defnition, types.and managrent

1. LEIOMYOMALEIOMYOMA
What is a leiomyoma?What is a leiomyoma?
It is a benign neoplasm of the muscular wall of the uterusIt is a benign neoplasm of the muscular wall of the uterus
composed primarily of smooth muscle and fibrouscomposed primarily of smooth muscle and fibrous
connective tissues.connective tissues.
What is the incidence of leiomyomas?What is the incidence of leiomyomas?
They are the most common pelvic tumorsThey are the most common pelvic tumors
It is found in 25% of white women & 50% of black womenIt is found in 25% of white women & 50% of black women

2. UTERINE FIBROIDUTERINE FIBROID
BEINGN SOLID TUMOURSBEINGN SOLID TUMOURS

3. ETIOLOGYETIOLOGY
UnknownUnknown
Each individual myoma is unicellular in originEach individual myoma is unicellular in origin
EstogensEstogens no evidence that it is a causative factor , itno evidence that it is a causative factor , it
has been implicated in growth of myomashas been implicated in growth of myomas
Myomas contain estrogen receptors in higherMyomas contain estrogen receptors in higher
concentration than surrounding myometriumconcentration than surrounding myometrium
Myomas may increase in size with estrogen therapy & inMyomas may increase in size with estrogen therapy & in
pregnancy & decrease after menopausepregnancy & decrease after menopause
They are not detectable before pubertyThey are not detectable before puberty
Progestrone increase mitotic activity & reduce apoptosisProgestrone increase mitotic activity & reduce apoptosis
 in sizein size
There may be genetic predispositionThere may be genetic predisposition

4. PATHOLOGYPATHOLOGY
Frequently multipleFrequently multiple
May reach 15 cm in size or largerMay reach 15 cm in size or larger
FirmFirm
Spherical or irregularly lobulatedSpherical or irregularly lobulated
Have a false capsuleHave a false capsule
Can be easily enucleated from surrounding myometriumCan be easily enucleated from surrounding myometrium

5. CLASSIFICATIONCLASSIFICATION
Submucous leiomyomaSubmucous leiomyoma
Pedunculated submucousPedunculated submucous
Intramural or interstitialIntramural or interstitial
Subserous orSubserous or
subperitonealsubperitoneal
Pedunculated abdominalPedunculated abdominal
ParasiticParasitic
IntraligmentaryIntraligmentary
CervicalCervical

7. MICROSCOPIC STRUCTUREMICROSCOPIC STRUCTURE
Whorled appearanceWhorled appearance nonstriated muscle fibersnonstriated muscle fibers
arranged in bundles running in different directionsarranged in bundles running in different directions
Individual cells are spindle shaped uniformIndividual cells are spindle shaped uniform
Varying amount of connective tissue are interlacedVarying amount of connective tissue are interlaced
between muscle fibersbetween muscle fibers
Pseudocapsule of areolar tissue & compressedPseudocapsule of areolar tissue & compressed
myometriummyometrium
Arteries are less dense than myometrium & do not haveArteries are less dense than myometrium & do not have
a regular pattern of distributiona regular pattern of distribution
1-2 major vesseles are found at the base or pedicle1-2 major vesseles are found at the base or pedicle

8. SECONDARY CHANGESSECONDARY CHANGES

9. 11--BENIGN DEGENERATIONBENIGN DEGENERATION
AtrophicAtrophic
HyalineHyaline  yellow, soft gelatinous areasyellow, soft gelatinous areas
CysticCystic liquefaction follows extreme hyalinizationliquefaction follows extreme hyalinization
CalcificCalcific circulatory deprivationcirculatory deprivation precipitation of caprecipitation of ca
carbonate & phosphatecarbonate & phosphate
SepticSeptic circulatory deprivationcirculatory deprivation necrosisnecrosis  infectioninfection
Myxomatous (fatty)Myxomatous (fatty) uncommon, follows hyaline oruncommon, follows hyaline or
cystic degenrationcystic degenration

