Book Review

Uterine Myoma

By Lee Joo-Won

Epidemiology

• uterine leiomyoma, myoma, fibroids • most common benign uterine tumor • usually diagnosed on physical examination • at least 20 % of all women of reproductive age • asymptomatic myoma : 40 -50 % of women older t

han 40 years of age • occur singly but often are multiple • African american>White woman

CAUSE• unknown ① arises from a single neoplastic cell ② hormonal responsiveness estrogen-dependent - enlarge during pregnancy, - enlarge during estrogen combined oral contraceptive intaking,

- regress after menopause

GROSS FINDINGS

• various in size and number • may cause symmetric uterine enlargement • distort the uterine contour significantly • pseudocapsule of connective tissue • usually one major blood vessel supplying each

tumor

LOCATION

depending on anatomical site of uterus

① corpus (M/C) ② cervix <5 % ③ broad ligament ④ pedicle

LOCATIONdepending on uterine wall ① interstitial or intramural myoma : 80 % (M/C) ② subserosal myoma ③ submucous myoma

** bleeding, sarcomatous change, infection, necrosis ** pedunculated myoma (delivered myoma)

CLINICAL MANIFESTATION

• generally asymptomatic, 25 % produce symptoms ① Abnormal uterine bleeding (menorrhagia) most common presenting symptom presents in 1/3 of patients undergone myomectomy

② palpable mass ③ pain chronic : dysmenorrhea, dyspareunia, Pelvic pressure acute : torsion of a pedunculated leiomyoma,

infection, degeneration

CLINICAL MANIFESTATION

④ urinary symptoms

Frequency ← extrinsic pressure on the bladder

Partial ureteral obstruction ← pressure from large tumors at the pelvic brim

Complete ureteral obstruction ← elevation of the base of the bladder with impingement on the region of the internal sphincter

CLINICAL MANIFESTATION

⑤ infrequent symptoms rectosigmoid compression, with constipation or internal obstruction

prolapse of a pedunculated submucous tumor through the cervix venous stasis of the lower extremities and possible thrombophlebitis secondary to pelvic compression

polycythemia ascites

CLINICAL MANIFESTATION

• Infertility leiomyomas are infrequent primary cause of infertility

reported as a sole cause in less than 3% of infertile patients

DEGENERATIVE CHANGES OF MYOMA

• 2/3 of all specimens ① hyaline degeneration : M/C ② cystic degeneration liquid changes of hyaline degeneration ③ calcifiation ④ infection & suppuration

DEGENERATIVE CHANGES OF MYOMA

⑤ necrosis → red degeneration : 2nd trimester, hemorrhagic infarction, focal pain, tenderness, low- grade fever, moderate leukocytosis

⑥ fatty degeneration

⑦ sarcomatous change <0.5%, ≥10 mitoses/hpf

DEGENERATIVE CHANGES OF MYOMA

Leiomyomas with increased number of mitotic figures - during pregnancy or taking progeststional agents - with necrosis - smooth muscle tumor of uncertain malignant potential -> 5-9 mitoses/10HPF that do not demonstrate nuclear atypia or giant cells

DIAGNOSIS

① history ② abdominal palpation ③ bimanual pelvic examination : most important → hard, nodular mass in uterine surface size, shape, mobility, contour, consistency

DIAGNOSIS④ endometrial curettage - bleeding control in abnormal uterine bleeding - diagnosis of submucous myoma - ddx with other conditions combined to myoma

-> adenocarcinoma, polyp, endometrial hyperplasia, ovarian dysfunction, incomplete abortion

DIAGNOSIS

⑤ laboratary data reproductive age : s-hCG, PAP, CBC, stool test pelvic mass : CA-125

⑥ X-ray ⑦ imaging study US,hysteroscopy laparoscopy : ddx with pelvic mass ddx benign with malignant origin of tumor CT, MRI : when suspicious of malignancy

NONSURGICAL MANAGEMENT

primarily judicious patient observation & follow up periodic repeat pelvic examination

( uterine size, location, growing rate)

* GnRH agonist effect ; 40 - 60 % decrease in uterine volume side effect ; hypoestrogenism ( reversible bone loss, hot flush) regrowth about 50 % short term use, low-dose hormonal replacement

NONSURGICAL MANAGEMENT

Indications ① preservation of fertility in women with large leiomyomas before attempting or preoperative treatment before myomectomy before atempting conception

② treatment of anemia to allow recovery of normal hemoglobin levels before surgical management, minimizing the need for transfusion or allowing autologous blood donation

③ treatment of women approaching menopause in an effort

to avoid surgery

NONSURGICAL MANAGEMENT

Indications ④ preoperative treatment of large leiomyomas to make vaginal hysterectomy, hysteroscopic resection or ablation, or laparoscopic destruction more feasible

⑤ medical contraindications to surgery ⑥ treatment of women with personal or medical indication for

delaying surgery

** progestational agents-decrease in uterine size, amenorrhea

SURGICAL MANAGEMENNT

careful assessment for associated symptoms ① abdominal myomectomy : desire childbearing, young ② vaginal myomectomy : prolapsed pedunculated submucous fibroid ③ hysteroscopic resection : small submucous leiomyoma ④ hysterectomy : definitive surgical management of

symptomatic uterine leiomyomas

SURGICAL MANAGEMENNT

- Indications of Hysterectomy ** asymptomatic leiomyomas do not usually require surgery ① abnormal uterine bleeding with resultant anemia, unreponsive to hormonal management

② chronic pain with severe dysmenorrhea, dyspareunia, or lower abdomianl pressure and/or pain

③ acute pain, as in torsion of a pedunculated leiomyoma, or prolapsing submucous fibroid urinary symptom or sign such as hydronephrosis after complete evaluation

SURGICAL MANAGEMENNT

- Indications of Hysterectomy ④ rapid enlargement of uterus on premenopausal years, or any increase in uterine size in postmenopausal women

⑤ infertility, with leiomyoma as the only abnormal finding

⑥ enlarged uterine size with compression symptoms or discomfort

Journal Review

Radomized Controlled Trials

BJOG. 2002 Dec;109(12):1429; author reply 1429.Three methods for hysterectomy: a randomised, prospec

tive study of short term outcome.Ottosen C, Lingman G, Ottosen L.

• total abdominal hysterectomy vs vaginal hysterectomy vs laparoscopic assisted vaginal hysterectomy

• MEASURES: duration of surgery, anaesthesia, time in hospital and recovery time

BJOG. 2002 Dec;109(12):1429; author reply 1429.Three methods for hysterectomy: a randomised, prospec

tive study of short term outcome.Ottosen C, Lingman G, Ottosen L

• Traditional vaginal hysterectomy proved to be feasible and the faster operative technique compared with vaginal hysterectomy with laparoscopic assistance.

• The abdominal technique was somewhat faster, but time spent in theatre was not significantly shorter.

• Abdominal hysterectomy required on average a longer hospital stay of one day and one additional week of convalescence compared with traditional vaginal hysterectomy.

• Vaginal hysterectomy should be a primary method for uterine removal.

J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):333-8

Seracchioli R, Venturoli S, Vianello F, Govoni F, Cantarelli M, Gualerzi B, Colombo FM

122 women with large uterus caused by myomas

Febrile morbidity was statistically more frequent in patients who underwent abdominal hysterectomy than in patients who underwent laparascopic hysterectomy. Postoperative hospitalization and convalescence were statistically shorter in patients who underwent laparascopic hysterectomy.

Laparoscopic hysterectomy is safe and feasible even in the presence of large uterus, and is a valid alternative to abdominal hysterectomy when the vaginal route is contraindicated.

Thank You!