Uterine Leiomyoma
description
Transcript of Uterine Leiomyoma
Uterine LeiomyomaUNC School of Medicine
Obstetrics and Gynecology ClerkshipCase Based Seminar Series
Objectives for Uterine Leiomyoma Discuss the prevalence of uterine leiomyomas
Describe the symptoms and physical findings in patients with uterine leiomyomas
Describe the diagnostic methods to confirm uterine leiomyomas
List the management options for the treatment of uterine leiomyomas
Patient presentationPatient presentation• A 42-year-old G3 P3 female presents with a
history of abnormal bleeding and pelvic pain. She was well until approximately age 35, when she began developing dysmenorrhea and progressive menorrhagia. The dysmenorrhea was not fully relieved by NSAIDS. Over the next several years, the dysmenorrhea and menorrhagia became more severe. She then developed intermenstrual bleeding and spotting, as well as pelvic pain, which she describes as a constant feeling of pressure. She also complains of urinary frequency.
Patient presentationPatient presentation• Past gynecological history is otherwise non-
contributory. She delivered three children by caesarean section, the last with a tubal ligation at age 30. Her past medical history is unremarkable.
Physical ExamPhysical Exam• Reveals a well-developed, well-nourished
woman in no distress. Vital signs and general physical exam are unremarkable. Abdominal examination reveals an irregular-sized mass into extending halfway between the pubic symphysis and umbilicus and to the right of the midline. Pelvic exam reveals a normal appearing vagina and cervix. The uterus is markedly enlarged and irregular, especially on the right side where it appears to reach the lateral pelvic sidewalls. The examiner is unable to palpate normal ovaries due to the mass.
Patient PresentationPatient Presentation Diagnostic EvaluationDiagnostic Evaluation
• Laboratory• Beta HCG is negative. CBC reveals
hemoglobin of 10.3 and hematocrit of 31.2. Indices are hypochromic, microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap smear is normal with no evidence of dysplasia. Endometrial biopsy reveals proliferative endometrium. ECC is negative for malignancy. Ultrasound shows a large irregular mass, filling the pelvis and extending into the lower abdomen. The mass does extend into the right side of the pelvis. The ovaries are not visualized.
Uterine leiomyomas (“fibroids”) are benign tumors derived from the smooth muscle cells of the myometrium
Definition
Approximately 45% of women have uterine leiomyomas by the 5th decade of life
Vast majority are asymptomatic Primary indication for 200,000 hysterectomies in the
U.S. each year Sarcomatous changes occur in < 0.1%
Prevalence
Increasing age during reproductive years Ethnicity (African American) Nulliparity Family history
Risk Factors
Factors that initiate leiomyomas unknown Estrogen and progesterone important to growth
Increased levels of estrogen and progesterone receptors present
Estrogen induces proliferation of smooth muscle cells Progesterone produces proteins which prohibit apoptosis
Increased levels of growth factors produce fibronectin and collagen
Pathogenesis of Leiomyomas
Spherical, well-circumscribed, white, firm lesions Always arise within the myometrium (intramural) Migrate to various anatomic locations
Submucosal – toward endometrium Intramural – within myometrium Subserosal – toward serosal surface
Pedunculated and/or parasitic
Poor internal blood and lymphatic supply Cystic degeneration Calcification
Characteristics of Leiomyomas
Anatomic Locations
Pedunculated subserosal
UterusPedunculatedsubmucosal
Subserosal
Submucosal
Vagina
Intramural
Clinical Manifestations
Bleeding symptoms• Menorrhagia –
heavy bleeding• Metrorrhagia –
bleeding between menses
• Dysmenorrhea – painful menses
Bulk symptoms• Pelvic pressure• Urinary frequency• Infertility and/or
recurrent pregnancy loss
*Many women are asymptomatic; symptoms depend on size and location of fibroids
Clinical Manifestations
Abdominal exam Palpable mass if uterus > 12-14 wk gestational size
Pelvic exam Firm, irregularly enlarged uterus Midline, occasionally adnexal Mass displaced with cervix Usually nontender
Physical Exam
Uterine sarcoma Ovarian neoplasm Tubo-ovarian inflammatory mass Diverticular/inflammatory bowel mass Colon cancer Pelvic kidney
Differential Diagnosis
Bimanual pelvic exam Transvaginal ultrasound (TVUS) Sonohysterography Hysterosalpingography Diagnostic hysteroscopy MRI
Diagnosis
Pathology
Well circumscribed white tan firm masses with a whorled appearance
Pathology
Microscopically leiomyomas are composed of bland smooth muscle.
They can be more fibrotic than this example or more cellular.
Patient presentationsPatient presentations• 42yo P2 s/p BTL with 16 week size uterus,
menorrhagia, anemia, bulk symptoms Management options?
• 32yo G0 who desires fertility with otherwise the same presentation?
Management options?
• 42yo P3 s/p BTL with bleeding sx, no bulk sx and a normal size uterus
Could she still have fibroids? Management options?
Clinical Presentation Nonmedical OptionsDesire fertility Myomectomy or UAEDesire uterine preservation Endometrial ablation or UAENo desired fertility or uterine preservation Endometrial ablation or HysterectomyRapidly growing uterus Exlap, TAH
Management (Surgical)
*Intervention for patients with leiomyomas not amenable to medial therapy
Desire future fertility… Myomectomy
Laparotomy – larger fibroids Laparoscopic – pedunculated or subserosal fibroids Hysteroscopic – submucosal fibroids, >50% in cavity
Desire uterine preservation but not fertility… Endometrial ablation Uterine artery emboloization (UAE)
No desire for uterine preservation or fertility… Hysterectomy (definitive)
Laparotomy (TAH) – larger fibroids Laparascopic (TVH, TLH) – smaller fibroids
Management (Surgical)
Patient presentationsPatient presentations• 34 yo P1 with menorrhagia and
dysmenorrhea with an 8-10 weeks size uterus
Management options?
• What is this same patient were asymptomatic?
1st line treatment NSAIDS Progestin-only therapies (Depo Provera, Mirena IUD) Combination therapies (OCP’s, patches, vaginal rings)
2nd line treatment GnRH analog (Lupron) – blocks endometrial proliferation, shrinks
myometrium, and reduces leiomyoma volume Causes vasomotor symptoms (hot flashes) and bone loss Short courses, used primarily for pre-surgical shrinkage of leiomyoma
GnRH analog + hormonal agents Minimize adverse hypoestrogenism effects
Mifepristone (RU 486) – progesterone receptor antagonist Still experimental, shown to reduce volume by 50% over 3 months
Management (Medical)
Treatment is not necessary if…. Asymptomatic Fibroid small (<12 wk gestational size) Near menopause
Management (Conservative)
Bottom Line Concepts Most uterine leiomyomas are symptomatic and require no intervention. Uterine leiomyomas can cause excessive uterine bleeding, pelvic
pressure and pain, and infertility. Fibroids can be subserosal, intramural, or submucosal. Prolonged or
heavy bleeding may be associated with intramural or submucosal myomas.
Conservative or medical management should be considered prior to surgical management.
Treatment options for leiomyoma include myomectomy, endometrial ablation, uterine artery embolization and hysterectomy.
Pregnancies in women with fibroids are usually uneventful. Fibroids are rarely the cause of infertility. In women who have a
myomectomy in which the endometrial cavity is entered, future deliveries must be by cesarean birth.
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 53 (p114-115).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 44 (p389-392).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 19 (p241-245).