10. 11--BENIGN DEGENRATION (cont’dBENIGN DEGENRATION (cont’d))
Red (carneous) degenerationRed (carneous) degeneration
Commonly occurs during pregnancyCommonly occurs during pregnancy
Edema & hypertrophyEdema & hypertrophy impede blood supplyimpede blood supply asepticaseptic
degenration & infarction with venous thrombosis &degenration & infarction with venous thrombosis &
hemorrhagehemorrhage
Painful but self-limitingPainful but self-limiting
May result in preterm labor & rarely DICMay result in preterm labor & rarely DIC
2-MALIGNANT TRANSFORMATION2-MALIGNANT TRANSFORMATION
Transformation to leiomyosarcomas occurs in 0.1-0.5%Transformation to leiomyosarcomas occurs in 0.1-0.5%

11. CLINICAL FINDINGSCLINICAL FINDINGS

12. 11--SYMPTOMSSYMPTOMS
Symptomatic in only 35-50% of PtSymptomatic in only 35-50% of Pt
Symptoms depend on location, size, changes &Symptoms depend on location, size, changes &
pregnancy statuspregnancy status
1-Abnormal uterine bleeding1-Abnormal uterine bleeding
The most common 30%The most common 30%
Heavy / prolonged bleeding (menorrhagia)Heavy / prolonged bleeding (menorrhagia)  ironiron
deficiency anemiadeficiency anemia

13. 11--Abnormal uterine bleeding (cont’dAbnormal uterine bleeding (cont’d((
Submucous myoma produce the most pronouncedSubmucous myoma produce the most pronounced
symptoms of menorrhagia, pre & post-menstrual spottingsymptoms of menorrhagia, pre & post-menstrual spotting
Bleeding is due to interruption of blood supply to theBleeding is due to interruption of blood supply to the
endometrium, distortion & congestion of surroundingendometrium, distortion & congestion of surrounding
vessels or ulceration of the overlying endometriumvessels or ulceration of the overlying endometrium
Pedunculated submucousPedunculated submucous  areas of venouseareas of venouse
thrombosis & necrosis on the surfacethrombosis & necrosis on the surface intermenstrtualintermenstrtual
bleedingbleeding

14. 22--PAINPAIN
Vascular occlusionVascular occlusion  necrosis, infectionnecrosis, infection
Torsion of a pedunculated fibroidTorsion of a pedunculated fibroid acute painacute pain
Myometrial contractions to expel the myomaMyometrial contractions to expel the myoma
Red degenrationRed degenration acute painacute pain
Heaviness fullness in the pelvic areaHeaviness fullness in the pelvic area
Feeling a massFeeling a mass
If the tumor gets impacted in the pelvisIf the tumor gets impacted in the pelvis pressure onpressure on
nervesnerves back pain radiating to the lower extremitiesback pain radiating to the lower extremities
Dysparunea if it is protruding to vaginaDysparunea if it is protruding to vagina

15. 33--PRESSURE EFFECTSPRESSURE EFFECTS
If large may distort or obstruct other organs like ureters,If large may distort or obstruct other organs like ureters,
bladder or rectumbladder or rectum urinary symptoms, hydroureter,urinary symptoms, hydroureter,
constipation, pelvic venous congestion & LL edemaconstipation, pelvic venous congestion & LL edema
Rarely a posterior fundal tumorRarely a posterior fundal tumor extreme retroflexion ofextreme retroflexion of
the uterus distorting the bladder basethe uterus distorting the bladder base urinary retentionurinary retention
Parasitic tumor may cause bowel obstructionParasitic tumor may cause bowel obstruction
Cervical tumorsCervical tumors serosanguineous vaginal discharge,serosanguineous vaginal discharge,
bleeding, dyspareunia or infertilitybleeding, dyspareunia or infertility

16. 44--INFERTILITYINFERTILITY
The relationship is uncertainThe relationship is uncertain
27-40% of women with multiple fibroids are infertile27-40% of women with multiple fibroids are infertile 
but other causes of infertility are presentbut other causes of infertility are present
Endocavitary tumors affect fertility moreEndocavitary tumors affect fertility more
5- SPONTANEOUS ABORTIONS5- SPONTANEOUS ABORTIONS
~2X N~2X N  incidence before myomectomy 40%incidence before myomectomy 40%
after myomectomy 20%after myomectomy 20%
More with intracavitary tumorsMore with intracavitary tumors

