Uterine Leiomyoma

1. Uterine Leiomyoma Wu Ruijin

2. Introduction • Also known as myoma, fibroids, or fibromyomas • Most common benign tumor of female reproductive system • Most common uterine mass, present in 20-25% of reproductive–age women • Common in women at 30-50y • Proliferative, well-circumscribed, pseudoencapsulated • Vary in diameter from 1mm to 20 cm • Single, most are multiple • Usually asymptomatic

3. Etiology 1. Cytogenetic studiessuggest monoclonal tumors resulting from somatic mutations 2. Estrogen is a promoter of leiomyoma growth Not detectable before puberty and after menopause; Grow rapidly during pregnancy; GnRHa reduce leiomyomas size Probably relates to female hormones • Estrogen and ER ↑ • Progestin may promote mitosis of myoma 3. Local and paracrine factors may account for variations in tumor volume and rate of growth

4. Classification According to the location： • Uterine body myoma (90%) • Cervical myoma (10%)

5. Classification According to the relationship between myoma and uterine myometrium ： • intramural myoma：60%-70% • subserosal myoma：20% • submucous myoma：10%-15% Pedunculated (attached by a stalk) Intraligamentary myoma

6. Classification multiple myoma intramural myomas subserosal myomas submucous myomas

7. Pathology Gross Appearance： • round, smooth, and usually firm • false capsular covering ——pseudocapsule can be clearly demarcated from the surrounding myometrium

8. Pathology Gross Appearance： Transverse section : • light gray • a whorl-like arrangement or an intertwining pattern

9. Pathology Microscopic examination： • Composed of smooth muscle cells and varying amounts of connectives tissue • Individual cells are quite uniform in size, spindle shaped, have elongated nuclei. • Nonstriated muscle fibers are arranged in interlacing bundles of varying size running in different directions.

10. Degeneration • Hyaline degeneration --most common, overgrowth of fibrous elements • Cystic degeneration --sequel necrosis, liquefaction after hyaline dg • Red degeneration • Mucoid degeneration --arterial input impaired, large myomas • Sarcomatous change • Calcification --common in post-menopause pts

11. Degeneration Red degeneration • A specific kind of necrosis • Occurs frequently in pregnancy and puerperium • Caused by aseptic dg associated with local hemolysis • Venous thrombosis and congestion with interstitial hemorrhage

12. Degeneration ← Red degeneration ← Hyaline degeneration

13. Degeneration Sarcomatous change • malignant • rare, 0.4-0.8% • old women • enlarge rapidly with irregular vaginal bleeding

14. Degeneration Sarcomatous change

15. Clinical Findings__Symptoms • Vary greatly • Usually no symptoms • Symptoms occur in 10-40% of patients • Associate with location, and degenerations • Not associate with size and number

16. Symptoms 1. Menorrhagia and prolonged menses • Most common symptom, occur in 30% symptomatic pts • Excessive bleeding at menses, >80mL, >7d (1)necrosis of surface endometrium overlying the submucous leiomyoma, (2) disturbance in hemostatic contraction of muscle bundles, (3) increased surface area of endometrial cavity, (4) alteration in endometrial microvasculature. • Large intramural myoma • Submucous myoma • Result in profound anemia

17. Symptoms 2. Pain • usually not pain • torsion of a pedunculated leiomyoma • infarction progressing to carneous degeneration 3. Pressure effects • enlarged leiomyoma press surrounding structure • pressure on bladder → urinary frequency, urinary retention • intraligamentous myomaand large cervical myoma → obstruct ureter • pressure on rectum → constipation

18. Symptoms 4. Others • Infertility: -- Large intramural leiomyomas located in cornual regions or close the interstitial portion of tube --Submucous leiomyomas may impede embryo implantation • Spontaneous abortion -- 2 times incidence in normal pregnant women with unknown cause 5. Pregnancy-related disorders • Higher incidence of spontaneous abortion • Red degeneration • Premature labor • A factor in malpresentation, mechanical obstruction, or uterine dystocia • Postpartum hemorrhage • Increased cesarean sections

19. Sign associated with： • size • location • number • degeneration large myoma→ palpable abdominal mass Pelvic examination（ Bimanual or vagino-recto-abdominal examinations） uterus —— enlarged，irregular and hard

