CASE STUDY-UTERINE FIBROIDS/LEIOMYOMAS

INTRODUCTION

Uterine fibroids, otherwise known as myomatous or leiomyoma, are benign,

monoclonal tumours of the smooth muscle cells of the human uterus (Parker, 2007;
Kempson and Hendrickson, 2000). They are the most common tumours in women of
reproductive age and are asymptomatic in at least 50% of afflicted women (Gupta et
al,. 2008). Symptoms include menstrual disturbances such as menorrhagia,
dysmenorrhea and intermenstrual bleeding (Gupta et al., 2008); dyspareunia and non-
cyclic pelvic pain (Lippman et al., 2003) and pressure symptoms such as a sensation
of bloatedness, increased urinary frequency, and bowel disturbance are also common
(Ciavattini et al., 2013). It may also impair reproductive functions resulting in reduced
fertility, early pregnancy loss, increased preterm labour and delivery, and markedly
increase the risk for cesarean delivery (Payson et al., 2006, Ciavattini et al., 2013).

Fibroids according to (Sanders R.C. and Winter T.C, 2007); are classified based on
their location in relation to the endometrial cavity as:
 Submucosal - fibroids, which border on the endometrial cavity, often cause
frequent lengthy periods with intramenstrual spotting and may cause in fertility.
 Intracavitary- Fibroids that lie within the cavity or protrude into the cavity which
are even more likely to cause vaginal bleeding and cramping.
 Pedunculated- Fibroids that have a small neck and extend to the border of the
uterus. They may be hard to distinguish from adnexal masses and may twist and
infarct (torsion).

Several factors have been implicated in the etiology of fibroids. Epidemiological

studies have linked fibroids to the female reproductive hormones, oestrogens, and
progesterone. Oestrogens and their receptors are reported to exert a great influence on
fibroid growth. Several studies found that memory ribonucleic acid (mRNA) and
protein expression levels as well as the content of oestrogen receptor-alpha (ER-a)
and ER-[sz] are higher in leiomyoma compared to those in normal myometrium
(Benassayag et al., 1999; Kovacs et al., 2001). Oestrogens, it is hypothesized, may
exert their growth stimulatory effects on leiomyomas intermediated by cytokines,
growth factors, or apoptosis factors (Grings et al., 2012).
The role of progesterone in the etiology of fibroids is through its interaction with its
receptors, progesterone receptor-A (PR-A) and PR-B (Kastner et al., 1990).
Leiomyomas are known to have higher PR content and mRNA levels compared to
normal myometrium (Viville et al., 1997; Ying and Weiyuan, 2009). This is further
buttressed by the relative over-expression of PR-B mRNA in the surface of
leiomyoma as described by Fujimota et al., (1998).

A 49 year old patient in this case presented the Gynaecology OPD with a painful mass
in lower abdomen with gradual enlargement of abdomen for last 7 months. She had a
clinical history of nausea, vomiting, weight loss, loss of appetite, pain in the lower
abdomen, intermenstrual bleeding and intermittent constipation.

INDICATION
 Abnormal uterine bleeding ???. Rule out uterine fibroids/pelvic pathology.
Examination Date: 26 July 2022

PATIENT INFORMATION
Date of Birth 27 August 1973
Parity 3
Gravida 5
Last Menstrual Period Unknown
Contraceptive Nil
Marital Status Married
Sex Female
Level of Education Ordinary Level

EQUIPMENT
 Mindray DC-6 Ultrasound machine.
 3.5-5MHz curvilinear probe .
 Sony High glossy thermal paper.
 Ultrasound gel.
 Sony Ultrasound Printer.
PATIENT PREPARATION, PATIENT CARE AND PROTOCOL
Standard gynaecological transabdominal scan protocol documented in appendix B
attached
OBSERVATIONS AND FINDINGS
There was a bulky anteverted and non-gravid uterus with a heterogeneous echotexture
measuring 11.14 cm x 6.42 cm x 9.93 cm. The uterus had an irregular shape with well
defined margins and a short normal cervix.
 A symmetrical, well-defined, heterogeneous, solitary solid mass measuring 7.76
cm x 6.55 cm x 7.99 cm was seen occupying the myometrial layer of the uterus.
The intramural heterogeneous mass appeared as if it enclosed two echogenic
distinct masses with hypoechoic margins pushing the urinary bladder anteriorly.
 The intramural mass does not cover the cervix though it occupies the anterior and
posterior aspects of the myometrium.
 The endometrium was not visualised
 Color Doppler ultrasound showed the fibroid’s circumferential vascularity.
 Pulsed wave Doppler was not used to assess the waveform of the feeding vessels.
 The ovaries were not visualised and there were no adnexal solid or cystic masses
seen.
 The urinary bladder was distended with a relatively smooth mucosal outline and
its contents were not visualised hence its integrity was not assessed.
 There was no free fluid in the pouch of Douglas.
 There was a complex cystic abdominal mass seen antero-lateral to the uterus
with an echogenic irregular central intact solid mass. It measured 9,89 cm x 4,38
cm. Its length extends from the midline to the midclavicular line on the right
lower quadrant.
 There was evidence of peripheral vascularity on color Doppler interrogation.