17. EXAMINTIONEXAMINTION
Most myoma are discovered on routine bimanual pelvicMost myoma are discovered on routine bimanual pelvic
exam or abdominal examinationexam or abdominal examination
Retroflexed retroverted uterusRetroflexed retroverted uterus  obscure the palpationobscure the palpation
of myomasof myomas
LABORATORY FINDINGSLABORATORY FINDINGS
AnemiaAnemia
Depletion of iron reserveDepletion of iron reserve
Rarely erythrocytosisRarely erythrocytosis pressure on the ureterspressure on the ureters backback
pressure on the kidneyspressure on the kidneys  erythropoietinerythropoietin
Acute degeneration & infectionAcute degeneration & infection  ESR, leucocytosis,ESR, leucocytosis,
& fever& fever

18. IMAGINGIMAGING
Pelvic U/S is very helpful in confirming the Dx &Pelvic U/S is very helpful in confirming the Dx &
excluding pregnancy /excluding pregnancy / Particularly in obese PtParticularly in obese Pt
Saline hysterosonographySaline hysterosonography can identify submucouscan identify submucous
myoma that may be missed on U/Smyoma that may be missed on U/S
HSGHSG  will show intrauterine leiomyomawill show intrauterine leiomyoma
MRIMRI  highly accurate in delineating the size, location &highly accurate in delineating the size, location &
no. of myomas , but not always necessaryno. of myomas , but not always necessary
IVPIVP  will show ureteral dilatation or deviation & urinarywill show ureteral dilatation or deviation & urinary
anomaliesanomalies
HYSTROSCOPYHYSTROSCOPY  for identification & removal offor identification & removal of
submucous myomassubmucous myomas

19. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Usually easily diagnosedUsually easily diagnosed
Exclude pregnancyExclude pregnancy
Exclude other pelvic massesExclude other pelvic masses
-Ovarian Ca-Ovarian Ca
-Tubo-ovarian abscess-Tubo-ovarian abscess
-Endometriosis-Endometriosis
-Adenexa, omentum or bowel adherent to the uterus-Adenexa, omentum or bowel adherent to the uterus
Exclude other causes of uterine enlargement:Exclude other causes of uterine enlargement:
-Adenomyosis-Adenomyosis
-Myometrial hypertrophy-Myometrial hypertrophy
-Congenital anomalies-Congenital anomalies
-Endometrial Ca-Endometrial Ca

20. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Exclude other causes of abnormal bleedingExclude other causes of abnormal bleeding
Endometrial hyperplasiaEndometrial hyperplasia
Endometrial or tubal CaEndometrial or tubal Ca
Uterine sarcomaUterine sarcoma
Ovarian CaOvarian Ca
PolypsPolyps
AdenomyosisAdenomyosis
DUBDUB
EndometriosisEndometriosis
Exogenouse estrogensExogenouse estrogens
Endometrial biopsy or D&C is essential in the evaluation ofEndometrial biopsy or D&C is essential in the evaluation of
abnormal bleeding to exclude endometrial Caabnormal bleeding to exclude endometrial Ca

21. COMPLICATIONSCOMPLICATIONS

22. 11--COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY
≥≥ 2/3 of women with fibroids & unexplained2/3 of women with fibroids & unexplained
infertility conceive after myomectomyinfertility conceive after myomectomy
Red degenerationRed degeneration
In the 2In the 2ndnd
or 3or 3rdrd
trimester of pregnancytrimester of pregnancy rapidrapid 
in sizein size  vascular deprivationvascular deprivation  degenerationdegeneration
Causes pain & tendernessCauses pain & tenderness
May initiate preterm laborMay initiate preterm labor
Managed conservatively with bedrest & narcoticsManaged conservatively with bedrest & narcotics
+ tocolytics if indicated+ tocolytics if indicated
After the acute phase pregnancy will continue toAfter the acute phase pregnancy will continue to
termterm

23. COMPLICATIONS IN PREGNANCYCOMPLICATIONS IN PREGNANCY
DURING LABORDURING LABOR
Uterine inertiaUterine inertia
MalpresentationMalpresentation
Obstruction of the birth canalObstruction of the birth canal
Cervical or isthmeic myomaCervical or isthmeic myoma  necessitate CSnecessitate CS
PPHPPH

24. COMPLICATIONS IN NONPREGNANT WOMENCOMPLICATIONS IN NONPREGNANT WOMEN
Heavy bleeding with anemia is the most commonHeavy bleeding with anemia is the most common
Urinary or bowel obstruction from large parasitic myomaUrinary or bowel obstruction from large parasitic myoma
is much less commonis much less common
Malignant transformation is rareMalignant transformation is rare
Ureteral injury or ligation is a recognized complication ofUreteral injury or ligation is a recognized complication of
surgery for Cx myomasurgery for Cx myoma
No evidence that COCPNo evidence that COCP  the size of myomasthe size of myomas
Postmenopausal women on HRT must be followed upPostmenopausal women on HRT must be followed up
with pelvic exam or U/S every 6 Mwith pelvic exam or U/S every 6 M

