1. UTERINE LEIOMYOMA AND NEOPLASIA
Department of Obstetrics and Gynecology
Wu Jie

2. Key Points
Introduction
Symptoms
Diagnosis
Treatment

3. INTRODUCTION
Leiomyoma is common in clinical practice. It is estimated that up to 30% of American women have these benign tumors, although the majority do not present with significant symptoms and do not require therapy.

4. INTRODUCTION
Leiomyomas are present in 20-25% of reproductive-age women.
? Leiomyomas are 3-9 times more frequent in black than white women. About 50% of black women will have leiomyoma.

5. INTRODUCTION
Leiomyomas are the most common indication for hysterectomy, accounting for approximately 30% of all such cases.
Leiomyomas account for a large number of more conservative operations including myomectomy, uterine curettage, and operative hysteroscopy.

6. INTRODUCTION
Histologically, these benign tumors represent localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers.

7. INTRODUCTION Most frequent clinical manifestations include:
Mass: irregular enlargement of the uterine
Pain: torsion or degeneration
Bleeding, hypermenorrhea and dysmenorrhea
Pressure: symptoms from neighboring organs

8. INTRODUCTION
Leiomyomas are considered hormonally responsive tumors because the growth potential of these tumors is related to estrogen production, often with rapid growth occurring in pregnancy or high estrogen states.
Menopause generally brings about cessation of tumor growth and even some atrophy.

9. INTRODUCTION
In 0.1% of cases, malignancy such as leiomyosarcoma may develop. These are not thought to represent “degeneration” of a fibroid, but rather a new neoplasm.
Uterine malignancy is more typical in older patients.

10. INTRODUCTION
Be evaluated with considerable more concern for malignancy:
Rapidly enlarging uterine masses
Postmenopausal bleeding
Unusual vaginal discharge
Pelvic pain

12. Key Points
Introduction
Symptoms
Diagnosis
Treatment

13. SYMPTOMS
The symptoms associate with uterine leiomyomas frequently lead women to seek medical advice.

14. SYMPTOMS Bleeding It is the most common presenting symptom in
uterine fibroids.
Progressively heavier menstrual flow that lasts
longer than the normal duration.
Resulting from significant distortion of the
endometrial cavity by the underlying tumor.

15. SYMPTOMS Submucous leiomyoma endometrial cavity of uterus.
The smooth muscle tumor projects toward the
endometrial cavity of uterus.
Subserous leiomyoma
Intramural leiomyoma
It may contribute to excessive bleeding if they become
large enough to significantly distort the endometrial
cavity.

16. SYMPTOMS
Anemia
Blood loss from submucous leiomyoma may be heavy enough to contribute to chronic iron-deficiency anemia.

17. SYMPTOMS Pelvic pressure
This may be a sense of progressive pelvic fullness, and/or the sensation of a pelvic mass.
Most commonly, this is caused by slowly enlarging intramural or subserous myomas. This type of leiomyoma is the most easily palpated on bimanual or abdominal examination.

18. SYMPTOMS
Pelvic pain
The pain may be the result of rapid enlargement of leiomyoma (areas of tissue necrosis or areas of subnecrotic vascular ischemia).

19. SYMPTOMS Pelvic pain Tortion of a pedunculated myoma
Acute pain:
Tortion of a pedunculated myoma
Dull, intermittent low midline cramping pain:
Submucous myoma becomes pedunculated and
progressively prolapses through the internal os
of the cervix

20. SYMPTOMS Degeneration Red degeneration
hemorrhagic changes associated with rapid growth
Hyaline degeneration
hyalinization of the smooth muscle elements,
occurring commonly after menopause
Calcification
calcific replacement of inactive smooth muscle
elements, occurring after menopause.

21. SYMPTOMS
Infertility
Spontaneous abortion
Enlarging uterine masses

22. Key Points Introduction Symptoms of uterine fibroids Diagnosis
Treatment

23. DIAGNOSIS Clinical examination
(including abdominal and bimanual palpation)
A large mobile pelvic mass with an irregular
contour
The mass usually ‘hard feel” or solid quality
The degree of enlargement is usually stated in
terms (weeks size)

24. DIAGNOSIS
Clinical examination
The mass is often appreciated as separate from adnexal disease, although on occasion pedunculatedly subserosal myoma may be difficult to distinguish from a solid adnexal mass.

25. DIAGNOSIS Pelvic ultrasound For confirmation of uterine myomas
Hypoechogenic areas (to indicate myomas
undergoing degeneration)
Adnexal structures, including the ovaries
(separating from these masses)
(Obese women)

26. DIAGNOSIS CT
MRI ( magnetic resonance imagine)

27. DIAGNOSIS Biopsy or dilation & curettage Irregular uterine bleeding
Patient’s clinical presentation or age makes
endometrial carcinoma significant probability

28. DIAGNOSIS Hysteroscopy
It may be used to evaluate the enlarged uterus by
directly visualizing the endometrial cavity.
Submucous fibroids can be visualized and
removed.
Long-term follow-up suggests that up to 20% of
patients require additional treatment.

