UTERINE MYOMA

Lia Tadesse, M.D

March 2012

Lia Tadesse,M.D
Outline
Learning Objectives
Introduction
Pathology and pathogenesis
Risk factors and epidemiology
Classification
Secondary changes
Clinical findings
Complications in pregnancy
Diagnostics
Differential Diagnosis
Management
Lia Tadesse,M.D
Learning Objectives
Understand what is myoma
Understand the different types of myoma
Understand the risk factors for myoma
Understand the clinical presentation of myoma
Understand how to diagnose uterine myoma
Understand the modalities of treatment for myoma

Lia Tadesse,M.D
Introduction
 Benign monoclonal tumors
Arise from the smooth muscle cells of the myometrium.
 Present in 20–25% of reproductive-age women
Occur 2–3 times more frequently in black than in white
women.
Are hormonally responsive and therefore grow only
during the reproductive years and mostly shrink in
menopause
Can be single but more commonly multiple in number
and usually less than 15 cm (But as large as 45 kg
recorded)
Lia Tadesse,M.D
Introduction
Different Nomenclatures
MYOMA
LEIOMYOMA
LEIOMYOMATA
UTERINE FIBROIDS
FIBROMYOMA

Lia Tadesse,M.D
Pathology and pathogenesis
The cause of uterine leiomyomata is not known
Estrogen has a role in the growth but no evidence that
it is the cause
usually multiple, discrete, either spherical or irregularly
lobulated, solid and usually pinkish-white
Has Pseudocapsule demarcating them from the
surrounding myometrium(helps for easy inoculation of
tumor during surgery)
composed of smooth muscle and fibrous connective
tissue,
firm and rubbery; cut surface is whorled
Lia Tadesse,M.D
Risk factors and epidemiology
Parity: Having one or more pregnancies decreases the
chance of having myoma
Age at first delivery: Early age at first birth decreases
the risk (>35 years has increased risk)
Early menarche <10yrs has increased risk
Taking OCP tends to protect from myoma
Family history
Black Race

Lia Tadesse,M.D
Classification/Types of Myoma
Is Based on location
Submucous myomas
Intramural or interstitial myomas
Subserous or subperitoneal myomas
Intraligamentary myomas
Cervical myomas

Lia Tadesse,M.D
…Classification/Types of Myoma
Submucous myomas: lie just beneath the
endometrium and tend to compress it as they grow
toward the uterine lumen and protrude into the
uterine cavity.
Occasionally they form pedicle and pass through the
cervical canal while still attached within the corpus
by a long stalk (delivered myoma). When this
occurs, they are subject to torsion or infection

Lia Tadesse,M.D
…Classification/Types of Myoma
Intramural or interstitial myomas: are the
commonest type and lie within the uterine wall,
giving it a variable consistency.
Can distort the uterine cavity or the external
surface of the uterus.
Can also cause symmetric enlargement of the
uterus when they occur singly.

Lia Tadesse,M.D
…Classification/Types of Myoma
Subserous or subperitoneal myomas: may lie just at the
serosal surface of the uterus or may bulge outward from the
myometrium. The subserous leiomyomata may become
pedunculated. If such a tumor acquires an extrauterine blood
supply from omental vessels, its pedicle may atrophy and
resorb; the tumor is then said to be parasitic (uncommon).

When subserous tumors arising laterally extend between the

2 peritoneal layers of the broad ligament they are called
Intraligamentary myomas

Cervical myomas: are located in the cervix, rather than the

uterine corpus.
Lia Tadesse,M.D
 Secondary changes
Benign (the commonest) or Malignant (very rare) changes
Benign Changes
Atrophic degeneration: as tumor size decreases at menopause or after
pregnancy.
Hyaline degeneration: the most common type and is caused by an
overgrowth of the fibrous elements, which leads to a hyalinization of the
fibrous tissue and, eventually, calcification. Usually asymptomatic.
Cystic degeneration; Liquefaction after extreme hyalinization
Calcific (Calcareous) degeneration: Subserous leiomyomata are
commonly affected by circulatory deprivation, which causes
precipitation of calcium carbonate and phosphate within the tumor.
Septic Degeneration: Circulatory inadequacy may cause necrosis of
the central portion of the tumor followed by infection. Acute pain,
tenderness, and fever result.
Myxomatous (Fatty) degeneration : Not common
Lia Tadesse,M.D
Secondary changes
Benign Changes
Carneous (Red) Degeneration:
Usually occurs during pregnancy
The physiologic changes in the leiomyoma are not the
same as in the myometrium during pregnancy; this
results in anatomic discrepancy that impedes the
blood supply, resulting in aseptic degeneration and
infarction.
Usually accompanied by pain but is self-limited.
Malignant (sarcomatous) Change: Leiomyosarcoma
(rare - <1%)
Lia Tadesse,M.D
Clinical Findings
Symptoms
Most are asymptomatic
30-35% present with symptoms
Abnormal uterine bleeding is the commonest of all
symptoms: Menorrhagia, pre-menustral spotting and
others. Commonly in Submucous myomas and
associated with iron deficiency anemia
Abdominal pain: could be due to degeneration,
infection, or torsion of pedunculated myoma, sense of
heaviness in large tumors, impacted myomas pressing
nerves
Lia Tadesse,M.D
…Clinical Findings
…Symptoms
Pressure Effects: Compression on urinary tract
causing frequency and urgency, difficulty to empty
bladder and rarely urinary obstruction.
Vaginal discharge and dysparenuia in cervical myomas,
lower extremity edema and constipation in large
tumors
Rarely parasitic tumors may cause bowel obstruction
Vaginal Discharge (Uncommon): Due to
transcervical prolapse into the vagina