Uterine Measurements
Serial Parameter Measurement (cm)
(a) (b) (c)
1. Uterine length 11.4
2. Uterine width 9.93
3. Uterine height 6.42
4. Uterine volume 371.2 cc
5. Uterine body 27.49

Comment
1. Bulky non gravid fibroid uterus.
2. An intramural symmetrical, well-defined, heterogeneous, solitary solid mass
measuring 7.76 cm x 6.55 cm x 7.99 cm occupies the entire myometrium.
3. Complex cystic pelvi-abdominal mass measuring 9,89 cm x 4,38 cm.
4. Ultrasound guided biopsy is recommended.
5. Differential diagnosis could be:
 Uterine lipoleiomyoma.
 Focal adenomyosis.
 Uterine leiomyosarcoma; though rare.
Correlate clinically.

Signed………………………………….S. TANGWADZANA
(Diagnostic Radiographer/Student Sonographer)

DISCUSSION

Etiology and Pathophysiology

Although, the exact etiology of fibroid is not known yet, the growth of uterine fibroid
is featured as a benign, hormone sensitive diffuse or nodulus hyperplasia of
myometrium, and is characterized by having multiple factors of pathogenesis and
systemic changes. Uterine fibroid is developed on the background of hyperestrogens,
progesterone deficits and hypergonadotropins.

The role of ovarian steroid hormones in the pathogenesis of uterine fibroids is

supported by epidemiological, clinical, and experimental evidence. Estradiol
and progesterone induce mature leiomyoma cells to release mitogenic stimuli to
adjacent immature cells, thereby providing uterine leiomyoma with undifferentiated
cells that are likely to support tumour growth.
Progesterone action is required for the complete development and proliferation of
leiomyoma cells, while estradiol predominantly increases tissue sensitivity to
progesterone by increasing the availability of progesterone receptors (PRs).
The selective estrogen receptor modulator (SERM) raloxifene and the selective PR
modulators (SPRMs) mifepristone, asoprisnil, and ulipristal acetate have been shown
in clinical trials to inhibit fibroid growth. The role of sex steroids is critical for
leiomyoma development and maintenance, but a number of autocrine and paracrine
messengers are involved in this process; hence, numerous pathways remain to be
explored in therapeutic innovations for treating this common disease. The majority of
the researchers consider that the growth of fibroid depends on concentration of
cytosolic receptors to the sexual hormones and their interactions with the endogenous
or exogenous hormones. In accordance to clinical observations, it can be admitted that
both growth and regression of fibroid are oestrogen-dependant; the tumour size gets
increased during pregnancy and is regressed after menopause.
em
Risk factors
Even if many risk factors suggested by epidemiology studies have linked uterine
leiomyomas to the effects of oestrogen and progesterone levels and their metabolism,
other mechanisms may be involved in fibroids pathogenesis. In fact, recently,
Peddada et al. have questioned the exact role of female hormones (oestrogens and
progesterone) in the development and growth of uterine fibroids. The authors
measured the growth of fibroids in black and white women with clinically relevant
fibroids using MRI technology; they demonstrated that fibroids within the same
woman often have different growth rates despite having a similar hormonal milieu. In
the same patients, fibroids were found to vary in size, regress, or remain stable. Each
tumour appeared to have its own intrinsic growth rate, and fibroid growth appeared
not to be influenced by tumour characteristics such as size and location. 

