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	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 2^nd and 3^rd 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

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

Causes of symmetrical enlargement of uterus:

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