Lia Tadesse,M.D
…Clinical Findings
…Symptoms
Infertility and Spontaneous abortion:
 Myoma account for 1 to 2 percent of infertility (around
1/3rd of myoma cases could be infertile) .
Compromised implantation and placental growth over the
myoma site, Cornual myoma blocking the tube
Rapid fibroid growth in early pregnancy,
Increased uterine contractility.
Leiomyomas that distort the uterine cavity (submucosal
or intramural with an intracavitary component) result in
difficulty to conceive and an increased risk of miscarriage
Lia Tadesse,M.D
…Clinical Findings
Signs
Uterine size is defined as the equivalent gestational size as
determined by abdominal and pelvic examination.
Abdominal examination: Irregular, nodular tumors
protruding against the anterior abdominal wall and are
usually firm on palpation

Pelvic examination. The most common finding is uterine

enlargement.
 The shape of the uterus is usually asymmetric (could also

be symmetric) and irregular in outline on bimanual exam.

 The uterus is usually freely movable unless concomitant

pelvic disease exists such as endometriosis or pelvic

adhesions.Lia Tadesse,M.D
Complications in pregnancy and labor
80% remain the same size during pregnancy
Red(Carnous) Degeneration (vascular deprivation due
to rapid enlargement) - pain
Abortion, Preterm labor, IUGR
In Labor :uterine inertia,
- Fetal malpresentation,
- Obstruction of the birth canal
- Postpartum hemorrhage

Lia Tadesse,M.D
Diagnostics
Hematocrit and Hemoglobin
Ultrasound: Helps to identify the site, rule out other
pelvic tumors and rule out pregnancy
Transvaginal ultrasound has high sensitivity (95 to 100
percent) for detecting myomas in uteri less than 10 weeks'
size.
Other diagnostics: MRI (to differentiate from
adenomyosis and rarely needed), hysterescopy ( for
identification, and may also be used for removal, of
submucous leiomyomata)
Endometrial biopsy: For abnormal uterine bleeding,
ruling out other cases like endometrial tumor
Lia Tadesse,M.D
Differential Diagnosis
pregnancy,
Any pelvic mass
- Ovarian cyst or tumor
 Tubo-ovarian abscess
 Endometriosis
 Endometrial cancer
 Adenomyosis

Lia Tadesse,M.D
Management
Choice of treatment depends on:
 Patient's symptoms
 Age
Parity
Pregnancy status
Reproductive plans
General health
Size and location of the myomas

Lia Tadesse,M.D
Management
Expectant management: For asymptomatic and size
less than 12weeks(?) with follow up every 3-6 months
Helpful if near menopause
Medical treatment: To relieve or reduce symptoms
usually to temporarily reduce size and improve
hematocrit preoperatively; 3-6mths
- Gonadotropin releasing hormone agonists
(create a hypoestrogenic environment)

Lia Tadesse,M.D
..Management
Surgical Treatment: when symptoms fail to respond to
conservative management.
Myomectomy:
If there is need to preserve fertility
Disadvantage is risk of recurrence (50-60% in 5 years)
In case of pedunculated submcous tumors, removal can be
done hysterescopically
Hysterectomy: Mass and uterus removed in toto
In small myomas Total Vaginal Hysterectomy can be done
Commonly Total abdominal hysterectomy is
done(Laparatomy or Laparascopy)
Curative
Lia Tadesse,M.D
..Management
Others
Uterine Artery Embolization (UAE)
Endometrial Ablation

Myolysis

Other Treatment of complications

Correction of anemia

Hydration and analgesics in Red degeneration

Don’t forget the Psychological aspect

Lia Tadesse,M.D