 It has been generally accepted that myomas are more prevalent in blacks than in
Caucasian and Hispanic populations (Kjerulff, K. H. et al 1996). Although the cause
of the higher prevalence among black women is unclear, differences in circulating
oestrogen levels have been found. It is still unclear (Parker, W. H. 2007) whether
these ethnical differences are genetic or due to known variations in hormonal
metabolism, diet, or environmental factors.
 Leppert et al. reported that the pathogenesis of fibroids seems to involve a positive
feedback loop between extracellular matrix production and cell proliferation, and
vitamin D might act to block the positive feedback. It is also interesting that myomas
and keloids, both more common in black women, have similar gene characteristics.
Furthermore, it is well known that family history could represent a strong
predisposing factor; the first-degree relatives of affected women have a 2.5 times
increased risk of developing fibroids. However, as recently reported from Saldana et
al., such bias would invalidate self-reported family history as a predictor of fibroid
risk (Saldana. T.M. 2013).

Patient Presentation
Abnormal uterine bleeding and intermenstrual bleeds are common symptoms of
uterine fibroids. Other symptoms however, include anaemia, back pain, pelvic pain
and pressure, constipation, urinary frequency/retention, miscarriages, or infertility.
These characteristic symptoms resembles those of 49 years old patient in this case
who presented to the Gynaecology OPD with a painful mass in lower abdomen with
gradual enlargement of abdomen for last 7 months. She had a clinical history of
nausea, vomiting, weight loss, loss of appetite, pain in the lower abdomen,
intermenstrual bleeding and intermittent constipation.

ULTRASOUND FEATURES OF UTERINE FIBROIDS

Sanders R.C. and Winter T.C, 2007 describe the sonographic features of uterine
fibroids as:
 An enlarged uterus, usually with a lobulated contour that may indent the urinary
bladder. If the urinary bladder volume is small, documentation of the size
becomes paramount. Thus frequency is a common complication of fibroids
because they reduce urinary bladder capacity.
 Focal ovoid or circular masses within the uterus. These masses may have a
similar echogenicity to the remainder o the uterus, but tissue within is organized
in a whirled (circular) fashion. Blood vessels form a rim around the fibroid,
whereas with other entities, they may look similar, such as in focal adenomyosis
in which blood vessels traverse the lesion.
 The fibroid may be surrounded with a rim of calcification that can occasionally
be so dense that the centre cannot be seen with ultrasound.
Other sonographic features relate to the classification of fibroids in relation to
endometrial cavity as already elucidated in the paragraphs above. It then suffice to
note that ultrasound was very useful in the diagnosis of fibroids in this patient as she
had typical symptoms and sonographic appearances of fibroids as those found in
literature.

MANAGEMENT
Because of the high likelihood of uterine problems such as necrosis and malignant
transformation of benign fibroid tumours, treatment of uterine fibroids should be
tailored to the size and location of the tumour, patient’s age, presenting symptoms,
desire to maintain fertility and the gynaecologicals experience. Uterine artery
embolization, ablative treatments, expectant care, surgery, and medicinal management
are all options for treating this fibroid. Conservative, medicinal, or surgical treatment
options are available.

Patients who are asymptomatic are treated conservatively. This includes periodic
explanations, reassurances, and re-examinations. If anaemia is discovered in
symptomatic cases of menorrhagia, it should be treated. Menorrhagia can be treated
with tranexamic acid, combined oral contraceptives, or a levonogestrel-releasing
intrauterine device. Prescription of agonadotropin-releasing hormone analogue, which
has been used to limit oestrogen production and, as a result, reduces the mass of
existing fibroids, making them suitable for laparoscopic surgery.

In order to maintain productiveness and menstrual function in young female patients,

proper counselling and the possibility of myomectomy is recommended in patients
with symptomatic fibroids as well as those with large, asymptomatic fibroids.
Females who want to keep their fertility and uterus should have their treatment
focused on improving symptom alleviation and quality of life.

CONCLUSION
Because of the risk of excessive haemorrhaging, obstetricians usually avoid the
removal of uterine fibroids during cesarean deliveries unless they are tiny and
pedunculated. Despite the fact that the majority of fibroids are asymptomatic, their
location and size may have an impact on the pregnancy and delivery process.
Performing routine myomectomies during cesarean section is not indicated, but it is a
feasible and safe technique in some cases, with a good prognosis for the patient.
Consequently, the decision of performing myomectomies during pregnancy can be a
challenge and must be performed for selected cases. This procedure may have several
benefits, such as avoiding another operation to remove fibroids. Therefore ultrasound
plays an important role in obstetrics and gynaecology for the diagnosis and evaluation
of fibroids, their location as well as their number for monitoring their growth and
planning of mode of management appropriately.
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