1. Leiomyoma of uterus Liuna
First affiliated hospital of the medical college, shihezi university
Obstetrics and Gynecology department
Liuna

2. Incidence
Myomas of the uterus are the commonest tumours of female. It is estimated that nearly 20% women of reproductive age harbour uterine myomas of different sizes.

3. leiomyoma (fibroid, myoma or fibromyoma)
The fibroids arise from the muscle tissue and not from the fibrous tissue of the uterus.

4. Types of myomas key point
Fibroids are classified according to the location
of their growth.
be divided into the following types
Intramural
Subserous
submucous

5. Intramural myomas
Intramural fibroids develop within the wall of the uterus.
They are surouded by myometrial tissue.

6. Intramural fibroids
As intramural fibroids grow, they can increase the bulk of the uterus and enlarge the uterine cavity.

7. Subserous myomas
Subserosal fibroids are located just beneath the outer capsule of the uterus and grow outwards. Subserosal fibroids can develop a stalk, referred to as a pedunculated fibroid.

8. Submcous myomas
Submucosal fibroids develop deep within the uterine wall and can deform the uterine cavity as they grow.

9. Submcous myomas
They are covered by the endometrium.

10. Gross features
Myoma may be single or multiple.
Single fibroid

11. Multiple fibroids

12. Gross features
Their size is variable from a few millimeters to the size of a football,filling whole of the abdomen.

13. Gross features
Some myomas are spherical, some are lobulated in shape, firm in consistency.

14. Gross features key point
Myoma is surrounded by a pseudo-capsule, which is formed by compression of the myometrial tissue surrounding the myoma.

15. Gross features
Due to the pseudo-capsule myomas can be easily enucleated from the uterine wall.

16. Gross features
Cut the surface of the fibroid becomes convex and has a white whorled appearance.
They are generally lighter in colour than surrounding myometrium.

17. Clinical features Age: commonly seen at 35~45 years of age.
rarely seen below the age of 20 years.
Parity: Infertility is commonly associated with myomas. The majority of patients are either nulliparous or of low parity.

18. Clinical features
Mass in lower abdomen: sensation of heaviness in the lower abdomen.

19. Clinical features key point
Menorrhagia :The characteristic symptom of submucous myomas is menorrhagia,the menstrual loss is heavy and prolonged.
The causes of menorrhagia due to myomas are increase surface area of the uterine cavity and increased vascularity and congestion of the uterus.

20. The intramural myomas cause menorrhagia if there is an increase in the size of uterine cavity.
The subserous myomas uaually do not cause menorrhagia.

21. Pressure symptoms Urinary bladder
frequency of micturition retention of urine may change ,overflow incontinence by pressing on the bladder neck causing elongation of urethra.This is more likely to happen with cervical myomas.

22. Vaginal examination key point
Usually myoma moves with the movement of the cervix.
firm, irregularly nodular ,enlarge of the uterus

23. Differential diagnosis
Adenomyosis
Ovarian tumours
Pelvic inflamatory disease

24. Complications of myomas
Degeneration
Sarcomatous change
Infection
Torsion

25. Degeneration key point
Degeneration of the myomas is the result of
reduced blood supply to the tumours.
Atrophic
Hyaline
Cystic
Calcific (calcareous)
Red (carneous)
Myxomatous (fat)

26. Red degeneration
This type of degeneration is most commonly seen during pregnancy.
The causative factor is perhaps ischaemia or necrosis,due to thrombosis of the veins.
After red degeneration, feels soft,on section it looks red or pink,with areas of necrosis in the centre.

27. Hyaline degeneration
The degenerated areas may be scattered as small patches or as iterlacing areas throughout the tumour.These areas become soft and the myoma loses its typical whorled appearance.

28. Sarcomatous change This change is rare,less than 0.2% of cases.
If a myoma enlarges rapidly in size,or becomes painful and tender,a malignant change should be suspected.

29. Torsion A pedunculated subserous myoma may undergo torsion.
More commonly seen during pregnancy and puerperium.
Torsion causes a sudden attack of pain,the tumour enlarges in size and becomes tender.

30. Investigations Ultrasonography Conventional laboratory tests Pap smear
Endometrium biopsy
Hysteroscopy

31. Ultrasonography

32. Treatment key point Expectant treatment Medical treatment Myomectomy
Hysterectomy
Interventional therapy

33. Expectant treatment No symptoms Tumours are small
No complications of myomas
Approaching menopause
During expectant treatment, the patient should
be examined at six monthly intervals. A sudden
increase in size indicates some complication of
the myomas ,or degeneration change.

34. Medical treatment
General health
GnRH-a
Danazol ,progestogens

35. Surgery
Indications :
If the uterus is more than 10 weeks of gestation.
Have typical symptom.

36. Myomectomy Age : less than 40 years .
Parity : if the patient desire conservation of reproductive function.
Consent : if the patient is keen to save her uterus then myomectomy may be carried out.

38. Hysterectomy The operation may be carried out by the
vaginal or abdominal route.
Abdominal
Hysteroscopic
Vaginal

39. Hysterectomy Indications :
If the uterus is more than 12 weeks of gestation.
Have typicla symptom.
Sarcomatous change
If the patient doesn’t desire conservation of reproductive function.

40. Interventional therapy