with infarction from torsion or red degeneration can be excruciating and
produce a clinical picture consistent with acute abdomen.(2). The incidence of chronic pelvic
pain was 14.5% whilepain during menstrual bleeding or period was 59,7%.(11)
The patient also complained of constipation because pressure effects may cause
intestinal obstruction if they are large or involved omentum or bowel.(1)Pressure symptom
happened in 28,8% women with uterine myoma. (12)
The abnormal bleeding commonly produces iron deficiency anemia, which may not
be uncontrollable even with iron therapy if the bleeding is heavy and protracted. This
symptom didn’t happened in this patient. (1).
A sufficiently enlarged uterus can cause pressure sensation, urinary frequency,
incontinance, and constipation. Rarely, leiomyomas extend laterally to compress the ureter
and lead to obstruction and hydronephrosis. (3)Pressure on the bladder or inside the abdomen
happened in 32,6% women with uterine myoma (11)
butthe patient didn’t complained it.
Although the mechanism are not clear, leiomyomas can be associated with infertility. It is
estimatedthat2 to 3 %of infertilitycasesdue sorely to leiomyomas. Their putative effects include
occlusion of tubal ostia and disruption of the normal uterine contractions that proper sperm or
ovum. Distortion of the endometrial cavity may diminish implantation and sperm transport.
Importantly,leiomyomas are associated with endometrial inflammation and vascular changes that
may disrupt implantation.(3)
The study at Pirngadi Hospital reported that based on the parity, the
highestproportionwasmultiparaparitywomen45,2%. (12)
Thissymptompossiblydidn’thappenedin
this P3A1 woman because she got the myoma after she had 2 children.
The patient is Asian which is Asian was at the third races that possible to get uterine
myoma.(3)Family and twin studies have shown the risk of leiomyoma formation to be
approximately two times greater in women with affected first- degree relatives, but the
patient didn’t have the familial history of uterine myoma.(3)
Most myomas are discovered by routine bimanual examination of the uterus or
sometimes by palpation of the lower abdomen. In this case, the mass was palpable in this
patient lower abdomen. (1)
The Pelvic ultrasound examination are useful in confirming the diagnosis of
leiomyomas. While ultrasound should never be a substitute for a thorough pelvic
examination, it can be extremely helpful in identifying leiomyomas, detailing the cause of
other pelvic masses, and in the identification of pregnancy, the USG result for this patient
was myoma uterine 7,01 x 5,9 cm.(1)
In the diagnose of myomas, MRI demonstrated sensitivity of 94,1 %, specificity of
68,7%,PPV pf 95,7%, and NPV of 61,1%. The Area Under the Curve (AUC) for the
diagnostic perfomance of MRI in the detection of mymoas was 0,81, respectively. MRI
17. exhibits a high AUC for the diagnosis of myomas. In this case, we didn’t use it for the
patient. (6)
In this case, the total hysterectomy was planned for this patient at January, 2nd 2013.
This is based on the theory that removal of the uterus is the definitive and most common
surgical treatmet for leiomyomas. Hysterectomy for leiomyoma can be performed vaginally,
abdominally, or laparoscopically. Uterine with small myomas may be removed by total
vaginal histerectomy, particularly if vaginal relaxation demands repair of cystocele, rectocele,
or enterocele. When numerous large tumors especially intraligamentary myomas are found,
total abdominal histerectomy is indicated. (1)
Myomectomy should be planned for the symptomatic patient who wishes to preserve
fertility or conserve the uterus or for those who decline histerectomy, but one can never be
certain before operation that myomectomy can accomplished easily. In this case, the patient
preffered total hysterectomy than myomectomy. (1)
Postoperative intra abdominal adhesions leiomyoma recurrence are more common
after myomectomy compared with hysterectomy. Recurrence rates following myomectomy
range from 40 to 50%. New leiomyoma development, however,diminished in women who
become pregnant following myomectomy, perhaps because of protective effect of increasing
parity.(3)While in the other study, reported a rate of 2-3% per year of symptomatic myomas
after myomectomy.(1)In this case, the patient have a uterine myoma with myomectomy
history in 2010.
Conclution
The conclution of these case report is Uterine Myoma are benign neoplasms
composed primarily of uterine smooth muscle cells, that typically originate from the
myometrium.It also known as myomas or fibroids. (1-10).
Incidenceof uterine myoma in Indonesia 2,39-11,% from all hospitalized benign
gynecology.(12)
, happened between 36 and 49 years old women(7)
, 20% of all women of
reproductive age.(2)
The cumulative incidence byage 50 yearswas nearly70% inCaucasiansand over
80% inAfrican- Americanwomen.(9)
The incidence in multipara parity women 45,2%. (12)
The highest
proportion was 5-10 cm (67,5%). (12)
The most happened location was Intramural myoma
41,9%(12)).
Abnormal uterine bleeding is the most common and most important clinical
manifestation of leiomyomas, being present in up 30% of patients.(1) The incidence of heavy
menstrual bleeding 59,8%, , Prolonged menstruation 37,3% (11)
While the incidenceof chronic
pelvic pain was 14.5%, pain during menstrual period 59,7%..(11)
The incidence of pressure
symptom cause the intestinal obstructin was 28,8%. (11)
It is estimated that 2 to 3 % of
infertility cases due sorely to leiomyomas.(3)
18. Pelvic ultrasound examination are useful in confirming the diagnosis of
leiomyomas.(1)MRI demonstrated sensitivity of 94,1 %, specificity of 68,7%. (6)The
gonadotropin releasing hormone (GnRH) agonist have proven very useful for limiting growth
or to cause a temporary decrease in tumor size. (1)Progesterone receptors, such as
mifepristone with 5 or 10 mg daily during 6 months had a similar efficacy in reducing the
uterine myoma volume, 48,1% and 39,1%.(7).
Leiomyosarcoma are reported to developed with a frequency of 0,1- 0,5% that of
diagnosed leiomyomas. (1,2)Recurrence rates following myomectomy range from 40 to 50%.
(3)Ureteral injury or ligation is a well- recognized complication of surgery for leiomyomas,
particularly cervical.(1)
.
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