General Objective:

At the end of the session, the group should be able to learn the principles of
diagnosis and management of the case and correlate it with the topic on leiomyoma.

Specific Objectives:
1. To discuss the history and physical examination findings of the case.
2. To give possible differential diagnoses.
3. To discuss the primary diagnosis and its pathophysiology.
4. To discuss what is leiomyoma.
5. To discuss the clinical manifestations of leiomyoma.
6. To discuss the diagnostic and therapeutic management.
7. To enumerate the possible complications and risk factors of leiomyoma.

Guide Questions:
1. What are the pertinent findings in the history?
JEN 42-year old G3P3 (3003)
● Came in due to Body weakness
● Diabetic and Hypertensive (poor compliance to medications)
● Denies contraceptive use
● 8 months PTA patient began experience heavy menstrual bleeding ( described
as soaking 4-5 baby diaper/day, lasting for 7 – 10 days) associated with dysmenorrhea
3 days heavy menstrual flow soaking 4-5 abby diapers associated with dysmenorrhea

JIM For the body weakness it can be attributed with the heavy menstrual bleeding because it may
cause anemia, the patient soaks 4-5 baby diapers a day lasting for 7-10 days. Normal menstrual
bleeding
Mean interval- 28 days +- 7 days
Duration- 4 days
Average menstrual blood loss- 35 ml
Heavy menstrual bleeding- blood loss of 80 ml or greater

JERIEL Pregnancy-related bleeding

● This is the first consideration in woman of reproductive age who presents with
abnormal uterine bleeding
● This consideration is immediately ruled out due to the presence of cyclical
menstrual bleeding, a negative pregnancy test and transvaginal ultrasonography
revealed no viable intrauterine pregnancy or ectopic pregnancy

If pregnancy is ruled out

Non pregnancy related--->Genital tract causes, may come from the cervix, uterus, vagina or the
ovaries
By history, vaginal cancer presents with bleeding not related to menstrual period and will also
complain of painful urination or pelvic pain but thi is not the case of our patient
Cervical polyp- presents as intermenstrual bleeding- light bleeding as compared to the heavy
menstraul bleeding in our patient nd this is easily diagnosed upon speculum exam
Cervical malignancy classically presents as coital bleeding or intermenstrual bleeding
Ovarian- can be physiologic or neoplastic. Functional cyst include follicular and corpus luteum
cyst(ruled out-cause amenorrhea) and these are classically asymptmatic and if it becomes
symptomatic, its due to torsion or rupture which presents with acute abdomen
Ovarian neoplasm-strong family history of breast or ovarian cancer, also presents with pelvic or
abdominal pain,bloating,early satiety and urinary symptoms.
And adnexal masses can easily be ruled out by physical examination
That leaves us with the uterus as the primary cause of the patients heavy flow. We use now the AUB-
PALM COIEN classification.

2. What are the additional information you would like to ask?

3. What are the pertinent findings in the physical examination?

JUDY Vital signs 90/60 HR 104 RR 20 Temp 36.7C Physical examination findings revealed pale
palpebral conjunctivae and perioral pallor
● BMI 28 (categorizes as Obese I in Asia-Pacific BMI classification)
DOMS ● Speculum exam revealed fleshy mass occupying the vaginal vault and prolapsing from
the external os covered with blood clots
● Internal examination showed cervix dilated by the said mass measuring 4 x 3 x 3 cm
smooth firm with regular contour, corpus 8 weeks size with irregular border movable, no adnexal
masses or tenderness
● No masses revealed in the cul de sac

4. What are the additional information you would like to ask?

 History of myoma in the family



5. What were the diagnostics done and their results?

JEN Negative pregnancy test

 ● TVS revealed a normal ovary with four uterine masses with the following
characteristics
o M1 measuring 4 x 4 x 3 cm prolapsed submucous
o M2 measuring 8 x 8 x 6 cm subserous Grade 6
o M3 measuring 5 x 4 x 4 cm intramural Grade 4
o M4 measuring 2 x 1 x 1 cm intramural Grade 3

6. What are your differential diagnoses?

JIM Pregnancy-related bleeding/Gestational causes of bleeding

● This is the first consideration in woman of reproductive age who presents with
abnormal uterine bleeding
● This consideration is immediately ruled out due to the presence of cyclical menstrual
bleeding, a negative pregnancy test and transvaginal ultrasonography revealed no viable intrauterine
pregnancy or ectopic pregnancy

JERIEL Non-Gestational Causes of Bleeding

What is PALM-COEIN Classification?

