Uterine leiomyoma or Fibroid

Definition: Most common benign neoplasm of female genital tract composed of smooth muscle and connective tissue that is hormonally responsive (Growth ↑ in pregnancy and ↓ after menopause).

Gross pathology:

  1. Discrete, round, firm, irregularly lobulated and often multiple.
  2. Enlarged uterus
  3. Smooth and white cut surface with whorled appearance
  4. False capsule: pinkish color
  5. Center of tumor is least vascular and likely to degenerate

Risk factors:

  1. Nulliparity
  2. Obesity
  3. Hyperestrogenic state
  4. Black race
Types:
Types Features
Intramural Within uterine wall
Subserosal Projects into the pelvis à irregular uterine contour; may be pedunculatedWandering/Parasitic fibroid: Nourishment from omental/mesenteric adhesion
Submucosal Projects into uterine cavity; irregular uterus; may be pedunculated
Cervical and Broad ligament RarePseudocervical fibroid: Arising from uterine body & occupying cervical canal 

Secondary changes in fibroid:

  1. Degeneration: Hyaline (commonest), Cystic, Fatty (Myxomatous), Calcific (Womb stone), Atrophic
  2. Septic degeneration: Necrosis followed by infection
  3. Red degeneration (Carneous degeneration)
    • During 2nd and 3rd trimesters of pregnancy, myomas may rapidly increase in size and undergo vascular deprivation and subsequent degenerative changes (aseptic degeneration and infarction)
    • C/F: Pain and localized tenderness
    • Complications: Preterm labor, DIC
    • Venous thrombosis and congestion with interstitial hemorrhage is responsible for color
  4. Sarcomatous changes: Rare

History:

  1. Age: peak in 35-45 years
  2. Often asymptomatic (75%)
  3. Abnormal Uterine Bleeding:
    • Cause: Increased vascularity and venous congestion, Increased surface area of uterine cavity
    • Menorrhagia (Prolonged, heavy bleeding), Metrorrhagia (Intermenstrual bleeding), Premenstrual spotting and Anemia symptoms
  4. Pressure:
    • Constipation (Intestinal obstruction),  Urinary symptoms of hydroureter, Lower extremity edema (Pelvic venous congestion)
  5. Pain:
    • Cause: Torsion, Degeneration, Protrusion (Myometrial contraction to expel submucosal myoma from uterine cavity)
    • Secondary dysmenorrhea, Dyspareunia
    • Sensation of heaviness or fullness in pelvic area with large tumor
  6. Infertility:
    • Cause: Mechanical obstruction or distortion of uterine cavity interfere with implantation and sperm transport

Examination:

  1. Pallor (AUB)
  2. Abdominal examination:
  3. Palpation: If >14 wks size, firm/non-tender/irregular/mobile side-to-side only
    • Percussion: Dull
    • Peritoneal signs: Infarcted myoma
  4. Bimanual pelvic examination:
    • No groove or separation of mass from uterus
    • Cervix moves with movement of tumor felt per abdomen
    • Exception: Subserous pedunculated fibroid often confused with ovarian mass

Uterine retroversion and retroflexion may obscure the physical examination diagnosis of even moderately large leiomyoma

Differential Diagnosis:

  1. Fetus (Pregnancy)
  2. Full bladder
  3. Adenomyosis
  4. Myohyperplasia
  5. Tubo-ovarian mass
  6. Ovarian tumor

Investigations:

  1. Lab: Anemia (Bleeding), Polycythemia (Erythropoietin induced by ureteral back pressure), Degeneration or Infection (Leukocytosis, Fever, Elevated ESR), Pregnancy test, CA-125 (Differentiating from other gynecologic adenocarcinomas)
  2. Imaging:
    1. Pelvic USG: To confirm diagnosis
    2. MRI: Can delineate intramural and submucous myomas (location); evaluate urinary tract
    3. Hysterosalpingography or Hysteroscopy: In infertile patient
    4. Laparoscopy: Helpful if uterine size < 12 wks
    5. AXR: Calcification, Preoperative assessment
    6. IVU: Anatomic changes in ureter
    7. D & C:  Detect co-existing pathology in presence of uterine bleeding

Management:

1) Asymptomatic fibroid:

  • Regular supervision @ 6 months interval
  • Surgery: If size > 12 wks, Diagnosis uncertain, Unexplained infertility or abortion, Pedunculated fibroid, Size increase or symptoms appear

2) Symptomatic fibroid:

  1. Medications:
    • Goal: To slow or stop bleeding, To decrease size of myoma, suppress further growth and reduce vascularity (as neoadjuvant therapy)
    • GnRH agonists: Hypoestrogenic state
    • Leuprolide (im), Nafarelin (intranasally), Goserelin (sc implant)
    • GnRH antagonists: Cetrorelix, Ganireflix
    • Progestogens: Medroxyprogesterone acetate 200mg im monthly; Norethindrone
    • Antiprogesterones: Mifepristone 25-30 mg daily X 3 months
    • Danazol 200-400 mg daily X 3 months
  2. Surgery:
    • Indications:
      • Medical therapy: Contraindication, Intolerance, Failure
      • Concern for malignancy
      • Mass effect: pain, pressure, urinary or GI symptoms
      • Infertility, Repeated abortions
    • Modalities:
      • Hysterectomy
        • Definitive treatment with no chance of recurrence
        • Indications: Extensive disease, suspected malignancy, Myomas is association with other pelvic abnormalities, Future pregnancy not desired
        • Total or Subtotal hysterectomy (Ovaries can be removed in postmenopausal)
        • Vaginal hysterectomy: can be done if size 10-12 wks associated with uterine prolapse
      • Myomectomy: Preferred if future pregnancy desired
      • Laparotomy: Multiple myomas or Uterus > 16 wks size
      • Laparoscopy: 1-2 easily accessible myoma <8cm diameter and uterine size <16 wks
      • Hysteroscopy +/- Endometrial ablation: Submucosal myomas 3-4 cm diameter
      • Myolysis:
        • Laparoscopy: Coagulation/Freezing of myoma
      • Uterine artery embolization:
        • Fluoroscopic guidance: Gels, beads, or coils through a catheter in common femoral artery
        • Disrupts blood supply, causing degeneration

      • High-intensity focused ultrasound: Heat generation; Developmental stage

Causes of symmetrical enlargement of uterus:

  1. Pregnancy
  2. Submucosal or intramural fibroid
  3. Adenomyosis
  4. Myohyperplasia
  5. Metras: Pyo/Hemao/Lochio-metra
  6. Malignancy: Carcinoma body, Choriocarcinoma, Sarcoma

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