Myoma Uteri

• A benign tumors of the smooth muscle cells of the uterus

• Synonyms: Fibroids, Leiomyomata.

What is Myoma uteri

Epidemiology

• The most common non-cancerous tumours in women • The most common indication for hysterectomy• Apparent in up to 25% of women. • More common in a higher body mass index women• 3 times more common in black American women than w

hite women.• Asian women have a lower incidence • Symptoms appear at age of 30s or 40s • The incidence increases with age up to the menopause.

Pathophysiology

• Exact etiology is unclear

• Hormonally responsive to estrogen; grow during pregnancy and regress with menopause

• May outgrow blood supply and degenerate causing pain

ClassificationAccording to position 70 % Intramural

(in uterine wall)

20% Subserosal

(beneath serosa)

10 % Submucosal

( beneath endometrium ) pedunculated submucosal or pedunc

ulated vaginal

Symptoms

• Half of women with fibroids have no symptoms • symptoms depends on their size, position and

condition

– Hypermenorrhea (submucosal are more likely) .

– Persistent intermenstrual bleeding (cause by pedunculated submucosal fibroid)

– Dyspareunia (cause by torsion of a pedunculated fibroid)

– abdominal cramps, discomfort, and heaviness( cause by large uterus)

– Constipation and urinary frequency (cause by pressure)

– Recurrent miscarriage or infertility

Clinical Findings

• Palpable abdominal mass

• PV examination – irregularly enlarged and asymmetrical.– tender and large sizes unlike the soft uterus c

ontaining a pregnancy

• Signs of anaemia due to menorrhagia

Differential diagnosis

• Chronic pelvic inflammatory disease

• Tubo-ovarian abscess

• Ovarian tumour

• Uterine sarcoma

• Endometrial polyps, endometrial carcinoma

• Endometriosis

• Dysfunctional uterine bleeding

• Other causes of a pelvic mass include tumour of large bowel, appendix abscess, diverticular abscess

• Pregnancy

Investigation• Pregnancy test may be indicated.

• Full blood count

• Pelvic ultrasound:

• Transvaginal ultrasound is more accurate.

• MRI: occasionally required if ultrasound not definitive in assessing depth

• Endometrial sampling for histology in the assessment of abnormal uterine bleeding.

• Hysteroscopy with biopsies.

Treatment

• Medical• Surgical

Medicine• NSAID to reduce menstrual blood loss and dysmenorrhea • Antifibrinolytic agents, e.g. tranexamic acid to reduce men

orrhagia • Combined oral contraceptive if women also requires effecti

ve contraception • Danazol reduces menorrhagia by suppressing gonadotropi

n secretion and abolishing cyclical ovarian function • GnRH agonists:

– Reduce size of fibroid 50% within 3 months but once discontinued, fibroids regrow to their former size within about 2 months; therefore mainly useful preoperatively.

– Beware of side effects including amenorrhoea, menopausal symptoms and osteoporosis in long term use.

Surgery

• Indication– excessively enlarged uterine size ( > 12 wks gestation)– pressure symptoms ( urinary frequency or retention etc.)– abnormal uterine bleeding causing anemia– severe pelvic pain secondary to amenorrhea– growth after menopause– infertility– rapid increase in size (r/o leiomyosarcoma)

• Oophorectomy if ovaries are damaged or age > 45

Surgical option

• Myomectomy for patients who want to preserve their fertility – Laparoscopic myomectomy for subserous fibroids

– Hysteroscopic myomectomy for submucosal fibroids – Vaginal myomectomy for Pedunculated vaginal

– recur in 50% of patients

• Hysteroscopic endometrial ablation for menorrhagia.

Total hysterectomy technique

• Abdominal hysterectomy• Vaginal hysterectomy

most often used in cases of uterine prolapsed

• Laparoscope-assisted vaginal hysterectomyVaginal hysterectomy performed with laparoscope, the uterus is removed in sections through the laparoscope tube or through the vagina.

COMPARISON Laparoscopic Hysterectomy with Vaginal and Abdominal

  ABDOMINAL LAPAROSCOPIC VAGINAL

INDICATIONS Large fibroids

Endometriosis

Ovarian masses

Poor accessAdhesions

All indications Small uterus Prolapse

REMOVE OVARIES Possible Possible Not possible

STAY IN HOSPITAL 5-6 days 1-3 days 3-4 days

POSTOPERATIVE PAIN

Significant Negligent Minimal

RETURN TO WORK 4-6 weeks 2 weeks 3-5 weeks

COSMETIC RESULTS

Large scar 3 ½  cm scars No scar

Abdominal hysterectomy

Vaginal hysterectomy

1.cervix prolapsing through vaginal introitus grasped by tenaculi

2.cervix being bivalved with scalpel

3.uterine corpus being bivalved after separation of cervix has been completed

4.uterus halved after bivalving procedure to facilitate its removal

5.after half of uterus is removed. cervix is grasped with uterine corpus below

6.bladder is drained with foley catheter revealing non-bloody urine

LAVH (laparoscopically assisted vaginal hysterectomy)

• Surgical procedure using a laparoscope to remove the uterus and/or fallopian tubes and ovaries through the vagina

• Not all hysterectomies can or should be done by LAVH.

LAVH

Uterine artery embolisation

• Is both effective and relatively safe for women who no longer wish to have children

• Ensuring the tumour is a benign

• Compared with uterine artery embolisation (UAE), hysterectomy is associated with better improvement in pelvic pain

Uterine artery emobilization

Myoma uteri & Complication in pregnancy

Complication in pregnancy

– Recurrent miscarriage – Fetal malpresentation– Red degeneration: presents with fever, pain a

nd vomiting – Intrauterine growth retardation– Premature labour– Postpartum haemorrhage

• Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus

a very large leiomyoma of the uterus

leiomyosarcoma protruding from myometrium into the endometrial cavity