Benign diseases of the uterus

Benign dis. of the uterus can be classified in terms of the tissue of origin: The uterine cervix the endometrium the myometrium.

The endometrium

1.endometrium polyps:- symptomes May cause abnormal bleeding, especially intermenstrual bleeding

investigations Transvaginal ultrasound. Sonohysterography Hysteroscopy Endometrial biopsy Curettage .

treatment Medications: such as progestins or gonadotropin-releasing hormone agonists.the symptoms will return after the medications are stopped. Hysteroscopy to remove any polyps that are found. Curettage : to scrape the lining and remove any polyps A hysterectomy:in cases where cancer cells are found in the uterine polyps.

2.Asherman`s syndrome:- It is the process of adhesion of anterior and posterior layers of the uterine wall caused by removal of basalis layer after agressive curetage following labour or abortion. Symptoms: amenorrhea or oligomenorrhea. Diagnosis: HSG Treatment: by hysteroscopy lysis of the adhesion and put IUCD or gave high dose of estrogen. .

3.Myometrium:

uterine fibroids:- Pathology: A fibroid is a benign tumor of uterine smooth muscle, termed a leiomyoma.

uterine leiomyoma (fibroid)

classification

Submucous leiomyoma Pedunculated submucous Intramural or interstitial Subserous or subperitoneal Pedunculated abdominal Parasitic Intraligmentary Cervical

Classifications Fibroids are often described according to their location in the uterus

CLINICAL MANIFESTATIONS

Clinical features:- Fibroids being detectable clinically in about 20% of women over 30 years of age. Risk factors Nulliparity Obesity positive family history African racial origin OCP depot DMPA injections may be associated with reduced risk

Abnormal uterine Bleeding Pelvic pressure & pain Reproductive Dysfunction

Common presenting complaints are 1.menstrual disturbance; Menorrhagia may occur, it is likely that only submucous fibroid distorting the endometrial cavity and increasing the surface area Dysmenorrhoea

2.pressure symptoms especially; Nerves pressure:backache Bladder— frequency / retention /Difficulty in micturition /Incomplete bladder emptying / incontinence Ureter— Unilateral ureteral obstruction; hydroureter, hydronephrosis Bowel—constipation/tenesmus. / difficult defecation can caused by large posterior fibroid Vessels: Varicosity or edema of the lower extremities.

3.Pain is unusual. Uncomplicated uterine fibroid usually do not produce pain.

Acute pain is usually caused by either torsion of pedunculated fibroid Red degeneration of fibroid extrusion from the uterus (In submucous fibroid; the uterus contracts to try to deliver the fibroid through the cervical os) Associated endometriosis Adhesions to other organs. Malignant changes(sarcomatous change)

Other Rare clinical manifestations: myomatous erythrocytosis syndrome: result from excessive erythropoietin production by the kidneys or by the leiomyomas themselves, in either case, red cell mass returns to normal following hysterectomy. pseudo-Meigs syndrome: Meigs syndrome consists of ascites and pleural effusions that accompany benign ovarian fibromas. However, any pelvic tumor including large, cystic leiomyomas or other benign ovarian cysts can cause this.from discordancy between the arterial supply and the venous and lymphatic drainage from the leiomyomas. Resolution of ascites and hydrothorax follows hysterectomy.  

Complications of fibroids 1. Torsion of pedunculated fibroid 2 Complications of fibroids 1.Torsion of pedunculated fibroid 2.Degenerations:

1.Red degeneration : 5% of pregnant women with fibroids, undergo red degeneration DDX. Appendicitis twisted ovarian cyst placental abruption ureteral stone pyelonephritis  

Symptoms and sighs sudden onset of focal pain and tenderness on palpation localized to an area of the uterus low-grade fever vomiting  

Investigations: leukocytosis raised ESR Ultrasound

Treatment : is treated conservatively Bed rest and observation Analgesia to relieve pain. Sedatives Antibiotics: If required Most often, acut symptoms subsid within a 3-10 days, but inflammation may stimulate labor. Surgery is rarely necessary during pregnancy.

2.Hyaline degeneration the most common type

3.Cystic degeneration

4.Infection of a leiomyoma 5.Mucoid degeneration 6.Atrophy 7.Fatty degeneration

8.Calcification of leiomyomas :is a common finding in postmenopausal patients. May be detected incidentally on an abdominal X-ray.

3. Malignancy: Leiomyosarcoma: occur in less than 0.1-0.5%.

Sarcoma may be suspected clinically when a leiomyoma, usually in a postmenopausal woman, becomes painful and tender and grows rapidly, producing systemic upset and pyrexia.

4.Hemorrhage – It can be intracapsular or intraperitoneal due to rupture of surface veins of a subserous fibroid 5.Rare paraneoplastic complications – polycythemia, thromboembolism, hypoglycemia, hypokalemia 6.Inversion of uterus

7.Pregnancy related complications:

Effect of the fibroid on the pregnancy: Infertility Less successful results with in vitro fertilization in patients who have large submucosal fibroids. ectopic pregnancy Abortion and premature labor:

Malposition and malpresentation of the fetus Obstructed labour Cesarean section placental abruption Red degeneration

Torsion of a pedunculated fibroid. Postpartum hemorrhage, inertia of uterus &delayed involution. Myomectomy not done during pregnancy because bleeding may be profuse, resulting in hysterectomy. Rupture of myomectomy scar during pregnancy

Effects of pregnancy on fibroid Red degeneration Increased size in 20 to 30% cases Torsion of a pedunculated fibroid, may cause gradual or acute symptoms of pain and tenderness. Infection during puerperium Expulsion Necrosis

Pelvic examination. Abdominal examination firm mass arising from the pelvis on bimanual examination the mass is felt to be part of the uterus, usually with some mobility. Pelvic examination. uterine enlargement The shape of the uterus is usually asymmetric and irregular in outline The uterus is usually freely movable unless concomitant pelvic disease exists such as endometriosis or pelvic adhesions.

