Uterine LeiomyomaUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

Objectives for Uterine Leiomyoma

Discuss the prevalence of uterine leiomyomas

Describe the symptoms and physical findings in patients with uterine leiomyomas

Describe the diagnostic methods to confirm uterine leiomyomas

List the management options for the treatment of uterine leiomyomas

Patient presentationPatient presentation

• A 42-year-old G3 P3 female presents with a history of abnormal bleeding and pelvic pain. She was well until approximately age 35, when she began developing dysmenorrhea and progressive menorrhagia. The dysmenorrhea was not fully relieved by NSAIDS. Over the next several years, the dysmenorrhea and menorrhagia became more severe. She then developed intermenstrual bleeding and spotting, as well as pelvic pain, which she describes as a constant feeling of pressure. She also complains of urinary frequency.

Patient presentationPatient presentation

• Past gynecological history is otherwise non-contributory. She delivered three children by caesarean section, the last with a tubal ligation at age 30. Her past medical history is unremarkable.

Physical ExamPhysical Exam

• Reveals a well-developed, well-nourished woman in no distress. Vital signs and general physical exam are unremarkable. Abdominal examination reveals an irregular-sized mass into extending halfway between the pubic symphysis and umbilicus and to the right of the midline. Pelvic exam reveals a normal appearing vagina and cervix. The uterus is markedly enlarged and irregular, especially on the right side where it appears to reach the lateral pelvic sidewalls. The examiner is unable to palpate normal ovaries due to the mass.

Patient PresentationPatient Presentation Diagnostic EvaluationDiagnostic Evaluation

• Laboratory

• Beta HCG is negative. CBC reveals hemoglobin of 10.3 and hematocrit of 31.2. Indices are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap smear is normal with no evidence of dysplasia. Endometrial biopsy reveals proliferative endometrium. ECC is negative for malignancy. Ultrasound shows a large irregular mass, filling the pelvis and extending into the lower abdomen. The mass does extend into the right side of the pelvis. The ovaries are not visualized.

Uterine leiomyomas (“fibroids”) are benign tumors derived from the smooth muscle cells of the myometrium

Definition

Approximately 45% of women have uterine leiomyomas by the 5th decade of life

Vast majority are asymptomatic Primary indication for 200,000 hysterectomies in the

U.S. each year Sarcomatous changes occur in < 0.1%

Prevalence

Increasing age during reproductive years Ethnicity (African American) Nulliparity Family history

Risk Factors

Factors that initiate leiomyomas unknown Estrogen and progesterone important to growth

Increased levels of estrogen and progesterone receptors present

Estrogen induces proliferation of smooth muscle cells Progesterone produces proteins which prohibit apoptosis

Increased levels of growth factors produce fibronectin and collagen

Pathogenesis of Leiomyomas

Spherical, well-circumscribed, white, firm lesions Always arise within the myometrium (intramural) Migrate to various anatomic locations

Submucosal – toward endometrium Intramural – within myometrium Subserosal – toward serosal surface

Pedunculated and/or parasitic

Poor internal blood and lymphatic supply Cystic degeneration Calcification

Characteristics of Leiomyomas

Anatomic Locations

Pedunculated subserosal

UterusPedunculatedsubmucosal

Subserosal

Submucosal

Vagina

Intramural

Clinical Manifestations

Bleeding symptoms• Menorrhagia –

heavy bleeding• Metrorrhagia –

bleeding between menses

• Dysmenorrhea – painful menses

Bulk symptoms

• Pelvic pressure• Urinary frequency• Infertility and/or

recurrent pregnancy loss

*Many women are asymptomatic; symptoms depend on size and location of fibroids

Clinical Manifestations

Abdominal exam Palpable mass if uterus > 12-14 wk gestational size

Pelvic exam Firm, irregularly enlarged uterus Midline, occasionally adnexal Mass displaced with cervix Usually nontender

Physical Exam

Uterine sarcoma Ovarian neoplasm Tubo-ovarian inflammatory mass Diverticular/inflammatory bowel mass Colon cancer Pelvic kidney

Differential Diagnosis

Bimanual pelvic exam Transvaginal ultrasound (TVUS) Sonohysterography Hysterosalpingography Diagnostic hysteroscopy MRI

Diagnosis

Pathology

Well circumscribed white tan firm masses with a whorled appearance

Pathology

Microscopically leiomyomas are composed of bland smooth muscle.

They can be more fibrotic than this example or more cellular.

Patient presentationsPatient presentations

• 42yo P2 s/p BTL with 16 week size uterus, menorrhagia, anemia, bulk symptoms

Management options?

• 32yo G0 who desires fertility with otherwise the same presentation?

Management options?

• 42yo P3 s/p BTL with bleeding sx, no bulk sx and a normal size uterus

Could she still have fibroids?

Management options?

Clinical Presentation Nonmedical Options

Desire fertility Myomectomy or UAE

Desire uterine preservation Endometrial ablation or UAE

No desired fertility or uterine preservation Endometrial ablation or Hysterectomy

Rapidly growing uterus Exlap, TAH

Management (Surgical)

*Intervention for patients with leiomyomas not amenable to medial therapy

Desire future fertility… Myomectomy

Laparotomy – larger fibroids Laparoscopic – pedunculated or subserosal fibroids Hysteroscopic – submucosal fibroids, >50% in cavity

Desire uterine preservation but not fertility… Endometrial ablation Uterine artery emboloization (UAE)

No desire for uterine preservation or fertility… Hysterectomy (definitive)

Laparotomy (TAH) – larger fibroids Laparascopic (TVH, TLH) – smaller fibroids

Management (Surgical)

Patient presentationsPatient presentations

• 34 yo P1 with menorrhagia and dysmenorrhea with an 8-10 weeks size uterus

Management options?

• What is this same patient were asymptomatic?

1st line treatment NSAIDS Progestin-only therapies (Depo Provera, Mirena IUD) Combination therapies (OCP’s, patches, vaginal rings)

2nd line treatment GnRH analog (Lupron) – blocks endometrial proliferation, shrinks

myometrium, and reduces leiomyoma volume Causes vasomotor symptoms (hot flashes) and bone loss Short courses, used primarily for pre-surgical shrinkage of leiomyoma

GnRH analog + hormonal agents Minimize adverse hypoestrogenism effects

Mifepristone (RU 486) – progesterone receptor antagonist Still experimental, shown to reduce volume by 50% over 3 months

Management (Medical)

Treatment is not necessary if…. Asymptomatic Fibroid small (<12 wk gestational size) Near menopause

Management (Conservative)

Bottom Line Concepts Most uterine leiomyomas are symptomatic and require no intervention.

Uterine leiomyomas can cause excessive uterine bleeding, pelvic pressure and pain, and infertility.

Fibroids can be subserosal, intramural, or submucosal. Prolonged or heavy bleeding may be associated with intramural or submucosal myomas.

Conservative or medical management should be considered prior to surgical management.

Treatment options for leiomyoma include myomectomy, endometrial ablation, uterine artery embolization and hysterectomy.

Pregnancies in women with fibroids are usually uneventful.

Fibroids are rarely the cause of infertility. In women who have a myomectomy in which the endometrial cavity is entered, future deliveries must be by cesarean birth.

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 53 (p114-115).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 44 (p389-392).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 19 (p241-245).