This is a lecture note on myoma.

1. Myoma
Hale T., O & G Yr-2 Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
1Hale T., M.D., Resident Physician

2. • Leiomyomas are benign smooth muscle neoplasms that
typically originate from the myometrium
• Other names
– Uterine myomas
– Uterine fibroids (Misnomer)
Hale T., M.D., Resident Physician 2

3. • Incidence
– Generally cited as: 20-25%
– Based on histologic and sonographic evaluation: 70-
80%
Hale T., M.D., Resident Physician 3

4. • Pathology
– Pseuodcapsule gives myomas autonomy and easy to
be “shelled out” during surgery serving as a cleavage
plane
– Mitotic activity differentiates myomas from
leiomyosarcomas
• Rare in myomas
– Degenaration is when muscle cells are replaced with
other various degenerative substances because of
limited blood supply
Hale T., M.D., Resident Physician 4

5. • Degenerative changes
1. Hyaline,
2. calcific,
3. cystic,
4. myxoid,
5. carneous or red,
6. Fatty
7. Sarcomatous
Hale T., M.D., Resident Physician 5

6. • Acute pain my accompany degeneration
• Why degeneration?
– Limited blood supply, lower arterial density
– Lack of vascular organization
Hale T., M.D., Resident Physician 6

7. • Cytogenetics
– Each leiomyoma is derived from a single progenitor
myocyte
– Karyotypic defects are found in approximately
40 percent of leiomyomas
– A number of unique defects involving chromosomes
6, 7, 12, and 14 and less commonly X, 1, 3, 10, 13 have
been identified to correlate with rates and direction of
tumor growth
Hale T., M.D., Resident Physician 7

8. • Estrogen
– Uterine leiomyomas are estrogen- and progesterone-
sensitive tumors
– Sex steroid hormones likely mediate their effect by
stimulating or inhibiting transcription and production
of cellular growth factors
Hale T., M.D., Resident Physician 8

9. • Leiomyomas themselves create a hyperestrogenic
environment, which appears requisite for their growth
and maintenance
– First, compared with normal myometrium, leiomyoma
cells contain a greater density of estrogen receptors,
which results in greater estradiol binding
– Second, these tumors convert less estradiol to the
weaker estrone
– A third mechanism involves higher levels of
cytochrome P450 aromatase in leiomyomas compared
with normal myocytes
– This specific cytochrome isoform catalyzes the
conversion of androgens to estrogen in a number of
tissues Hale T., M.D., Resident Physician 9

10. Hale T., M.D., Resident Physician 10

11. Hale T., M.D., Resident Physician 11

12. • Obesity
– Increased conversion of androgens to estrogen
– Decreased hepatic production of sex hormone binding
globulin
Hale T., M.D., Resident Physician 12

13. • Progestins
– Evidences are conflicting
– Might stimulate or inhibit myoma growth
• COC
– Decrease or no effect on myoma
• MPA
– Might increase risk
– Use lowest possible dose in myoma patients
• Smoking
– Alter estrogen metabolisim and decrease risk of
myoma
Hale T., M.D., Resident Physician 13

14. Hale T., M.D., Resident Physician 14
Rarely located in
1. Vagina
2. Broad ligament
3. Vulva
4. Fallopian tubes

15. • Other rare types
– Leiomyomatosis
• Intravenous leiomyomatosis
– Uterine and other pelvic veins, the vena cava,
and even the cardiac chambers
• Benign metastasizing leiomyomas
– lungs, gastrointestinal tract, spine, and brain
• Disseminated peritoneal leiomyomatosis
Hale T., M.D., Resident Physician 15

16. • Parasitic leiomyomas are subserosal variants that attach
themselves to nearby pelvic structures from which they
derive vascular support, and then may or may not detach
from the parent myometrium
Hale T., M.D., Resident Physician 16

17. • The European Society of Hysteroscopy defines
leiomyomas as follows:
– Type 0, if the mass is located entirely within the
uterine cavity;
– Type I, if less than 50 percent is located within the
myometrium; and
– Type II, if greater than 50 percent of the mass is
surrounded by myometrium
Hale T., M.D., Resident Physician 17

18. • Symptoms
– Bleeding
– Pain
– Pressure sensation
– Compressive symptoms
– Infertility and pregnancy wastage
Hale T., M.D., Resident Physician 18

19. • What causes infertility in leiomyoma?
– Amercian Society of Reproductive Medicine (2006)
1. Occlusion of tubal ostia
2. Disruption of the normal uterine contractions that
propel sperm or ova
3. Distortion of the endometrial cavity may also
diminish implantation and sperm transport
4. Endometrial inflammation and vascular changes
that may disrupt implantation
Hale T., M.D., Resident Physician 19