25. TREATMENTTREATMENT

26. TREATMENTTREATMENT
DEPENDS ON:DEPENDS ON:
AgeAge
ParityParity
Pregnancy statusPregnancy status
Desire for future pregnancyDesire for future pregnancy
General healthGeneral health
SymptomsSymptoms
SizeSize
LocationLocation

27. A-EMERGENCY MEASURESA-EMERGENCY MEASURES
Blood transfusion/ PRBC to correct anemiaBlood transfusion/ PRBC to correct anemia
Emergrncy surgery indicatd for:Emergrncy surgery indicatd for:
- infected myoma- infected myoma
-acute torsion-acute torsion
-intestinal obstruction-intestinal obstruction
Myomectomy is contraindicated during pregnancyMyomectomy is contraindicated during pregnancy

28. B-SPECIFIC MEASURESB-SPECIFIC MEASURES
Most cases asymptomaticMost cases asymptomatic  no treatmentno treatment
PostmenopausalPostmenopausal  no treatmentno treatment
Other causes of pelvic mass must be excludedOther causes of pelvic mass must be excluded
The Dx must be certainThe Dx must be certain
Initial follow up every 6 MInitial follow up every 6 M  to determine the rate ofto determine the rate of
growth of the myomagrowth of the myoma
Surgery is contraindicated in pregnancySurgery is contraindicated in pregnancy
The only indication for myomectomy in pregnancy isThe only indication for myomectomy in pregnancy is
torsion of a pedunculated fibroidtorsion of a pedunculated fibroid
Myomectomy is not recommended during CSMyomectomy is not recommended during CS
Pregnant women with previous multiple myomectomy /Pregnant women with previous multiple myomectomy /
especially if the cavity was enteredespecially if the cavity was entered  should beshould be
delivered by CS todelivered by CS to  risk of scar rupture in laborrisk of scar rupture in labor

29. GNRH AGONISTSGNRH AGONISTS
RX results in:RX results in:
1-1- size of the myomas 50% maximumsize of the myomas 50% maximum
2- This shrinkage is achieved in 3M of RX2- This shrinkage is achieved in 3M of RX
3-Amenorrhea & hypoestrogenic side-effects occur3-Amenorrhea & hypoestrogenic side-effects occur
4-Osteopososis may occur if Rx last > 6M4-Osteopososis may occur if Rx last > 6M
It is indicated forIt is indicated for
1-1- bleeding from myoma except for the polypoidbleeding from myoma except for the polypoid
submucous typesubmucous type
2-Preoperative to2-Preoperative to  sizesize  allow for vaginal hysterectomyallow for vaginal hysterectomy
myomectomymyomectomy
laparoscopic myomectomylaparoscopic myomectomy

30. C-SUPPORTIVE MEASURESC-SUPPORTIVE MEASURES
PAP smear & endometrial sampling for all Pt withPAP smear & endometrial sampling for all Pt with
irregular bleedingirregular bleeding
Before surgeryBefore surgery
-Correct Hb-Correct Hb
-Prophylactic antibiotics-Prophylactic antibiotics
-Mechanical & antibiotic bowel preparation-Mechanical & antibiotic bowel preparation  if difficultif difficult
surgery is anticipatedsurgery is anticipated
Prophylactic heparin postoperativeProphylactic heparin postoperative

31. D-SURGICAL MEASURESD-SURGICAL MEASURES
1-Evaluation for other neoplasia1-Evaluation for other neoplasia
2-Myomectomy2-Myomectomy
For symptomatic Pt who wish to preserve fertilityFor symptomatic Pt who wish to preserve fertility
Open myomectomyOpen myomectomy
Laparoscopic myomectomyLaparoscopic myomectomy
Hysteroscopic myomectomyHysteroscopic myomectomy
3-Hysterectomy3-Hysterectomy
Vaginal hysterectomyVaginal hysterectomy
Abdominal hysterectomyAbdominal hysterectomy
4-Uterine artery embolisation4-Uterine artery embolisation