Uterine leiomyomas

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Uterine leiomyomas

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Uterine leiomyomas

  1. 1. Dr. Yusri Arif Sapaee Supervised by Dr. Amy Suzanna Annuar
  2. 2.  Benign tumours of the uterine smooth muscle (the myometrium)  Also called myomas, fibromyomas and fibroids  Most common benign tumours of female genital organs  Major contributor for hyterectomy in Malaysia ~ 47.8%
  3. 3.  Exact etiology is UNKNOWN  Possible etiological factors include:  HYPERESTRENISM  GROWTH FACTORS  GENETIC FACTORS
  4. 4.  Evidenced by the following  Appear only in childbearing period  Commonly associated with endometrial hyperplasia and/or endometriosis  Increase in size during pregnancy and during estrogen hormonal therapy  Decrease in size and undergoes atrophy after menopause with hormonal depletion or with GnRH agonist therapy
  5. 5.  Parity  More common in nulliparous and low parity women  Hereditary  More common in women with positive family history (mother and sister)  Obesity  More common in obese women  Conversion of circulating androgens to estrone (E1) by excess adipose tissue
  6. 6.  Understanding their differences, how they grow and how they develop  Can help to decide the best treatment option  To evaluate degree of difficulty during operation
  7. 7.  proximate to the endometrium and grow toward and bulge into the endometrial cavity  Increase surface area of endometrial lining  Heavy menstrual bleeding  anemia  multiple blood transfusion  Large submucosal fibroid tumors  May block fallopian tubes  infertility
  8. 8.  The growth centered within the uterine walls  Tends to make uterus feels larger than normal  bulk symptoms  Prolonged heavy menses  Pelvic pain  Pressure on surrounding organs  Inhibit muscle contraction   cramping pain during menses
  9. 9.  originate from myocytes adjacent to the uterine serosa, and their growth is directed outward  Usually cause pelvic pain and compression symptoms  May extend to lie within the broad ligaments  difficult to remove during surgery
  10. 10.  Attached only by a stalk to their progenitor myometrium  Pedunculated submucosal myoma  Pedunculated subserosal myoma  It can be twisted on their stalk   acute pelvic pain
  11. 11.  Mostly asymptomatic  Usually accidentally discovered during routine bimanual examination or on performing pelvic ultrasound
  12. 12.  Mostly with submucosal and large multiple interstitial myomas  Increased surface area of the endometrium  Mechanical interference with uterine contraction  Associated endometrial hyperplasia  Increased myometrial vascularity due to venous congestion
  13. 13. At any level within the myometrium, submucous, subserosal, and intramural leiomyomas can compress adjacent veins and thereby cause dilatation of distal endometrial venules.
  14. 14.  Usually painless unless complicated  Dull aching pain: hyaline degeneration, infection of submucosal fibroid polyp  Acute pain: red degeneration and torsion of pedunculated myoma  Colicky pelvic pain: extrusion of pedunculated submucosal myoma through the cervix  Loin pain: ureteric compression  Congestive or spasmodic dysmenorrhea
  15. 15.  Urinary bladder  frequency, incontinence  Ureter  hydronephrosis  Rectum  constipation  Cervix  dyspareunia  Major veins  edema of lower limb(s)  Pelvic nerve  back pain and thigh pain
  16. 16.  Interference with implantation and distortion of uterine cavity  Tubal obstruction  Interference with ascent of sperm and fertilization
  17. 17.  Recurrent miscarriage  Preterm labour  Pre-labour rupture of membrane  Malpresentations  Obstructed labour  Post partum haemorrhage  Abruptio placenta
  18. 18.  Hyaline degeneration  Occurs in the centre due to poor vascularity  Becomes larger and softer  Red degeneration  More frequent in pregnancy  Thrombosis of capsular vessels  Rapid uterine growth  outgrowth its blood supply
  19. 19.  Calcification  Deposition of calcium phosphate and carbonate along blood vessels in long standing myomas  Peripheral  egg-shell appearance  Diffuse  womb stone  Common after menopause
  20. 20. Transvaginal sonogram of an intramural leiomyoma with calcified border
  21. 21.  Infection  Most frequent at the tip of a submucosal myoma polyp  Torsion  Pedunculated subserous myoma  Rarely torsion of the whole uterus  Malignant transformation  Very rare  No more than 0.2 – 0.5% of myomas
  22. 22.  Gold standard in diagnosis  Saline-infusion sonography  Injection of saline to delineate the endometrial cavity  Improve sensitivity of TVS in diagnosing submucosal myoma  Also very helpful to exclude associated pelvic pathology e.g. Ovarian cyst
  23. 23. Submucous fibroid clearly outlined by saline-infusion sonography and identified by long white arrows.
  24. 24.  These tools allow more accurate assessment of leiomyomas, which may help identify appropriate patients for alternatives to hysterectomy  Hysteroscope  Hysterosalpingography (HSG)  Magnetic resonance imaging (MRI)
  25. 25.  Structural factors  uterine size  size, number and location of the myomas  Desire for fertility  Definitive versus uterus-conserving treatment  General medical health  Age, BMI, co-morbidities, previous treatment, previous surgery  Preference  Focal versus global uterine treatment
  26. 26.  NSAIDs  Inhibit prostaglandin synthesis  Reduce menstrual flow (25-35%)  Relieve dysmenorrhea  Progestogens  Given for 21 days  Significant reduction in menstrual blood loss
  27. 27.  Danazol  Synthetic steroid  suppress estrogen and progesterone receptor in endometrium  thinning of lining of endometrium  reduction of blood loss  Disadvantage: masculinizing effect
  28. 28.  Tranexamic acid  Antifibrinolytic agent  Synthetic derivative of amino acid lysine  Reversible blockage on plasminogen  50% reduction of menstrual blood loss  Levonorgestrel intrauterine system  Reduces blood loss by 80%  Not applicable to all type of fibroid
  29. 29.  GnRH agonist  Induce a reversible hypoestrogenic state  Reduce uterine volume  Pre-operative use  3-4 months course prior surgery  Reduce fibroid size and uterine volume  Midline vertical laparotomy incision  lower transverse abdominal incision  Improve pre-operative haemoglobin level  Reduce perioperative blood loss and transfusion requirement
  30. 30. 1. Myomectomy 1. Abdominal myomectomy 2. Vaginal myomectomy 3. Hysteroscopic myomectomy 4. Laparoscopic myomectomy 2. Hysterectomy 3. Uterine artery embolization
  31. 31.  Benefits  80% improvement in abnormal menstrual bleeding  Removal of intracavitary fibroid improves fertility  Disadvantage  Need another treatment after myomectomy  20% over 2-5 years
  32. 32.  Removal of small submucosal myoma <5cm in diameter which protrude >50% into uterine cavity  Better preceded by GnRH agonist preparation to decrease vascularity and diminish the size of myomas  Advantage:  Significantly less pain  Shorter recovery period
  33. 33.  Indications  Postmenopausal women with symptomatic fibroids  Multiple or very large myoma  Future fertility not desired  Patient’s preference  Advantages  Sure relief of symptoms with no recurrence  Less blood loss during surgery  Lower post-operative morbidity
  34. 34.  Angiographic interventional procedure that delivers polyvinyl alcohol (PVA) microspheres or other particulate emboli into both uterine arteries.  Uterine blood flow is therefore obstructed, producing ischemia and necrosis  These microspheres are preferentially directed to the tumors, sparing the surrounding myometrium
  35. 35. Source: 1. William’s Gynaecology Textbook 2. RCOG website 3. Kasr El-Ainy School of Medicine Textbook

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