UTERINE LEIOMYOMATA

DEFINITION & INTRODUCTION:

A Leiomyomata is a tumour of Mullerian duct origin, composed of smooth muscle interlaced with fibrous
strands.
Synonyms include:
1. Fibromyoma
2. Leiomyoma
3. Myoma
4. Fibroid → this is a misnomer as the tumour is largely composed of muscle tissue

INCIDENCE/PREVALENCE:
They are the most common form of tumour in the human body, with a higher incidence in black patients.
They mostly occur > 35 years, and don’t present with clinical problems prior to puberty. They should not
grow after menopause. They mainly occur in uterine corpus, but may be found cervix, round ligament, and
broad ligament.

AETIOLOGY:
Growth is influenced by various hormonal stimuli (oestrogen) – theory supported by accelerated growth of
these tumours during pregnancy and their regression post-menopause.
Associated with:
1. Nulliparity/low parity 4. Early menarche
2. Obesity & alcohol 5. Hypertension
3. Persistent anovulation 6. Negative association with smoking

PATHOLOGY:
Growth:
Single/multiple seedling in the myometrium (intramural), can grow:
1. Inward → submucous (can grow into uterine cavity and form a polyp, may even prolapse through
cervix)
2. Outward → subserous (can develop a stalk → pedunculated

Macroscopic: Microscopic:
• Round, firm, white • Mixture of smooth m. & fibrous tissue
• Pseudocapsule with cut surface having a • Avascular – large tumours degenerate
trabeculated appearance (whorled pattern) • Malignant change very rare < 0.5%

Gareth Stott
CLINICAL FEATURES: Most are asymptomatic, symptoms depend of size & site
• Submucous, intramural leiomyomata cause an unfavourable uterine
environment:
1. Infertility
o Recurrent abortions
o If in cornua → occlude interstitial portion of Fallopian tubes
• 30-50% experience menorrhagia, due to ↑ bleeding surface and
abnormal vessels stretched over surface of tumour
• Irregular bleeding may occur due to infection/necrosis of the
2. Vaginal bleeding
endometrial surface of the tumour
• Fe-deficiency anaemia is a common sign in patients with uterine
leiomyomata
• Most common cause of pelvic mass in non-pregnant women (usually
3. Abdominal Mass
lobulated, firm, and indistinguishable from the uterus)
• Associated with pain due to PID
• Acute pain → due to torsion of pedunculated myoma
• Dysmenorrhoea → active myometrium attempting to expel a polyp
• Other causes of pain include:
4. Pain
o Red degeneration
o Prolapse
o Malignant changes
o Compression of surrounding structures
• Due to infection of submucous leiomyomata or polyp, and poor
5. Vaginal discharge
drainage of endometrial cavity
6. Uterine inversion • Very rare
• Urinary tract effects:
o Urinary retention
▪ Urethral compression
7. Pressure effects ▪ Impaction of posteriorly situated fibroid into Pouch of
Douglas resulting in distortion of the uterine retroversion
• GIT:
• Constipation (large fibroids compress the lower intestinal tract)

Gareth Stott
COMPLICATIONS:
1. Degeneration:
a. Hyaline in 10%, tumour outgrows blood supply → avascular necrosis at the centre
b. Cystic Follows hyaline degeneration
c. Calcification In older patients, calcium phosphate deposited in hyalinised portions
d. Red Necrobiosis, rare. Usually a complication of pregnancy, due to enlarging
gravid uterus obstructing venous return, causing ↑ intravenous pressure,
resulting in rupture of capillaries and blood flowing into tumour, causing
red appearance. In non-pregnant patient, due to exogenous hormones
(oestrogen or progesterone).
e. Sarcomatous Presents with rapid growth and pain. Occur more in older women and are
aggressive in post-menopausal women (i.e. not dependant on hormones).

2. Metastasis: Same as benign, except they spread to pelvic organs, omentum, and lungs.
3. Anaemia: May be so severe that cardiac failure occurs
4. Infection: Submucous leiomyoma (especially polyps) in the puerperium period. Leiomyoma is
commonly associated with PID.
5. Torsion: Rare. DDx of acute abdomen.
6. Ascites: Pseudo-Meigs Syndrome. Rare.

