8th Edition APGO Objectives for Medical Students Uterine leiomyomas

Rationale Uterine leiomyomas represent the most common gynecologic neoplasm and are often asymptomatic.

Objectives The student will be able to describe the following: Prevalence of uterine leiomyomas Symptoms and physical findings Methods to confirm the diagnosis Indications for medical and surgical treatment

Definition well-circumscribed, non-encapsulated, smooth-muscle benign tumors of myometrium

Prevalence 30% of women in U.S. (>35 yr. of age)

Risk factors Black Caucasion Asian

Location Submucous Intramural Subserosal

Most common site corpus

Pathophysiology Pathophysiology - unknown, estrogen plays a role, estrogen receptors? Genetically abnormal clones, each fibroid from a single progenitor cell Estrogen, progesterone, growth factors, all play role Increased estrogen and progesterone receptors present

Symptoms Symptoms vary with location, size Asymptomatic Menorrhagia Pelvic pressure and/or heaviness Urinary frequency Dysmenorrhea Abdominal enlargement Pregnancy loss/prematurity/complications

Physical findings Uterine enlargement - globular/nodular B. Abdominal displacement of uteru

Diagnosis Physical exam Ultrasound X-ray - calcified myomas CT scan MRI - good for differentiating from other tumors Hysterosonography Hysteroscopy - submucous tumors

Treatment Medical - reduce endogenous estrogen GnRH analog - temporary shrinkage to stop bleeding and facilitate surgery; reduces mean uterine size by 30-64% after 3-6 months treatment Trial NSAIDs, OCPs help decrease bleeding Uterine artery embolization Mifepristone (RU 486) - still experimental

Treatment Conservative - wait and watch (especially near menopause)

Treatment Surgery Myomectomy Hysterectomy Abdominal-reserve for women desiring future fertility or who strongly desire uterine retention Laparoscopic especially for pedunculated or subserosal fibroids Hysteroscopic-submucous fibroids, >50% in cavity Hysterectomy Size > 12 wk., i.e. unable to evaluate ovaries bimanually Excessive menorrhagia Pelvic discomfort Rapid growth - think leiomyosarcoma (found in 0.5% of women with suspected leiomyomata) Laparoscopic myomectomy, especially for subserosal or pedunculated fibroids Hysteroscopic resection of submucous fibroids

Treatment Interventional Radiology Uterine artery embolization

References Beckmann CRB, Ling FW, et al., Obstetrics and Gynecology, 4th ed., Lippincott Williams and Wilkins, Philadelphia, PA, pp 568-76. Mishell DR, ed., Comprehensive Gynecology, 3rd ed., Mosby Publishing Company, St. Louis, MO, 1997. Eisinger SH, Meldrum S. Fiscella K, le Roux HD, Guzick DH. Low-dose mifepristone for uterine leiomyomata. Obstet and Gynec 2003; 101:243-250. ACOG Practice Bulletin #16, Surgical Alternatives to Hysterectomy in the Management of Leiomyomas. Washington, DC, May 2000. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

Clinical Case Uterine Leiomyoma

Patient 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 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.

Patient presentation Physical examination 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 presentation 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. There is mild hydronephrosis on that side. The ovaries are not visualized.

Diagnosis Uterine leiomyoma (fibroids) Iron deficiency anemia Mild hydronephrosis

Teaching points No intervention is needed for women with asymptomatic fibroids. Many women are asymptomatic. The most frequent symptoms of uterine fibroids are pain, bleeding and pressure symptoms. Fibroids can be subserosal, intramural or submucosal. Submucosal fibroids are frequently associated with bleeding. Treatment options for leiomyoma include hysteroscopic resection, endometrial ablation to control bleeding, myomectomy, hysterectomy and uterine artery embolization. Pregnancies in women with fibroid are usually uneventful Fibroids are rarely a cause of infertility. There are specific criteria for the use of myomectomy in infertile patients.