ASSOCIATE PROFESSOR IOLANDA BLIDARU

MD, PhD

Epidemiology Epidemiology The commonest of all pelvic T. (1/3).The commonest of all pelvic T. (1/3).20% of female > 320% of female > 35 5 yyearsears have fibroid. have fibroid.Childbearing life.Childbearing life.Often enlarge during pregnancy or during oral contraceptive use, and regress after

menopause

occur in women of reproductive age, often

Uterus Uterus deprived deprived from a baby from a baby consoles consoles itself with a itself with a fibroid.fibroid.

CausesCauses

UnknownHyperestrogenemia – E2 / ER,

P / PR, GnRH, growth factors (IGF-1, EGF< PDGF< FGF)

RaceObesityChromosomal abnormalities (7, 12,

14)

PathologyPathologyMACROSCOPYMACROSCOPY site shape size consistency cut section capsule number varieties

Uterine leiomyoma

Corporeal •98%•multiple

Cervical •1-2%•solitary

Corporeal leiomyoma

submucus •24%•not capsulated

Subserous •18%

Interstitial •58%

Cervical leiomyoma

Supravaginal cervix •sessile•pedunculated

Exocervix •small •sessile•polypoid

CONSISTENCYCONSISTENCYFirmFirmHarder Harder ((hyaline degenerationhyaline degeneration).).Soft Soft ((pregnancy-cystic degenerationpregnancy-cystic degeneration).).

Stony hard (Stony hard (CalcificationCalcification))

Leiomyomata Uterus

CUT SECTIONCUT SECTIONwell demarcated surrounding muscle.well demarcated surrounding muscle.

whorly (intermingling muscle fibers whorly (intermingling muscle fibers

and fibrous tissue).and fibrous tissue).

paler than surrounding (ischaemia).paler than surrounding (ischaemia).

Microscopic Microscopic ExaminationExamination

Few formed blood vessels (blood lakes).

Smooth muscle cells and fibrous tissue cells.

Leiomyoma:

Changes occurChanges occuringing with with fibroidfibroid

General

Genital tract

Tumor itself

Genital tractGenital tract

Endometrium - hyperplasia

Tubes - inflammation

(salpingitis)

Endometriosis (30-40%)

Tumour itselfTumour itselfBenign degeneration atrophic hyaline red cystic fatty calcification necrosis with or without infection vascular (edema, lymphangiectasia)

Malignant degeneration (0.1-0.5 % - growth after menopause, rapid

enlargement, recurrent fibroid polyp).

DIAGNOSISDIAGNOSISHistoryExamination.Investigation.D.D.

SYMPTOMSSYMPTOMS No symptom Bleeding (menorrhagia - metrorrhagia). Pain - uncomplicated → congestion →

dysmenorrhea; complicated → degeneration (malignant, infection, torsion)

Infertility Mass Discharge Pressure symptoms (urinary, lower limb

edema, constipation)

SignsSigns

•Symmetrically enlarged uterus

(submucosal fibroid)

•Asymmetrically enlarged uterus (subserous fibroid)

InvestigationsClinical (examination)Laboratory (Hb, Ht, urinary tests,

pregnacy test, Pap test etc)Imaging & instrumental

techniques (US, hysteroscopy, hysterography, colposcopy, fractional curettage, Ct scan)

Miscellaneous (intravenous urography, etc)

DIFFERENTIAL DIAGNOSISPregnancy (normal / abnormal)

Ademomyosis. Leiomyomas - myomectomy, adenomyosis - hysterectomy

Solid Adnexal Mass (fibromas, Brenner tumors, inflammatory mass)

Uterine Leiomyosarcoma ( histologically - the presence of infiltrative margins, nuclear atypia, and increased mitotic figures )

Uterus Adenomyosis:

DIFFERENTIAL DIAGNOSIS

Uterine Leiomyosarcoma

Treatment of Treatment of LeiomyomaLeiomyoma

No treatmentConservativeRadiologicalSurgicalGnRH agonistsUterine artery

embolization.

Patient (age, parity, symptoms).

Tumor (number, size, type)

Complications.

Treatment of LeiomyomaTreatment of Leiomyoma

MEDICALMEDICALProgesterone / ProgestinsProgesterone / ProgestinsSelective PR modulator / antagonist (Mifepristone, Ulipristal)(Mifepristone, Ulipristal)

GnRH agonists (Buserelin, Triptorelin, Leuprolid, Histerelin, Goserelin)

SURGICALSURGICALMyomectomy (Hysteroscopy, laparoscopy, laparotomy)

Hysterectomy