20. • Other manifestations
– Myomatous erythrocytosis syndrome
• This may result from excessive erythropoietin
production by the kidneys or by the leiomyomas
themselves
– Pseudo-Meigs syndrome
• The presumed etiology stems from discordancy
between the arterial supply and the venous and
lymphatic drainage from the leiomyomas
Hale T., M.D., Resident Physician 20

21. Hale T., M.D., Resident Physician 21

22. • Diagnosis
– Historically with symptomatic myomas
– Enlarged uterus with irregular border on pelvic exam
– Lab: Serum or urine hCG to rule out pregnancy
– Imaging
• Sonography
• SIS
• Hysteroscopy
• HSG
• MRI
Hale T., M.D., Resident Physician 22

23. • Management
– Observation
• Anual pelvic and sonographic evaluation
– Drug therapy
• Avoid Leupride use for > 6 months
• Add-back therapy after 3 months
– Uterine artery embolization
– Surgical removal
Hale T., M.D., Resident Physician 23

24. UAE Absolute and Relative Contraindications
Hale T., M.D., Resident Physician 24
Advantages of this procedure
Short hospital stay
Lower pain score
Early return to work
Disadvantages
Postembolization syndrome -
10%
25% require another treatment
Pregnancy complications
Increased vaginal discharge
Transitient amenorrhea
Groin hematoma

25. Magnetic Resonance Imaging-Guided Focused Ultrasound (MRgFUS)
• Advantages
– Noninvasive
– Done in conscious sedation
– Early return to work
–
• Disadvantages
– 28 percent of women seek alternative
treatments for their symptoms by 12
months following MRgFUS
– Contraindications include
• Total uterine size > 24 wks
• Desire for future fertility
• Contraindications for MRI
• Obstructions to the energy path
such as abdominal wall scars or
intraabdominal
clips,
• Moreover, leiomyoma
characteristics such as size, blood
perfusion qualities, and location
near adjacent tissues may limit
feasibility
• Although few major adverse
events have been documented,
long-term data regarding the
duration of symptom relief are
limited
Hale T., M.D., Resident Physician 25

26. Hale T., M.D., Resident Physician 26

27. Hale T., M.D., Resident Physician 27

28. Hale T., M.D., Resident Physician 28

29. Hale T., M.D., Resident Physician 29

30. Myoma In Pregnancy
Hale T., O & G Yr-2 Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
30Hale T., M.D., Resident Physician

31. • Contents
– Introduction
– Complications
– Management
Hale T., M.D., Resident Physician 31

32. Introduction
• Uterine fibroids (leiomyomas) are benign smooth muscle
tumors of the uterus
• Prevalence in Pregnancy
– 1.6 – 10.7 %
– Prevalence varies depending upon the trimester of
assessment and the size threshold
Hale T., M.D., Resident Physician 32

33. • Changes in size during pregnancy
– 49-60% have negligible (defined as <10 percent)
change in volume across gestation,
– 22 to 32 % increase in size, and
– 8 to 27 % decrease in size
Hale T., M.D., Resident Physician 33

34. – Most of the growth occurs in the first trimester
– Larger fibroids (>5 cm in diameter) are more likely to
grow
– Mean increase in fibroid volume during pregnancy is
12 percent, and
– Very few fibroids increase by more than 25 percent
Hale T., M.D., Resident Physician 34

35. – 90 percent of women with fibroids detected in the first
trimester will have regression in total fibroid volume
when re-evaluated three to six months postpartum,
but
– 10 percent will have an increase in volume
– Regression may be less in women who use progestin-
only contraception.
Hale T., M.D., Resident Physician 35

36. Complications
• Pain
– Most common complication
– Frequency specially high in fibroids of > 5 cms
– Patients with degenerating fibroids have
• Localized pain (Majoirty)
• Mild leukocytosis,
• Fever,
• Nausea and
• Vomiting can occur
Hale T., M.D., Resident Physician 36

37. • Fibroid pain likely results from decreased perfusion in the
setting of rapid growth, leading to ischemia, necrosis (red
degeneration) and release of prostaglandins
• This hypothesis is supported by the observation that
fibroid pain typically presents in the late first or early
second trimester, which corresponds to the period of
greatest fibroid growth
• Another theory is that vessels supplying the fibroid
become partially obstructed as the uterus grows and
changes its orientation to the fibroid
Hale T., M.D., Resident Physician 37