20. Diagnosis • Typical symptoms and signs • Ultrasound • Hysteroscopy • Laparoscopy • MRI

21. Ultrasound Small intramural leiomyomas

22. Ultrasound subserous leiomyomas

23. Diagnosis Hysteroscopy submucous leiomyomas

24. Diagnosis Laparoscopy

25. Differentialdiagnosis • Pregnancy • Ovarian neoplasms • Adenomyosis • Malignant tumors of uterus • uterine sarcoma • endometrial carcinoma • cervical cancer

26. Treatment Individualized,nonsurgical or surgical According to : • age • desire for childbearing • symptoms • location, size, growth rate and amount of myoma

27. Treatment Observation and Follow Up • Small, asymptomatic, especially near menopause -- leiomyomas will atrophy as estrogen levels fall • Interval：3～6 months (1) Bimanual examinations: uterine size and tumor growth rate. Slow growth or stable size --annual follow-up. Rapid growth--suspicious for malignancy and surgical intervention. (2) Pelvic US or MRI performed if physical examination inadequate

28. Medical measure Indications： • smaller than 2 months pregnancy in size • slight symptoms • near menopause

29. Medical measure 1. Androgenic agents： testosterone propionate:25mg im 1/5d, 25mg/d 3 at menses, no more than 300mg/m to against estrogen, atrophy endometrium, enhance hemostatic contraction of muscle bundles 2. Gonadotropin-releasing hormone agonist （GnRH-a） × GnRH-a LH、FSH↓ E2↓ shrinkage of myoma(50%) • leuprorilin • goserelin • subcutaneous implant, H • or intramuscular depot injection • Monthly or every 3 months

30. Medical measure • 2.GnRH-a • Efficacy : • GnRHa suppress gonadotropin secretion and create a hypoestrogenic state similar to postmenopause level. • Side effects: • Hypoestrogenic side effects • Osteoporosis --- no more than 6 m • Regrow within 12w after GnRHa discontinued GnRHa recommended for : • a. large submucous myoma to facilitate hysteroscopic resection • b. symptomatic perimenopausal pts to avoid surgery • c. pts with anemia taking iron to increase HB prior to surgery 3.Mifepristone (RU486)

31. Surgical measures Indications： • greater than 10 weeks in size • menorrhagia→ anemia or interferes normal lifestyle • protrusion through the cervix • pressure effects • rapid growth • failure in medical treatment • infertility or recurrent abortion • progressive hydronephrosis or impair renal function

32. Surgical measures Depends on age, symptoms, size, location, and desires for fertility. • Myomectomy • removal of leiomyomas, preserving uterus • preserve fertility, <35 years old • 80% improve symptoms, 15% symptom recurrence, 10% require additional treatment. • recurrence of myomas depends on number, age, completenessof original myomectomy.

33. Types of Myomectomy • Abdominal myomectomy • Hysteroscopic resection --submucous leiomyomas --less pain and shorter recovery periods • Laparoscopic myomectomy --shorter recovery times --But large, multiple, deep, lower posterior wall leiomyomas are technically more challenging • MRI-guided focused ultrasound --uses ultra­sound-generated heat to cause cell death --new treatment option • Laparoscopic myolysis (using laser or coagulation current) and cryomyolysis (using a -180°C probe) --persistent decrease size --another promising therapeutic option

34. Hysterectomy • Both leiomyomas and any associated disease removed permanently. No risk of recurrence. • Numerous large tumors • Obviously symptomatic patient • No wish of preserving fertility • Suspected to malignant transformation

35. Uterine artery embolization (UAE) • Injected with embolic material to occludes vessel feeding the uterus and leiomyomas, causing shrinking or necrosis of leiomyomas. Efficacy: • 60% reduction in size • Controls menorrhagia ≥90% Indications： • near menopause • no longer desire fertility • large uterus • multiple risks for surgery, or do not desire surgery • uncontrollable menorrhagia

36. Complications of UAE : • fibroid expulsion • vaginal discharge • Infection • premature ovarian failure • persistent pain

37. Myomas during pregnancy Impact on pregnancy：abortion Impact on delivery： • preterm labor • fetal malpresentation • placenta previa • birth canal obstruction • postpartum hemorrhage

38. Myomas during pregnancy Red degeneration • Clinical finding: • pain, fever, WBC↑ • rapid growth of myoma，tenderness • Conservative treatment antibioticsusing

39. Thank You !