COMPLICATIONS IN PREGNANCY:
1. First Trimester:
a. Red degeneration causing pain; must exclude abruptio placentae
b. Large-for-date pregnancies (leiomyomas mistaken for foetal parts)
c. Submucosal and large intramural fibroids may cause recurrent miscarriage

2. Second Trimester:
a. Red degeneration & recurrent miscarriage

3. Third Trimester:
a. PPROM
b. Premature labour
c. Abruptio placentae (if the placenta implants on a fibroid)
d. IUGR (due to placental insufficiency)
e. Large-for-date pregnancies; ↑ caesarean sections

4. Intrapartum:
a. Uterine inertia, foetal malpresentation, birth canal obstruction → C-section
b. If in lower uterine segment → classical upper C-section

5. Postpartum:
a. May interfere with contraction and retraction in 3rd stage → PPH

Gareth Stott
DIFFERENTIAL DIAGNOSIS:

Genital tract: Urinary tract:

• Pregnancy (intra- & extra-uterine) • Bladder masses
• Ovarian Tumours • Kidney masses:
• Inflammatory masses (including TB) o Horseshoe kidney
• Endometrial carcinoma o Pelvic kidney
• Adenomyosis
• Endometriosis

DIAGNOSIS:
Clinical picture of:
1. Infertility
2. Abnormal menses
3. Abdominal mass

Physical Examination:
1. Helpful feature: cervix is displaced upwards under the symphysis pubis (a feature of fibroids,
pregnancy, or chronic pelvic abscess)
2. An enlarged, mobile uterus with an irregular contour is consistent with a leiomyomatous uterus.
a. if uterus is fixed → suspect inflammatory process (endometriosis) or malignancy.
3. Prolapsed submucosal fibroid may be visible on speculum examination

Imaging:
Pelvic ultrasound is the imaging study of choice for uterine leiomyomas.
1. Typically performed in all patients, with further studies ordered depending on the clinical
indications.
a. Transvaginal ultrasound has high sensitivity (95 to 100 %) for detecting myomas in uteri
less than 10 gestational weeks' size.
b. Fibroids are seen on ultrasound usually as hypoechoic, well-circumscribed round masses,
frequently with shadowing. Calcification implies degeneration.
c. It may be difficult to differentiate between ovarian tumours and leiomyomas.
2. MRI may be used if ultrasound findings are not sufficient for surgical planning or if the diagnosis is
uncertain, that is, if there is a suspicion of uterine sarcoma or adenomyosis.

Saline infusion sonography:

1. An imaging study in which pelvic ultrasound is performed while saline is infused into the uterine
cavity. Use of this technique allows identification of submucosal lesions (some of which may not be
seen on routine ultrasonography) and intramural myomas that protrude into the cavity and
characterizes the extent of protrusion into the endometrial cavity. Alternatively, a hysteroscopy
may be performed.

Gareth Stott
MANAGEMENT:
1. Conservative:
a. If small, asymptomatic, discovered incidentally → don’t do surgery, rather assess the exact
nature of the leiomyoma, and observe.
b. Assess every 3 months; if it grows or symptoms develop → do surgery.
c. Leiomyomas are best left alone during pregnancy.

2. Medical - administer GnRH analogue:

a. ↓ size by 50% in 3 months
b. ↓ menstrual flow, dysmenorrhoea, pain
c. Side effects of prolonged use:
i. Osteoporosis
Medically induced
ii. Hot flushes
menopause
iii. Headaches

d. Expensive, and not a good option if fertility is still desired

e. Currently used to shrink uterus prior to surgery (to make vaginal hysterectomy possible),
but may make surgery difficult if can’t see fibroid capsule
f. An alterative is Mifepristone (Selective Progesterone-Receptor Modulator):
i. Has the same clinical effect as GnRH

3. Non-Invasive Surgery:
a. Uterine artery embolization (UAE):
i. Less recovery time & fewer post-procedural complications
b. MR-guided focused Ultra-Sound Surgery (MRgFUS):
i. Thermo-ablation

4. Invasive Surgery:
a. Indications:
i. Size > 14 weeks gestation or > uterus
ii. Leiomyoma distorts the uterine cavity in a patient who wants more children
iii. Leiomyoma in lower part of uterus (may complicate labour)
iv. Doubt about nature of leiomyoma
v. Presence of complications
vi. Sudden enlargement of a leiomyoma

b. Pre-operative → Correct anaemia. Also remember to make horizontal incisions.

c. Procedures:
i. Myomectomy:
ii. Abdominal hysterectomy:
iii. Hysteroscopic resection:
Preserves potential for reproduction (young
patient, desire to have children, small fibroid
uterus, few tumours, healthy Fallopian tubes).
Less blood loss, less post-op mortality, prevents re-
occurrence, easier, certain that symptoms are
relieved
For small submucous fibroids

Gareth Stott