2. Leiomyomata are the most common tumors of the uterus and the female
pelvis
The most common indication for hysterectomy
Advances in gynecologic surgery just 100 years ago = reasonable control.
Before the 20th century, no effective treatment was available.
It often grew to enormous size and caused great suffering from bleeding,
pain, and emaciation
3. LeiomyomaBenign clonal tumor arising from smooth muscle cells with increased amount
of extracellular matrix
Most common tumor of uterus and female pelvis
Parallels with the ontogeny & life cycle change of reproductive hormones
Most common indication for hysterectomy in USA-175,000/year
4. Occurs in 20-40% of reproductive age women
Rare in women < 18 years of age,
Report at 1 year of age
Responsible for one third of gynecologic admissions
Postmenopausal incidence is not lower than premenopausl.
6. Factors related to tumorogenesis of leiomyoma classified as:
Predisposing factors
Initiators
Promoters
Effectors
7. Predisposing factors
There is overlap of factors-obesity, diet
Many of the factors effect is attributed to their effects on estrogens &
progesterone
Proving the association is difficult
8. I. Predisposing factors Cont’d
1. Menarche: Early menarche
2. Parity:
- Having one or more pregnancies beyond 20 weeks decreases the chance,
- women at least given birth to 2 children has 2x less risk
3. Age: Reproductive age
4. Obesity:
- Fibroids increase by 21% for each 10 kg (USA) or 6% increase for each BMI
increase (Thailand)
9. Cont’d
5. Diet:
- High intake of vegetables = protective effect -
increased risk with high intake of beef, red meat &
ham
6. Exercise
7. Racial differences: 3-9 x common in blacks
10. Cont’d
Myomas in blacks are larger, numerous, more symptomatic & occur at
younger age
basis is not known, estrogen metabolism
8. Geographic differences: Shows importance of diet, environmental factors &
ethnicity
• Prevalence in Nigeria-68% (1981)
9.Smoking;decreases the risk of fibroid by unknown mechanism
12. 1. Increased level of estrogen and progesterone
lead to increased mitotic rate that end in increased somatic mutation
13. 2. A response to injury
Analogous to development of keloids
potential injury associated with release of vaso-constrictve substances (PGs &
vasopressin)
Smooth muscle cells react by changing themselves from contractile type to
proliferative type
14. 3. Theory of genetic and/or epigenetic changes
Karyotypic changes occur secondarily
Preceding stimuli, condition or injury is responsible for the
induction of genetic & epigenetic changes
Probable potentiators or effectors of initiating event
Could be the primary event
15. III. PromotersEvidence of estrogen and progesterone
1. Clinical observations: develop during reproductive years,
shrinkage with GnRH analog Rx, etc
2. Laboratory
- 17β estradiol is higher in myoma
- Over expression of aromatase activity
3. Estrogen and progesterone receptors
- Were greater in myoma than myometrium
16. IV. Effectors
The growth promoting effects of E & P upon myometrium &
uterine myoma
- mediated through the mitogenic effects of growth factors
produced locally by the smooth muscle cells & fibroblasts.
They are important in controlling cell proliferation.
18. Fibroids are often described according to their location in the uterus
Intramural fibroids
Submucosal myomas
Subserosal myomas
Intraligamentary
Cervical fibroids
22. Degenerative changes
The very poor vascularity of fibroids encourages the degenerative
changes that are common in big myomas
23. Hyaline degeneration
The most common of all secondary changes
Asymptomatic
Yellowish, soft and often gelatinous area is seen
24. Cystic Degeneration
Formation of multiple small cystic spaces, giving a sponge-like
appearance and soft consistency to the tumor
Some times mimic cystic ovarian tumor
25. Calcific Degeneration
Occurs when there is some circulatory disturbance.
This is seen most often in pedunculated myoma.
Can be seen using X- Ray
26. necrosis
May occur in any tumor.
This is commonly due to impairement of the blood supply or severe
infection.
◦ E.G Torsion of a pedunculated myoma.
27. Carneous (red)
degeneration Commonly seen during pregnancy or near the menopause, but
can occur any time.
Venous thrombosis and congestion with interstitial hemorrhage
are responsible for the color of the myoma undergoing red
degeneration.
The process is usually associated with extreme pain but is always
self limited.
Its exact mechanism is not known
31. Clinical feature
Symptoms attributable to uterine myomas can generally be classified into
three distinct categories:
1. Increased uterine bleeding
2. Pelvic pressure and pain, termed bulk-related symptoms
3. Reproductive dysfunction
These symptoms are related to the number, size, and location of the
neoplasms
32. 1. Increased uterine bleeding
the most common symptom = 1/3rd
Menorrhagia or hypermenorrhea
is the typical bleeding pattern of myomas;
intermenstrual bleeding is not characteristic of myomas and should be
investigated
Problems:-
◦ iron deficiency anemia,
◦ social embarrassment, and
◦ lost productivity in the work force.
33. several mechanisms
The surface area 15 cm2 to 200 cm2
Local hyperestrogenism
Endometrial hyperplasia and endometrial polyps
Thinning and ulceration, submucous
Interfere with myometrial contractility
Interfere with contractility of the spiral arterioles
35. Reproductive dysfunction
do not interfere with ovulation, but have been associated with subfertility and
adverse pregnancy outcomes:-
First trimester bleeding,
Preterm labor
Placental abruption,
Breech presentation / malpresentation,
Dysfunctional labor and
Increased risk of cesarean delivery
PPH
Endomyometritis
36. Infertility
Features that may contribute to subfertility
Cavity distorsion
size larger than 4 to 5 cm, which might affect uterine contractility or impair
normal endometrial function thereby impairing implantation, and
location near the tubal ostia or cervix, which could potentially impede
gamete transport
37. Less common symptoms of fibroid:-
Prolapse into the vagina resulting in ulceration or infection
Polycythemia from autonomous production of erythropoietin
Hypercalcemia from autonomous production of PTHrP