38. • Pregnancy Loss
– Submucosal fibroids appear to be associated with
adverse effects
– Mechanisims
• Decidual atrophy
• Increased contractility and
• Increased production of catalytic enzymes
Hale T., M.D., Resident Physician 38

39. • Antepartum Bleeding
– APH more common in pregnancies with myoma
– Location of the fibroid important factor
– 72 percent of patients with retroplacental fibroids
reported vaginal bleeding compared to only 9 percent
with non-retroplacental fibroids
Hale T., M.D., Resident Physician 39

40. • Preterm Labor and Birth
– Possible mechanisims
• Fibroid uteri are less distensible than nonfibroid
uteri, so that contractions occur when the uterus
distends beyond a certain point
• Decreased oxytocinase activity in the gravid fibroid
uterus, which may result in a localized increase in
oxytocin levels thereby predisposing to premature
contractions
Hale T., M.D., Resident Physician 40

41. – Characteristics reported to increase this risk include
• Multiple fibroids,
• Placentation adjacent to or overlying a fibroid, and
• Size greater than 5 cm
Hale T., M.D., Resident Physician 41

42. • Preterm premature rupture of membranes
– The greatest risk of pPROM appears to be when the
fibroid is in direct contact with the placenta
Hale T., M.D., Resident Physician 42

43. • Placental abruption
– Location of the fibroid appears to be important factor
– The endometrium overlying a fibroid may have
reduced blood flow leading to placental ischemia and
decidual necrosis, making it more susceptible to
abruption
– Submucosal and retroplacental fibroids and fibroids
with volumes >200 mL (corresponding to 7 to 8 cm
diameter) had the highest risk of abruption in one
study
Hale T., M.D., Resident Physician 43

44. • Placenta Previa
– Slight increased risk
Hale T., M.D., Resident Physician 44

45. • Preeclampsia
– Increased risk was due to disruption of trophoblast
invasion by the multiple fibroids leading to inadequate
uteroplacental vascular remodeling leading to the
development of preeclampsia
Hale T., M.D., Resident Physician 45

46. • Fetal Growth Restriction
– Large fibroids (greater than 200 mL) may be associated
with delivery of small-for-gestational age infants
(<10th percentile for gestational age)
Hale T., M.D., Resident Physician 46

47. • Fetal anomalies
– Spatial restrictions from uterine fibroids can cause fetal
deformations, but this is extremely rare
– Case reports have described fetal anomalies including
limb reduction defects, congenital torticollis, and head
deformities in pregnancies with large submucosal
fibroids
Hale T., M.D., Resident Physician 47

48. • Malpresentatioin
– Large submucosal fibroids that distort the uterine
cavity have consistently been associated with fetal
malpresentation
– Increased incidence of malpresentation only if
• the uterus had multiple fibroids,
• if there was a fibroid located behind the placenta or
in the lower uterine segment, or
• if the fibroid was large (over 10 cm)
Hale T., M.D., Resident Physician 48

49. • Dysfunctional Labor
– Fibroids in the myometrium may decrease the force of
uterine contractions or disrupt the coordinated spread
of the contractile wave, thereby leading to
dysfunctional labor
– Higher rates of tachysystole (defined as >5
contractions in 10 minutes) have also been reported
Hale T., M.D., Resident Physician 49

50. • Cesarean Delivery
– Uterine fibroids are associated with an increased risk of
cesarean delivery
Hale T., M.D., Resident Physician 50

51. • PPH
– Fibroids could predispose to postpartum hemorrhage
by decreasing both the force and coordination of
uterine contractions, thereby leading to uterine atony
– Especially if the fibroids are large (>3 cm) and located
behind the placenta or the delivery is by cesarean
Hale T., M.D., Resident Physician 51

52. • Management
– Pain
• Acetaminophen
• Indomethacin
– Labor
• Avoid intrapartum myomectomy (only in rare cases
can it be done)
• Classic or Posterior incision if myoma obstructs the
lower uterine segment
Hale T., M.D., Resident Physician 52

53. • Other complications
– Disseminated intravascular coagulation,
– Spontaneous hemoperitoneum,
– Uterine inversion,
– Uterine incarceration,
– Acute renal failure, and
– Urinary retention
– Pyomyoma (suppurative leiomyoma) is rare
• Clinical findings may include Fever, leukocytosis, tachycardia,
pelvic pain, and characteristic features on imaging studies
(heterogeneous mass which may contain gas).
Hale T., M.D., Resident Physician 53

54. Thank you for listening!
Hale T., M.D., Resident Physician 54