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Uterine Leiomyoma: A Comprehensive Guide for Women

Learn about uterine leiomyoma, also known as fibroids, including etiology, classification, pathology, degeneration, clinical findings, symptoms, diagnosis, and differential diagnosis. This informative guide covers everything you need to know about this common benign tumor of the female reproductive system.

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Uterine Leiomyoma: A Comprehensive Guide for Women

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  1. Uterine Leiomyoma Wu Ruijin

  2. Introduction • Also known as myoma, fibroids, or fibromyomas • Most common benign tumor of female reproductive system • Most common uterine mass, present in 20-25% of reproductive–age women • Common in women at 30-50y • Proliferative, well-circumscribed, pseudoencapsulated • Vary in diameter from 1mm to 20 cm • Single, most are multiple • Usually asymptomatic

  3. Etiology 1. Cytogenetic studiessuggest monoclonal tumors resulting from somatic mutations 2. Estrogen is a promoter of leiomyoma growth Not detectable before puberty and after menopause; Grow rapidly during pregnancy; GnRHa reduce leiomyomas size Probably relates to female hormones • Estrogen and ER ↑ • Progestin may promote mitosis of myoma 3. Local and paracrine factors may account for variations in tumor volume and rate of growth

  4. Classification According to the location： • Uterine body myoma 宫体肌瘤(90%) • Cervical myoma宫颈肌瘤 (10%)

  5. Classification According to the relationship between myoma and uterine myometrium ： • intramural myoma：肌壁间肌瘤 60%-70% • subserosal myoma：浆膜下肌瘤 20% • submucous myoma：粘膜下肌瘤 10%-15% Pedunculated (attached by a stalk) Intraligamentary myoma

  6. Classification multiple myoma intramural myomas subserosal myomas submucous myomas

  7. Pathology Gross Appearance： • round, smooth, and usually firm • false capsular covering—pseudocapsule假包膜 can be clearly demarcated from the surrounding myometrium

  8. Pathology Gross Appearance： Transverse section : • light gray • a whorl-like arrangement （漩涡状）or an intertwining (编织状)pattern

  9. Pathology Microscopic examination： • Composed of smooth muscle cells and varying amounts of connectives tissue • Individual cells are quite uniform in size, spindle shaped, have elongated nuclei. • Nonstriated（非横纹） muscle fibers are arranged in interlacing bundles of varying size running in different directions.

  10. Degeneration • Hyaline degeneration （玻璃样变、透明变性） --most common, overgrowth of fibrous elements • Cystic degeneration（囊性变） --sequel necrosis, liquefaction after hyaline dg • Red degeneration（红色样变） • Sarcomatous change（肉瘤样变） • Calcification（钙化） --common in post-menopause pts

  11. Degeneration Red degeneration • A specific kind of necrosis • Occurs frequently in pregnancy and puerperium • Caused by aseptic dg associated with local hemolysis • Venous thrombosis and congestion with interstitial hemorrhage

  12. Degeneration ← Red degeneration ← Hyaline degeneration

  13. Degeneration Sarcomatous change • malignant • rare, 0.4-0.8% • old women • enlarge rapidly with irregular vaginal bleeding

  14. Degeneration Sarcomatous change

  15. Clinical Findings__Symptoms • Vary greatly • Usually no symptoms • Symptoms occur in 10-40% of patients • Associate with location, and degenerations • Not associate with size and number

  16. Symptoms 1. Menorrhagia and prolonged menses • Most common symptom, occur in 30% symptomatic pts • Excessive bleeding at menses, >80mL, >7d (1)necrosis of surface endometrium overlying the submucous leiomyoma, (2) disturbance in hemostatic contraction of muscle bundles, (3) increased surface area of endometrial cavity, (4) alteration in endometrial microvasculature. • Large intramural myoma • Submucous myoma • Result in profound anemia

  17. Symptoms 2. Pain • usually not pain • torsion of a pedunculated leiomyoma • infarction progressing to carneous degeneration 3. Pelvic mass and Pressure effects • enlarged leiomyoma press surrounding structure • pressure on bladder → urinary frequency, urinary retention • Intraligamentous（阔韧带） myomaand large cervical myoma → obstruct ureter • pressure on rectum → constipation(便秘)

  18. Symptoms 4. Others • Infertility: -- Large intramural leiomyomas located in cornual regions or close the interstitial portion of tube --Submucous leiomyomas may impede embryo implantation • Spontaneous abortion -- 2 times incidence in normal pregnant women with unknown cause 5. Pregnancy-related disorders • Higher incidence of spontaneous abortion • Red degeneration • Premature labor • A factor in malpresentation, mechanical obstruction, or uterine dystocia（难产） • Postpartum hemorrhage • Increased cesarean sections

  19. Sign associated with： • size • location • number • degeneration large myoma→ palpable abdominal mass Pelvic examination（ Bimanual or vagino-recto-abdominal examinations） uterus —— enlarged，irregular and hard

