LEIOMYOMATA UTERI Dr. N Sravanthi Dr. Bharti Dr. L.K. Dhaliwal 21-03-2012

DEFINITION A LEIOMYOMA is a benign monoclonal tumour composed of smooth

muscle cells but containing various amounts of fibrous connective

tissue. Its well circumscribed but not encapsulated.

Various terms to refer these tumors : fibromyoma,

myofibroma,

leiomyofibroma,

fibroleiomyoma,

Myoma

Fibroma

Fibroid

INCIDENCE

Most common benign tumours of uterus and female pelvis.

In 20 – 40 % women in reproductive age group.

About one third of hospital admissions to gynecology services.

Reported to occur in 77% of uteri obtained from TAH specimens

The hysterectomy specimens from

premenopausal women - 7.6 myomas;

postmenopausal women - 4.2 myomas

ETIOLOGY Precise cause is unknown

Genetic factors – 40% have chromosomal abnormalities

(t:12,14), (del 7) (trisomy 12)

Hormones

Estrogen and progesterone appear to promote development

Growth factors

TGF – β, bFGF, EGF, PDGF, IGF, PRL

RISK FACTORS Age (increases with age)

Ethnicity ( African women 2.9 times than White )

Endogenous hormonal factors

Weight ( 21% increased risk with every 10kg rise body weight)

Diet and Exercise and Obesity

Family history/genetic predisposition(first degree relative- 2.5 times

increases risk)

Oral contraceptives(no definite relationship)

Menopausal HRT: Therapy will not stimulate growth

Parity( nulliparous > multiparous )

Smoking (reduced)

Tissue injury

PATHOLOGY Benign tumors that originate from smooth muscle cells of the

uterus

Range in size from seedlings to large uterine tumors

solitary or multiple

Depending on the location

Within the myometrium (intramural)

Externally extending to the serosa (sub serous)

internally impinging on the uterine cavity (submucous)

TYPES

OTHER SPECIAL TYPES

Disseminated peritoneal leiomyomatosis,

Benign metastasizing leiomyoma,

Intravenous leiomyomatosis,

Parasitic leiomyoma, and

Retroperitoneal leiomyomatosis

CLINICAL FEATURES

ABNORMAL BLEEDING In one-third of patient

Usually menorrhagia, but also can present as metrorhhagia or as

menometrorrhagia.

Associated with any type of fibroids, but there is a distinct clinical

pattern with each type.

Bleeding is more common and severe in in submucous fibroids.

The submucous leiomyoma bleeds freely at menstruation and may

also bleeds between periods

If the submucous myoma is pedunculated, there is usually a constant,

thin, blood-tinged discharge in addition to the menorrhagia.

Intramural myoma beginning to encroach the uterine cavity can also

present as menorrhagia.

Intramural fibroid near serosa, pedunculated serous tumours can also

present with abnormal bleeding.

Rule out cervical and endometrial

malignancy in case of inter-menstrual

bleeding

VARIOUS MECHANISMS OF ABNORMAL BLEEDING

a) Increased surface area

b) Local hyperestrogenism in areas adjacent to the submucous

tumor, endometrial hyperplasia and endometrial polyps.

c) Thinning and ulceration of the endometrial surface

d) Interference with myometrial and spiral arteriolar(basalis

portion) contractility

e) Congestion and Endometrial venule ectasia

PRESSURE

Urgency

Frequency

Urinary incontinence

Acute retention

Overflow incontinence

Constipation/ Tenesmus

PAIN

Abdominal and pelvic discomfort, Feeling of heaviness in

pelvis, Dyspareunia

Spasmodic dysmenorrhoea

Torsion in pedunculated myoma

Red degeneration

Diffuse adenomyosis

Concomitant pelvic disease: ovarian pathology, PID,

endometriosis, urinary tract or intestinal pathology

INFERTILITY In 5-10% of infertile women

Only 2-3% of infertility may attributed to

them(provided other causes have been excluded)

“Removal of fibroids that distort the uterine cavity

may be indicated in infertile women, where no

other factors have been identified, and in women

about to undergo in vitro fertilization treatment.”

