LEIOMYOMAS (UTERINE MYOMA)

• Benign smooth muscle neoplasms that typically

originate from the myometrium.

• Their incidence among women is generally cited as 20

to 25 pecent.

PATHOLOGY

• Grossly, leiomyomas are round, pearly white, firm, rubbery

tumors that on cut-surface display a whorled pattern.

• Histologically, leiomyomas contain elongated smooth muscle cells

aggregated in bundles.

• Leiomyomas possess a distinct autonomy from their surrounding

myometrium because of a thin, outer connective tissue layer.

• This clinically important cleavage plane allows leiomyomas to be

easily “shelled out” of the uterus during surgery.

Pathophysiology:
 Uterine leiomyomas are estrogen and progesterone sensitive
tumors. Consequently, they develop during the reproductive
years. After menopause, leiomyoma generally shrink and new CLASSIFICATION OF LEIOMYOMA
tumor development is infrequent.

Estrogen effect:

• Leiomyomas themselves create a hyperestrogenic environment,

which appears requisite for their growth and maintenance.

• First, compared with normal myometrium, leiomyoma cells

contain a greater density of estrogen receptors, which results in
greater estradiol binding.

• Second, these tumors convert less estradiol to the weaker estrone

(Englund, 1998; Otubu, 1982;Yamamoto, 1993).
SUBSEROSAL LEIOMYOMAS
• A third mechanism involves higher levels of cytochrome P450
aromatase in leiomyomas compared with normal myocytes. This  Originate from myocytes adjacent to the uterine serosa, and their
specific cytochrome isoform catalyzes the conversion of growth is directed outward.
androgens to estrogen in a number of tissues. (Bulun and
colleagues 1994) INTRAMURAL LEIOMYOMAS

RISK FACTORS:  Those with growth centered within the uterine walls.

SUBMUCOUS LEIOMYOMAS

• Are proximate to the endometrium and grow toward and bulge

into the endometrial cavity.

CLASSIFICATION OF SUBMUCOUS MYOMA

SYMPTOMS

LLOYD F. ALIAS
#Matatag 2016
BLEEDING: • Regardless of their size, asymptomatic leiomyomas usually can be
observed and surveilled during annual pelvic examination
 Most common symptoms (American College of Obstetricians and Gynecologists, 2001).

• The pathophysiology underlying this bleeding may relate to
dilatation of venules.
• Bulky tumors are thought to exert pressure and impinge on the
uterine venous system, which causes venous dilatation within the
myometrium and endometrium. (Wegienka, 2003).
• Leiomyomas in general are slow-growing. A longitudinal
sonography-based study showed the average diameter growth to
be only 0.5 cm/yr, although diameter growth greater than 3 cm/yr
has been observed (DeWaay, 2002).
DRUG THERAPY:

• In some women with symptomatic leiomyomas, medical therapy

may be preferred.

• In addition, because leiomyomas typically regress

postmenopausally, some women choose medical treatment to
relieve symptoms in anticipation of menopause.

PELVIC DISCOMFORT AND DYSMENORRHEA

 A sufficiently enlarged uterus can cause pressure sensation,

urinary frequency, incontinence, or constipation.
SURGICAL MANAGEMENT:
ACUTE PELVIC PAIN
HYSTERECTOMY
 This is a less frequent complaint with leiomyomas, but is most
often seen with a degenerating leiomyoma (due to limited blood • Removal of the uterus is the definitive and most common surgical
supply of the tumors) treatment for leiomyomas

INFERTILITY • Carlson and coworkers (1994) found that hysterectomy for

women with symptomatic leiomyomas resulted in satisfaction
• Occlusion of tubal ostia and disruption of the normal uterine rates greater than 90 percent.
contractions that propel sperm or ova.
• There were marked improvements in pelvic pain, urinary
• Importantly, leiomyomas are associated with endometrial symptoms, fatigue, psychological symptoms, and sexual
inflammation and vascular changes that may disrupt implantation dysfunction.

DIAGNOSIS MYOMECTOMY:

• Leiomyomas are often detected by pelvic examination with • Resection of tumors is an option for symptomatic women who
findings of uterine enlargement, irregular contour, or both. desire future childbearing or for those who decline hysterectomy.

• In reproductive-aged women, uterine enlargement should prompt • Myomectomy usually improves pain, infertility, or bleeding.
determination of a urine or serum β-hCG level.

IMAGING
Differential diagnosis:
• The sonographic appearances of leiomyomas vary from hypo- to
hyperechoic depending on the ratio of smooth muscle to  Adenomyoma
connective tissue and whether there is degeneration.  Pregnancy
 Threatened abortion
• Calcification and cystic degeneration create the most  Ovarian new growth
sonographically distinctive changes.

MANAGEMENT:

OBSERVATION:

LLOYD F. ALIAS
#Matatag 2016