● PALM stands for Polyps, Adenomyosis, Leiomyoma, and Malignancy (included in this
category are Hyperplastic disorders)
o Structural problem which is commonly assessed virtually, through imaging and
histopathologic studies
● COEIN stands for Coagulopathies, Ovulatory Disorders, Endometrial Disorders,
Iatrogenic, and Not otherwised classified
o Nonstructural problem

Nonstructural causes (COEIN) may be worked up but are not really considered for this case because of
the presence of gross structural problems identified in the physical examination, speculum
examination, and internal examination.

7. What is the final diagnosis?

JUDY G3P3 (3003), Multiple myoma uteri, subserosal, submucosal, and intramural; Anemia secondary;
Diabetes Mellitus type II, poorly controlled; Hypertension, poorly controlled.

8. What is myoma uteri or leiomyoma of the uterus and its pathophysiology?

DOMS Leiomyoma are benign tumors of muscle cell origin. These tumors are often referred to by their
popular names, fibroids or fibromyomas. It is the most common benign neoplasm of the uterus. This
condition represents a tremendous public health burden and the most frequent indication for
hysterectomy.
8. What are the different types of Leiomyoma based on anatomical location?
JEN ● Myomas are classed into subgroups by their relative anatomic relationship and
position to the layers of the uterus
● The three most common types of myomas are intramural, subserous, and submucous,
with special nomenclature for broad ligament and parasitic myomas

Though the origin of uterine leiomyomas is incompletely understood, cytogenetic studies

have yielded some clues to how and why myomas develop

9. What are the common types of leiomyoma?

JIM
These tumors are classified numerically based on their location
(Fig. 9-2) (Munro, 2018). Subserosal leiomayomas originate from
myocytes adjacent to the uterine serosa. As variants, parasitic
leiomayomas attach themselves to nearby pelvic structures from
which they derive vascular support. These myomas then may
or may not detach from the parent myometrium. Intramural
leiomayomas are those with growth centered within the uterine
walls. Submucousl leiomayomas are proximate to the endometrium
and grow toward and bulge into the endometrial caviry. Last,
pedunculated leiomayomas attach only by a stalk to their progenitor
myometrium. Type 0 and type 7 myomas are examples . Infrequently, leiomyomas develop in
the cervix or broad ligament and rarely in the ovary, fallopian tube, vagina, or vulva.

10. What are the common clinical manifestations of leiomyoma?

JERIEL Depending on the size and anatomical location of the leiomyoma, the patient may be
asymptomatic (represents 2/3 of the case).
● A third of myomas will become symptomatic causing abnormal and excessive uterine
bleeding, pelvic pain, pelvic pressure, bowel and bladder dysfunction, infertility, recurrent
miscarriage, and abdominal protrusion.
● Although only 5% to 10% of myomas become submucosal, they usually are the most
troublesome clinically. Usually associated with abnormal vaginal bleeding or distortion of the uterine
cavity that may produce infertility or miscarriage.
● Rarely, a submucosal myoma enlarges and becomes pedunculated. The uterus will try
to expel it, and the prolapsed myoma may protrude through the external cervical os (present in our
patient)
● Myomas are rare before menarche, and most myomas diminish in size following
menopause with the reduction of a significant amount of circulating estrogen.
 ● Myomas often enlarge during pregnancy and occasionally enlarge secondary to oral
contraceptive therapy

11. What are the risk factors and its correlation on the case?

JUDY Increasing age

● Early menarche
● Low parity
● Tamoxifen use
● Obesity, and a high-fat diet.
● Race (African-American women have the highest incidence)
● Inheritance/Family History (Rare genetic conditions such as hereditary
leiomyomatosis and renal cell cancer, and Alport syndrome feature development of myomas.

12. What are the diagnostics and management?

DOMS Clinical Examination
● The diagnosis of uterine myomas is usually confirmed by physical examination. Upon
palpation, an enlarged, firm, irregular uterus may be felt. The three conditions that
commonly enter into the differential diagnosis are pregnancy, adenomyosis, and an
ovarian neoplasm.
● The discrimination between large ovarian tumors and myomatous uteri may be
difficult on physical examination, because the extension of myomas laterally may
make palpation of normal ovaries impossible during the pelvic examination. The
mobility of the pelvic mass and whether the mass moves independently or as part of
the uterus may be helpful diagnostically.
JEN Diagnostics:
● Transvaginal Ultrasound
● This modality is diagnostic; it can easily differentiate fibroids from a pregnant uterus
or adnexal mass
● Sonohysterography, hysteroscopy, or as a filling defect on hysterosalpingography
● Abdominopelvic radiograph will note concentric calcifications

13. What will you advise to the patient?

JIM