SOGC CLINICAL PRACTICE GUIDELINES

No. 128,May 2003

Mechanisms:

Interference with sperm transport, ovum capture

Displacement of cervix

Deformity of uterine cavity

Distorted adnexal anatomy

Obstruction of proximal fallopian tubes

Interference with implantation

Increased or disordered uterine contractility

Local inflammation

Impaired blood flow

RAPID GROWTH

Common during pregnancy

OCPs containing high dose of estrogens

HOWEVER – “Rapid growth in post-menopausal women is

highly suggestive of malignancy”

Sarcomatous change in leiomyoma

Sarcoma

Carcinoma endometrium

Estrogen secreting ovarian neoplasm

Incidence of leiomyosarcoma in hysterectomy specimens

of women receiving surgical treatment for fibroid

0.1% in reproductive age group

1.7% after age of 60 years

Leiomyosarcoma in a series of hysterectomies performed for presumed uterine

leiomyomas.

Am J Obstet Gynecol 1990;162:968–76

DIAGNOSIS Careful history regarding symptoms.

Bimanual pelvic examination : (enlarged, irregularly shaped,

firm, and non-tender uterus )

IMAGING STUDIES

Ultrasound (TAS and TVS)

best initial test based on its noninvasive nature and cost-

efficiency.

lowest sensitivity and specificity

concentric, solid, hypo echoic masses

anechoic components - from necrosis.

Calcifications are hyper-echoic, with sharp acoustic

shadowing

SALINE INFUSION SONOGRAPHY

Provides contrast

Better defines submucous myomas, polyps, endometrial

hyperplasia, or carcinoma

Precisely defines the location, attachment of the submucous

fibroids and also determines whether it is amenable to

hysteroscopic resection

Limitation of detection of leiomyomata is o.5 cm diameter.

MRI More sensitive(64%) and specific(88%) than US

Evaluation of number , size, and position of sub-mucosal,

intramural fibroids and sub serous fibroids.

Allows precise myoma mapping - Helpful in planning surgery

May differentiate adenomyosis from myomas.

(adenomyosis is associated with junctional zone thickness of

more than 15mm (or 12 mm in a non-uniform junctional

zone).

Focal, not well-demarcated, high-intensity or low-intensity

areas in the myometrium also correlate with adenomyosis)

Expensive modality

FIGO CLASSIFICATION SYSTEM

FIGO classification system (PALM-COEIN) for causes of

abnormal uterine bleeding in nongravid women of

reproductive age

International Journal of Gynecology and Obstetrics 113 (2011) 3–13

MANAGEMENT

WATCHFUL WAITING

Women who are mildly or moderately symptomatic with

fibroids – observation may allow the treatment to be deferred,

perhaps indefinitely.

“As women approach menopause, there is limited time for new

symptoms and after menopause the bleeding stops and the

fibroids decrease in size.” Except for women with

Severe anemia from fibroid related menorrhagia

Or hydronephrosis from ureteric obstruction from a massively

enlarged fibroid uterus

Risk of malignancy is less than 0.1%.

“There is currently no evidence to substantiate

performing a hysterectomy for an asymptomatic

leiomyoma for the sole purpose of alleviating the

concern that it may be malignant.”

SOGC CLINICAL PRACTICE GUIDELINES

No. 128,May 2003

MEDICAL THERAPY GnRH AGONISTS :

Treatment reduces the uterine volume, fibroid volume(30%),

and bleeding with resultant increase in hemoglobin.

Menses return in 4-8weeks after discontinuation, and uterine

size returns to pre-treatment levels within 4-6 months

SIDE EFFECTS : hot flushes, vaginal dryness, transient

frontal headaches, arthralgia, myalgia, insomnia, edema,

emotional lability, depression, and decreased libido.

SURGICAL DRAWBACK S:

potential difficulties with enucleation of the myoma and longer intra-

operative times,

an inability to distinguish and remove smaller myomas at risk to regrow

after treatment

“The hypo-estrogenic state induced by GnRH agonists causes significant bone

loss after six months of therapy”

Low doses of estrogen and progestins may be added in an effort to reduce

the side effects and inhibit bone loss and allow long term use.

GnRH Agonists as temporary treatment for Peri-menopausal women may

be considered.

GnRH antagonists : (Ganirelix) immediate suppression of endogenous

GnRH.

