Recurrence of Leiomyomata (cont’d)

Indeed, between 10% and 25% of women undergoing myomectomies require another surgical procedure within the next decade.

Recurrence of Leiomyomata (cont’d)

Isolated large fibroids have lower recurrence rates than when multiple small tumors are present, despite an overall smaller volume of leiomyomata .

Postoperative Pelvic AdhesionsThe frequency of postoperative adhesions following

myomectomy exceeds 50% and can result in reduced fertility, pain, or bowel obstruction.

Careful surgical technique to minimize the degree of surgical trauma,

confining the incisions to the anterior uterine surface so as to prevent contact with the bowel and adnexal structures, and

covering the posterior uterine incisions with surgical barriers ,

have been advocated to minimize the rate of postoperative adhesions.

Non-extirpative Options

Myolysis UAE MRI-guided HIFUMedically induced hypogonadism GnRH agonist GnRH agonist with “add-back” therapy

Medical Suppression

Many medicinal agents have been considered for the treatment of symptomatic leiomyomata, including:

1.estrogen antagonists, 2.progesterone antagonists (mifepristone),

3.androgens (danazol), 4.pituitary down-regulation with GnRH

agonists.

Medical Suppression (cont’d)

Hypogonadism cannot be sustained for a prolonged interval because of the significant side effects such as:

vasomotor hot flashes, accelerated bone loss, genital tract atrophy, and loss of the cardiovascular protection.

Medical Suppression (cont’d)

The important question to ask is, “What is the goal of medical suppression?”

Currently, the most relevant clinical use of GnRH agonists is to stop excessive vaginal bleeding and improve the hemogram prior to surgery or in order to delay surgery to correct other medical problems that are posing an increased surgical risk.

Myolysis

There have been many attempts at inducing therapeutic necrosis of cells within the center of a fibroid (e.g., myolysis), thereby shrinking the tumor size, relieving symptoms, and preventing progressive growth of the tumors.

Myolysis (cont’d)

• The aseptic necrosis may cause significant pain in the immediate post-treatment interval, comparable to that observed with degeneration of leiomyomata seen in pregnancy.

Myolysis (cont’d)

Myolysis should be confined to those women who are not interested in subsequent pregnancy until well-designed, long-term comparative trials demonstrate safety.

Uterine Artery Embolization

When menorrhagia is the primary clinical symptom and either the surgical risk is judged unacceptable or the patient declines extirpative surgery, therapeutic embolization of the uterine arteries can be utilized to reduce symptoms. This strategy is to simultaneously deprive the uterus and the fibroids of their blood supply, induce necrosis, and reduce the symptoms .

UAE (cont’d)

Since UAE has only been widely utilized for only slightly over a decade, the long-term safety and efficacy remain to be demonstrated.

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Adenomyosis

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Definition

A benign uterine condition in which endometrial glands and stroma are present within the uterine musculature

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Etiology

• The cause of adenomyosis is unknown• uterine trauma – caesarean section– tubal ligation– pregnancy

• Basal endometrial hyperplasia invading a hyperplastic myometrial stroma.

Four primary theories

HeredityTraumaHyperestrogenemiaViral transmission

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The thickened and spongy appearing myometrial

wall of this sectioned uterus is typical of adenomyosis. There is also a small white leiomyoma at the lower left.

Adenomyosis, Hysterectomy Specimen

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• Adenomyosis correlates with abnormal amounts of multiple substances, possibly indicating a causative link in its pathogenesis:

– Endometrial IL-18 receptor mRNA and the ratio of IL-18 binding protein to IL-18 are significantly increased in adenomyosis patients in comparison to normal people

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Clinical features1• Asymptomatic

• Classic symptoms： secondary dysmenorrhea abnormal uterine bleeding• Chronic pelvic pain may occur

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Clinical features2：• Most common physical sign a diffusely enlarged uterus • particularly tender during menstruation

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Diagnosis：• History• Pelvic examinations• Ultrasonography• MRI• Serum markersCA-125 • definitive diagnosis can only be made from

histological examination of a hysterectomy specimen

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Treatment

• Hormone therapy• NSAIDs• Hysterectomy the only uniformly

successful treatment for adenomyosis is necessary.

Endometrial polyps

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Definition

• Benign localised overgrowth of endometrial glands and stroma, covered by epithelium, projecting above the adjacent epithelium

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epidemiology• 12-80 Years old• Most occur in women in their 40s and 50s• Endometrial polyps occur in up to 10% of

women• It is estimated that they are present in 25% of

women with abnormal vaginal bleeding• Large endometrial polyps can also be

associated with tamoxifen use(associated with a higher risk of neoplasia and different molecular alterations)

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Risk factors

• Risk factors include

• obesity• high blood pressure• history of cervical polyps• tamoxifen• hormone replacement therapy

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Pathological findings• Sessile or pedunculated• Size: 1mm and beyond – may fill the endometrial

cavity and project through the cervical os• red/brown color ,large ones can appear to be a

darker red• May be multiple• May originate anywhere, but most commonly

fundus

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etiology

• No definitive cause of endometrial polyps is known

• affected by hormone levels and grow in response to circulating estrogen

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symptoms

• They often cause no symptoms• Where they occur, symptoms include – "spotting" between menstrual periods, or after

menopause– irregular menstrual bleeding– bleeding between menstrual periods– excessively heavy menstrual bleeding – vaginal bleeding after menopause– If the polyp protrudes through the cervix into the

vagina, pain (dysmenorrhea) may result 39

Diagnosis

• vaginal ultrasound (sonohysterography)

• hysteroscopy

• dilation and curettage

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Treatment

• IntraUterine System containing levonorgestrel in women taking Tamoxifen may reduce the incidence of polyps

• Polyps can be surgically removed using curettage or hysterescopy

• If it is a large polyp, it can be cut into sections before each section is removed

• If cancerous cells are discovered, a hysterectomy may be performed

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Prognosis and complications

• Endometrial polyps are usually benign although some may be precancerous or cancerous

• About 0.5% of endometrial polyps contain adenocarcinoma cells

• Polyps can increase the risk of miscarriage in women undergoing IVF treatment

• Although treatments such as hysterescopy usually cure the polyp concerned, recurrence of endometrial polyps is frequent

• Untreated, small polyps may regress on their own

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