leiomyomata uteri

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  • 1. Dr. N Sravanthi Dr. Bharti Dr. L.K. Dhaliwal 21-03-2012

2. A LEIOMYOMA is a benign monoclonal tumour composed of smoothmuscle cells but containing various amounts of fibrous connectivetissue. Its well circumscribed but not encapsulated. Various terms to refer these tumors : fibromyoma, myofibroma, leiomyofibroma, fibroleiomyoma, Myoma Fibroma Fibroid 3. 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 4. 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 , bFGF, EGF, PDGF, IGF, PRL 5. 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- 2.5times increases risk) Oral contraceptives(no definite relationship) Menopausal HRT: Therapy will not stimulate growth Parity( nulliparous > multiparous ) Smoking (reduced) Tissue injury 6. Benign tumors that originate from smooth muscle cells of theuterus 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) 7. Disseminated peritoneal leiomyomatosis, Benign metastasizing leiomyoma, Intravenous leiomyomatosis, Parasitic leiomyoma, and Retroperitoneal leiomyomatosis 8. CLINICAL FEATURES 9. In one-third of patient Usually menorrhagia, but also can present as metrorhhagia or asmenometrorrhagia. Associated with any type of fibroids, but there is a distinct clinicalpattern with each type. Bleeding is more common and severe in in submucous fibroids. 10. The submucous leiomyoma bleeds freely at menstruation and mayalso bleeds between periods If the submucous myoma is pedunculated, there is usually aconstant, thin, blood-tinged discharge in addition to the menorrhagia. Intramural myoma beginning to encroach the uterine cavity can alsopresent as menorrhagia. Intramural fibroid near serosa, pedunculated serous tumours can alsopresent with abnormal bleeding. 11. a) Increased surface areab) Local hyperestrogenism in areas adjacent to the submucous tumor, endometrial hyperplasia and endometrial polyps.c) Thinning and ulceration of the endometrial surfaced) Interference with myometrial and spiral arteriolar(basalis portion) contractilitye) Congestion and Endometrial venule ectasia 12. Urgency Frequency Urinary incontinence Acute retention Overflow incontinence Constipation/ Tenesmus 13. Abdominal and pelvic discomfort, Feeling of heaviness inpelvis, Dyspareunia Spasmodic dysmenorrhoea Torsion in pedunculated myoma Red degeneration Diffuse adenomyosis Concomitant pelvic disease: ovarianpathology, PID, endometriosis, urinary tract or intestinalpathology 14. In 5-10% of infertile women Only 2-3% of infertility mayattributed 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 GUIDELINESNo. 128,May 2003 15. 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 16. Common during pregnancy OCPs containing high dose of estrogens HOWEVER Rapid growth in post-menopausal women ishighly suggestive of malignancy Sarcomatous change in leiomyoma Sarcoma Carcinoma endometrium Estrogen secreting ovarian neoplasm 17. Incidence of leiomyosarcoma in hysterectomy specimensof 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 uterineleiomyomas. Am J Obstet Gynecol 1990;162:96876 18. Careful history regarding symptoms. Bimanual pelvic examination : (enlarged, irregularlyshaped, rm, and non-tender uterus ) 19. 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 20. Provides contrast Better denes submucous myomas, polyps, endometrialhyperplasia, or carcinoma Precisely defines the location, attachment of the submucousfibroids and also determines whether it is amenable tohysteroscopic resection Limitation of detection of leiomyomata is o.5 cm diameter. 21. 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 ofmore than 15mm (or 12 mm in a non-uniform junctionalzone). Focal, not well-demarcated, high-intensity or low-intensityareas in the myometrium also correlate with adenomyosis) Expensive modality 22. FIGO classication system (PALM-COEIN) for causes of abnormal uterinebleeding in nongravid women of reproductive age 23. International Journal of Gynecology and Obstetrics 113(2011) 313 24. Women who are mildly or moderately symptomatic withfibroids observation may allow the treatment to bedeferred, perhaps indefinitely. As women approach menopause, there is limited time for newsymptoms and after menopause the bleeding stops and thefibroids decrease in size. Except for women with Severe anemia from fibroid related menorrhagia Or hydronephrosis from ureteric obstruction from a massivelyenlarged fibroid uterus 25. Risk of malignancy is less than 0.1%. There is currently no evidence to substantiateperforming a hysterectomy for an asymptomaticleiomyoma for the sole purpose of alleviating theconcern that it may be malignant. SOGC CLINICAL PRACTICE GUIDELINESNo. 128,May 2003 26. GnRH AGONISTS : Treatment reduces the uterine volume, fibroidvolume(30%), and bleeding with resultant increase inhemoglobin. Menses return in 4-8weeks after discontinuation, and uterinesize returns to pre-treatment levels within 4-6 months SIDE EFFECTS : hot flushes, vaginal dryness, transientfrontalheadaches, 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 27. The hypo-estrogenic state induced by GnRH agonists causes significant boneloss after six months of therapy Low doses of estrogen and progestins may be added in an effort to reducethe side effects and inhibit bone loss and allow long term use. GnRH Agonists as temporary treatment for Peri-menopausal women maybe considered. 28. GnRH antagonists : (Ganirelix) immediate suppression of endogenousGnRH. Progesterone mediated treatment : Mifepristone (RU 486 ) RISK OF ENDOMETRIAL HYPERPLASIA Progesterone releasing IUD : LNG-IUS may reasonable for selectedwomen with fibroid associated menorrhagia(