Progesterone mediated treatment :

Mifepristone (RU 486 )

RISK OF ENDOMETRIAL HYPERPLASIA

Progesterone releasing IUD : LNG-IUS may reasonable for selected

women with fibroid associated menorrhagia( <12 weeks, regular

cavity)

Decrease in mean estimated blood loss and increase in hemoglobin but no

decrease in uterine volume

Progesterone receptor modulators:

ASNOPRISNIL

SURGICAL TREATMENT OPTIONS

Serious medical conditions, such as severe anemia or ureteral

obstruction, often need to be addressed surgically.

Surgical intervention may also be indicated in women who have

myomas that are associated with menorrhagia, pelvic pain or

pressure, or urinary frequency or incontinence that compromises

quality of life.

Women with large symptomatic myomas who have completed

childbearing are most often recommended to have a hysterectomy.

INDICATIONS FOR SURGICAL MANAGEMENT

Abnormal uterine bleeding not responding to conservative

treatments

Infertility when there is distortion of the endometrial cavity or

tubal obstruction

Recurrent pregnancy loss (with distortion of the endometrial

cavity)

Pain or pressure symptoms (that interfere with quality of life)

Urinary tract symptoms (frequency and/or obstruction)

Anemia secondary to chronic blood loss

High level of suspicion of pelvic malignancy

Growth after menopause

ACOG, VOL. 104, NO. 2, AUGUST 2004

ABDOMINAL MYOMECTOMY

Myomectomy should be considered as alternative to hysterectomy .

May be considered in women with large fibroids and wish to retain

uterus and desire child bearing.

SURGICAL TECHNIQUE

Pre operative correction of anemia:

Iron supplementation

Blood transfusion

Erythropoietin alfa/ epoetin

GnRH Agonist Treatment:

mitigate the bleeding

Result in increase in hemoglobin.

MANAGING BLOOD LOSS :

Pre operative GnRH agonists treatment

Hypotensive anaesthesia

Vasopressin(20U in 20 ml NS) - as effective as vascular

occlusion for controlling blood loss

Tourniquets :

Bonney’s myomectomy clamp

Ring forceps

Elastic rubber catheter(around cervix)

Rumel’s Type tourniquet

GENERAL PRINCIPLES IN SURGERY Adequate exposure of the operative field.

Avoid traumatic instrumentation and injury to the serosa.

Sutures on serosal surface should be of fine absorbable non reactive

material.

Evaluate the size, number and location of myomas, and their

proximity to the endocervical canal, uterine vessels, and fallopian

tubes.

Careful planning of uterine incisions. Aim should be removal of all

myomas through a single incision made in anterior uterine corpus

and in the midline to avoid vascular areas and broad ligament laterally

VAGINAL MYOMECTOMY Traditionally used for submucous myomas.

When submucous myoma becomes pedunculated myoma can be

delivered gradually through the dilated cervix.

After satisfactory pre-op. preparation, and broad spectrum

antibiotics, vaginal myomectomy should be performed in the

operating room.

One should avoid too much of downward traction(may cause

uterine fundal inversion).

Pedicle is identified and clamped as high as possible within the

uterine cavity and ligature is applied.

In case of brisk bleeding tamponade with inflated Foley’s balloon

can be done.

HYSTEROSCOPIC RESECTION OF SUB-MUCOUS MYOMA

Mainly for submucous myomas.

Successful in treating the menstrual symptoms.

Menorrhagia is controlled in 90% patients.

Usually performed under laparoscopic guidance to prevent

inadvertent perforation.

In selected women who are not desirous of future fertility,

endometrial ablation may be efficacious in treating abnormal

bleeding.

LAPAROSCOPIC MYOMECTOMY

LESS POST OPERATIVE PAIN, SHORTER HOSPITAL STAY AND

SHORTER RECOVERY THAN ABDOMINAL MYOMECTOMY Limitations :

Difficult to remove in certain locations.

Large or multiple fibroids.

When myomas are embedded deep in the myometrium.

Retrieval of myomas could be a problem, morcellation may be required

Larger myoma can be removed vaginally through a posterior colpotomy

incision.