  20. Diagnosis • Typical symptoms and signs • Ultrasound • Hysteroscopy • Laparoscopy • MRI

  21. Ultrasound Small intramural leiomyomas

  22. Ultrasound subserous leiomyomas

  23. Diagnosis Hysteroscopy submucous leiomyomas

  24. Diagnosis Laparoscopy

  25. Differentialdiagnosis • Pregnancy • Ovarian neoplasms • Adenomyosis • Malignant tumors of uterus • uterine sarcoma • endometrial carcinoma • cervical cancer

  26. Treatment Individualized,nonsurgical or surgical According to : • age • desire for childbearing • symptoms • location, size, growth rate and amount of myoma

  27. Treatment Observation and Follow Up • Small, asymptomatic, especially near menopause -- leiomyomas will atrophy as estrogen levels fall • Interval：3～6 months (1) Bimanual examinations: uterine size and tumor growth rate. Slow growth or stable size --annual follow-up. Rapid growth--suspicious for malignancy and surgical intervention. (2) Pelvic US or MRI performed if physical examination inadequate

  28. Medical measure Indications： • smaller than 2 months pregnancy in size • slight symptoms • near menopause

  29. Medical measure 1. Androgenic agents： 甲基睾丸素、丙酸睾丸酮 no more than 300mg/m testosterone propionate:25mg im 1/5d, 25mg/d 3 at menses to against estrogen, atrophy endometrium, enhance hemostatic contraction of muscle bundles 2. Gonadotropin-releasing hormone agonist （GnRH-a） × GnRH-a LH、FSH↓ E2↓ shrinkage of myoma(50%) • Leuprorilin亮丙瑞林 • Goserelin戈舍瑞林 • subcutaneous implant, H • or intramuscular depot injection • Monthly or every 3 months

  30. Medical measure • 2.GnRH-a • Efficacy : • GnRHa suppress gonadotropin secretion and create a hypoestrogenic state similar to postmenopause level. • Side effects: • Hypoestrogenic side effects • Osteoporosis --- no more than 6 m • Regrow within 12w after GnRHa discontinued GnRHa recommended for : • a. large submucous myoma to facilitate hysteroscopic resection • b. symptomatic perimenopausal pts to avoid surgery • c. pts with anemia taking iron to increase HB prior to surgery 3.Mifepristone (RU486)米非司酮 12.5mg/d

  31. Surgical measures Indications： • greater than 10 weeks in size • menorrhagia→ anemia or interferes normal lifestyle • protrusion through the cervix • pressure effects • rapid growth • failure in medical treatment • infertility or recurrent abortion • progressive hydronephrosis or impair renal function

  32. Surgical measures Depends on age, symptoms, size, location, and desires for fertility. • Myomectomy（子宫肌瘤剔除术） • removal of leiomyomas, preserving uterus • preserve fertility, <35 years old • 80% improve symptoms, 15% symptom recurrence, 10% require additional treatment. • recurrence of myomas depends on number, age, completenessof original myomectomy.

  33. Types of Myomectomy • Abdominal myomectomy （经腹） • Hysteroscopic resection（宫腔镜） • --submucous leiomyomas --less pain and shorter recovery periods • Laparoscopic myomectomy 腹腔镜 --shorter recovery times --But large, multiple, deep, lower posterior wall leiomyomas are technically more challenging • MRI-guided focused ultrasound --uses ultra­sound-generated heat to cause cell death --new treatment option • Laparoscopic myolysis (using laser or coagulation current) and cryomyolysis (using a -180°C probe) --persistent decrease size --another promising therapeutic option

  34. Hysterectomy（子宫切除术） • Both leiomyomas and any associated disease removed permanently. No risk of recurrence. • Numerous large tumors • Obviously symptomatic patient • No wish of preserving fertility • Suspected to malignant transformation

  35. Uterine artery embolization (UAE) • Injected with embolic material to occludes vessel feeding the uterus and leiomyomas, causing shrinking or necrosis of leiomyomas. Efficacy: • 60% reduction in size • Controls menorrhagia ≥90% Indications： • near menopause • no longer desire fertility • large uterus • multiple risks for surgery, or do not desire surgery • uncontrollable menorrhagia

  36. Complications of UAE : • fibroid expulsion • vaginal discharge • Infection • premature ovarian failure • persistent pain

  37. Myomas during pregnancy Impact on pregnancy：abortion Impact on delivery： • preterm labor 早产 • fetal malpresentation 胎位异常 • placenta previa 前置胎盘 • birth canal obstruction 产道梗阻 • postpartum hemorrhage 产后出血

  38. Myomas during pregnancy Red degeneration • Clinical finding: • pain, fever, WBC↑ • rapid growth of myoma，tenderness • Conservative treatment antibioticsusing

  39. Thank You !

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