Differential diagnosis:- pregnancy Ovarian tumor Adenomyosis Malignancy :(eg. Ca.endometrium,choriocarcinoma,Leiomyosarcoma) pelvic kidney

Investigations:- CBC: indicate anemia if there is clinically significant menorrhagia. Ultrasonography/Doppler ultrasound Used to assess uterine dimension leiomyoma location,size, growth Adnexal anatomy. Detect hydroureter and hydronephrosis in the patient with marked uterine enlargement.

3.Sonohysterography or intrauterine infusion of sterile saline at the time of ultrasound examination identify the presence of pedunculated submucous fibroid endometrial polyps.

4.Hysteroscopy or hysterosalpingography : in the evaluation of patients with uterine fibroid and infertility or recurrent pregnancy loss.

Submucous myoma

5. Magnetic resonance imaging (MRI): used to exclude other DDX 5.Magnetic resonance imaging (MRI): used to exclude other DDX. Including adenomyosis and adnexal masses.

6.Imaging of the renal tract   7.Clinical suspicion of sarcoma will be an indication for needle biopsy or, urgent laprotomy

Treatment:- Treatment decisions are based on Symptoms fertility status uterine size rate of uterine growth

1.Expectant management(Conservative management)-

1.Expectant management(Conservative management)- Indication In the absence of pain, abnormal bleeding, pressure symptoms Size <12 weeks (of pregnancy size) The patient near menopause, at which time the leiomyomas will atrophy as estrogen levels fall.

observation with periodic examination is appropriate Bimanual examinations every 3 to 6 months Follow-up with pelvic ultrasound or MRI Endometrial biopsy if abnormal bleeding. Regular blood counts: iron deficiency anemia is common with menorrhagia, and iron replacement may be required

2.Medical treatment

2.Medical treatment Non-hormonal options: such as NSAIDs (e.g. mefenamic acid) and antifibrinolytics (e.g. tranexamic acid) are limited at treating symptoms of dysmenorrhea and heavy, prolonged bleeding and anemia.

Hormonal options include : combined oral contraceptive pills, progestins(medroxyprogesterone acetate, Mirena IUD, norethindrone acetate) mifepristone androgenic steroids(danazol and gestrinone) gonadotropin-releasinghormone (GnRH) agonists Antiprogesterones (Mifepristone): effective in shrinking fibroids at a low dose

3.surgery

Surgery Myomectomy involves the removal of single or multiple fibroid while preserving the uterus.

Indications for myomectomy Large myomas (especially the submucosal or intramural type) Any symptomatic fibroid (persistent uterine bleeding despite medical therapy, excessive pain or pressure symptoms) Unexplained infertility with distortion of the uterine cavity by fibroid Recurrent pregnancy wastage due to fibroid. When IVF is indicated (especially if the myoma results in the distortion of the uterine cavity)

Types of myomectomy (may be done by) Laparotomy Laparoscopy Hysteroscopy vaginaly

1.Abdominal myomectomy

Risks of this procedure include Bleeding prolonged operative time increased postoperative hemorrhage compared to hysterectomy It may be necessary to open the uterine cavity to remove intramural or submucous fibroid completely. This is a risk factor for future uterine rupture and an indication for cesarean section in future pregnancies

2.Hysteroscopic resection submucous fibroid

3.laparoscopic myomectomy

4. vaginal myomectomy: in submucos pedenculated fibroid Surgical Management 4. vaginal myomectomy: in submucos pedenculated fibroid   Vaginal myomectomy

Laparoscopic myomectomy used for removing subserosal fibroids& intramural fibroid

Laparoscopic Myomectomy

2.Hysterectomy Indications for hysterectomy Asymptomatic fibroid of such size that they are palpable abdominally and are a concern to the patient Excessive uterine bleeding Pelvic discomfort caused by myomata Patient complete her family and wishes for amenorrhea Other treatment options (medical, myomectomy, UAE, etc) have failed or contraindicated Rapid increase in size Ultrasound features suggestive of sarcoma

Hysterectomy

4. Destruction of the fibroids

1.Uterine artery embolization (UAE) By occludes the vessel feeding the uterus and leiomyomas, depriving the tumors of their vascular supply and causing shrinking or necrosis and death of the leiomyomas. Used: approaching menopause no longer desire fertility have a large uterus have multiple health risks for surgery

The most common complication vaginal discharge infection premature ovarian failure Amenorrhoea Treatment failure Failed canulation of uterine artery

Uterine Artery Embolization

2.MRI-guided focused ultrasound fibroid ablation: is a new procedure involves a focussed ultrasound energy beam using MRI to plot where the fibroids are located. The beam heats the fibroids which results in local necrosis and subsequent shrinkage

3.Laparoscopic myolysis (using laser or coagulation current) and cryomyolysis

The procedure is performed laparoscopically, in which either a laser or a cryo needle is passed directly into the fibroid to destroy both the fibroid tissue and the blood vessels feeding it.

4. Laparoscopic Uterine Artery Ligation