Conversion to laparotomy rate 7.5%

Complication rate 3.8%

Significant disadvantage is post- operative pelvic adhesions

Overall rate 35 -40%

Rate of adhesion per myomectomy site 15 – 20%

Rate of adhesion on adnexa 25%

Risk factors for adhesion:

Use of uterine sutures

Posterior uterine wall myomas

Prior existence of pelvic adhesions

ADHESION PREVENTION

A. INTERCEED : Oxidized regenerated cellulose can

be placed over uterine corpus to protect the tubes

and ovaries from the denuded peritoneal surfaces

and uterine incision.

B. GORE-TEX (Polytetrafluoroethylene surgical

membrane) :

Non absorbable barrier

Can be sutured over the uterine incisions

C. SEPRAFILM :

Bioresorbable membrane

Sodium hyaluronate and carboxymethyl cellulose

Reduce the incidence, severity, extent and areas of uterine

adhesions after myomectomy.

D. GnRH ANALOGUES

UTERINE ARTERY EMBOLIZATION Percutaneous cannulation of femoral artery

Embolization of uterine artery and its branches accomplished by

injecting gelatin sponges, Poly Vinyl alcohol particles, tris-acryl gelatin

microspheres via catheter until occlusion/ or slow flow.

Total radiation exposure (approx 5cGy).

Effects on early ovarian failure, fertility and pregnancy are unclear.

Appropriate candidates for UAE include women who have symptoms

severe enough to warrant hysterectomy or myomectomy.

CONTRAINDICATIONS :

Active pelvic infection

Severe contraction medium allergy

Arteriovenous malformations

Desire for future pregnancy

Pedunculated myoma

Undiagnosed pelvic mass.

COMPLICATIONS :

Post-procedural pain

Post embolisation syndrome

Early Ovarian Failure(controversial)

Effects on Fertility and Pregnancy (possibility of

decreased ovarian reserve and potential for increased

pregnancy complication, women who wish to conceive

should not be treated with UAE)

MR GUIDED FOCUSED ULTRASOUND (MR-G-HIFU)

Uses high-intensity ultrasound waves that are focused into a small area

of between 4 – 16mm, to produce heat and energy, which kills the

tumor cells.

Concurrent MRI allows

precise targeting of the tissue as well as to

monitor the temperature of treated tissues

Not recommended for women wishing future fertility

ADVANTAGES:

Very low morbidity

Rapid recovery with return to normal life

FIBROIDS IN PREGNANCY

Observed in 2.7% - 12.6% of pregnant women

EFFECTS OF PREGNANCY:

Most do not increase in size during pregnancy.

Pregnancy has a variable and unpredictable effect on myoma

growth, likely dependent on individual differences in genetics,

circulating growth factors, and myoma-localized receptors.

A reduction in myoma size was observed 4 weeks after delivery.

EFFECTS ON PREGNANCY:

Very rarely lead to an unfavorable pregnancy outcomes.

Cesarean section more common among women with fibroids.(23% Vs 12%)

However , there is increases risks of

preterm delivery(19.2% Vs 12.7%)

Placenta previa(3.5% Vs 1.8%)

Post partum hemorrhage(49.1% Vs 21.4%)

Malpresentation

“Uterine rupture during pregnancy or delivery as a consequence of

abdominal myomectomy appears to be rare.”

NEW APPEARANCE OF MYOMAS

Although new myomas may grow after

myomectomy, most women will not require

additional treatment.

Myomas detected after myomectomy, often

referred to as recurrence, either are the result

of persistence of myomas left at the time of

surgery or are newly developed myomas.

CLINICAL FOLLOW UP

Clinical exam alone may not be effective in

assessing the incidence of new appearance of

myomas, because women who return to the

gynecologist are more likely to have gynecologic

problems associated with new myomas than are

women who remain asymptomatic

SONOGRAPHIC FOLLOW-UP

Routine ultrasound follow-up is sensitive but

detects many clinically insignificant myomas.

Meaningful information for a woman with myomas

considering treatment is her approximate risk of

developing symptoms that would require yet

additional treatment.

PROGNOSTIC FACTORS RELATED TO NEW APPEARANCE OF MYOMAS

Age

Subsequent childbearing

Number of myomas initially removed

Gonadotropin-releasing hormone agonists

Laparoscopic myomectomy

ASYMPTOMATIC

Most leiomyomata are asymptomatic.