ch 15. Uterine fibroids

Posted: May 17, 2012 in Gynocology

Uterine fibroids ;Leiomyoma ; Fibromyoma ; Myoma ; Fibroids :  A leiomyoma  is a benign smooth muscle neoplasm that is very rarely (0.1%) premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.

Etiology :

  1. Etiology is unknown.
  2. Originates from Single Muscle Cell (Could be Embryonic Cells or Sooth Muscle Cell from blood vessels)
  3. Estogens : no evidence that it is a causative factor , it has been implicated in growth of myomas
  4. Myoma contains estrogen receptors in higher concentration than surrounding myometrium,so Estrogen helps Myoma to be enlarged.
  5. Progestrone helps Myoma for further cell division (Mitosis).
Features :
  1. Occurring frequently at 50 yr. and very rare before 20 yr.
  2. 25% in white women
  3. 50% in black women

Types: They are classified by anatomic locations. Most frequently,

  1. Subserous (beneath the peritoneum)
  2. Intramural (within the uterine wall)
  3. Submucous (beneath the endometrium)

a = Subserosal fibroids
b = Intramural fibroids
c = Submucosal fibroid
d = Pedunculated submucosal fibroid
e = Fibroid in statu nascendi

Microscopic Stracture of Myoma :

  1.  Nonstriated muscle fibers are localized  in different directions
  2. Pseudocapsule of areolar tissue (a type of loose connective tissue esp. made of collagens) & compressed myometrium
  3. Arteries are less dense than myometrium & do not have a regular pattern of distribution
  4. 1-2 major vesseles are found at the base or pedicle

Symptoms :

Depends on size and location

■Asymptomatic – small (and some large ones) – detected on routine examination

■Menorrhagia – if submucous. May lead to anaemia, with symptoms associated with this.

■Crampy pains may result from contraction of the uterus.

■Pressure symptoms from large fibroids

  • Dysuria
  • Constipation or backache
  • Pelvic pain and sometimes, impossible intercourse from cervical myoma
  • Subfertility and Recurrent miscarriage from submucous fibroids

Differential Diagnosis : Exclude other causes of abnormal bleeding

  1. Endometrial hyperplasia
  2. Endometrial or tubal Cancer
  3. Uterine sarcoma
  4. Ovarian Cancer
  5. Polyps
  6. Adenomyosis
  7. DUB (Dysfunctional Uterine Bleeding)
  8. Endometriosis
Exogenouse estrogens Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Cancer
Complications :
For Pregnant Women :
  1. Uterine inertia
  2. Malpresentation
  3. Obstruction of the birth canal
  4. Cervical or isthmeic myoma
  5. Postpartum Hemorrhage

For Non-Pregnant Women :

  1. Heavy bleeding with anemia is the most common
  2. Urinary or bowel obstruction from large parasitic myoma is much less common
  3. Malignant transformation is rare
  4. Ureteral injury or ligation is a recognized complication of surgery for Cervical  Myoma
Treatments :

Treatment for the symptoms of fibroids may include:

  1. Birth control pills (oral contraceptives) to help control heavy periods
  2. Intrauterine devices (IUDs) that release the hormone progestin to help reduce heavy bleeding and pain
  3. Iron supplements to prevent or treat anemia due to heavy periods
  4. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain
  5. Short-term hormonal therapy injections to help shrink the fibroids

Surgery and procedures used to treat fibroids include:

  1. Hysteroscopic resection of fibroids: Women who have fibroids growing inside the uterine cavity may need this outpatient procedure to remove the fibroid tumors.
  2. Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. Women who may want to become pregnant in the future should discuss this procedure with their health care provider.
  3. Myomectomy: This surgery removes the fibroids. It is often the chosen treatment for women who want to have children, because it usually can preserve fertility. More fibroids can develop after a myomectomy.
  4. Hysterectomy: This invasive surgery may be an option if medicines do not work and other surgeries and procedures are not an option.
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