29. DIAGNOSIS Laparoscopy
It may be used in cases in which physical examination and ultrasound imagine techniques are not clear as to whether the patient has a leiomyoma or other potentially more serious diseases.

30. Key Points Introduction Symptoms of uterine fibroids Diagnosis
Treatment

31. TREATMENT Observation Biopsy might rule out endometrial hyperplasia or
cancer.
Bleeding is not heavy enough to cause significant
alteration in lifestyle and is not contributing to
iron-deficiency anemia.

32. TREATMENT Observation
Assessment of further uterine growth may be done by repeat pelvic examinations and assisted by serial pelvic ultrasound measurements.

33. TREATMENT Hormonal supplementation
To make to minimize uterine bleeding by using intermittent progestin supplementation and/or prostaglandin synthetase inhibitors, which decrease the amount of secondary dysmenorrhea.

34. TREATMENT Surgical measures
Myomectomy is occasionally warranted in younger patients whose fertility is compromised by the presence of myomas.

35. TREATMENT Surgical measures Potential complications of myomectomy:
Excessive intraoperative blood loss
Risk of postoperative hemorrhage

36. TREATMENT Surgical measures
Criteria for myomectomy have been published to help guide the clinician’s decision making.

37. Confirmation of indication
Leiomyoma in infertility patients, as a probable factor in failure to conceive or in
recurrent pregnancy loss
Confirmation of indication
In the presence of failure to conceive or in recurrent pregnancy loss:
1.Presence of leiomyoma of sufficient size or specific location to be a probable factor
2.No more likely explanation exists for the failure to conceive or in recurrent
pregnancy loss
Actions before procedure
1.Evaluate other causes of male and female infertility or recurrent pregnancy loss
2.Evaluate the endometrial cavity and fallopian tubes
3.Document discussion that complexity of disease process may require hysterectomy

39. TREATMENT Surgical measures
Hysterectomy is commonly performed for uterine myomas in symptomatic women who have completed childbearing. Indications should be specific and well documented.

40. Criteria for Hysterectomy for Leiomyoma
Indication
Leiomyoma
Confirmation of indication
Presence of 1, 2, or 3:
1. Asymptomatic leiomyomas of such size that they are palpable
abdominally and are a concern to the patient
2. Excessive uterine bleeding evidenced by either of the following:
a.Profuse bleeding with flooding or clots or repetitive periods
lasting>8 days
b.Anemia caused by acute or chronic blood loss
3. Pelvic discomfort caused by myoma:
a.Acute and severe
b.Chronic lower abdominal or low back pressure
c.Bladder pressure with urinary frequency not caused by urinary
tract infection

41. Criteria for Hysterectomy for Leiomyoma
Actions before procedure
1.Confirm the absence of cervical malignancy
2.Eliminate anovulation and other causes of abnormal bleeding
3.When abnormal bleeding is present, confirm the absence of endometrial
malignancy
4.Assess surgical risk from anemia and need for treatment
5.Consider patient’s medical and psychological risks concerning hysterectomy
Contraindications
1.Desire to maintain fertility, in which case myomectomy should be considered
2.Asymptomatic leiomyomata of size <12 weeks’ gestation
determined by physical examination or ultrasound examination

42. TREATMENT Other measures “estrogen-dependent” benign neoplasms
Gonadotropin-releasing hormone agonists
Used for 3 to 6 months before planned hysterectomy
A temporizing medical therapy

43. TREATMENT Other measures
GnRH agonists not only can result in a reduction in uterine size, often by as much as 40% to 60%, but also can lead to a technically easier surgery with markedly diminished blood loss should surgery be undertaken.

44. TREATMENT Other measures Myolysis Arterial embolization
Further investigation is required before they may be considered a “mainstream” therapeutic modality.

45. TREATMENT Pregnancy with leiomyoma
Patients with leiomyoma do become pregnant and
clinical findings are unremarkable.
Myomas may grow or become symptomatic,
associated with red degeneration.
Bed rest and strong analgesics are usually sufficient
as treatment.

46. TREATMENT Pregnancy with leiomyoma
Vaginal birth after myomectomy is controversial
and must be decided on a case-by-case basis.
Cesarean birth: myomas are located below the fetus
in the lower uterine segment or cervix, causing a
soft tissue dystocia.

47. LEIOMYOSARCOMA Uterine sarcomas accounted for approximately 3%
of cancers involving the body of the uterus.
Progressive uterine enlargement
Postmenopausal bleeding
Unusual pelvic pain coupled with uterine enlargement
An increase in unusual vaginal discharge

48. LEIOMYOSARCOMA When uterine sarcoma is suspected, patients should
undergo typical tumor survey to include assessment
for distant metastatic disease.
Hysterectomy, it is necessary to thoroughly explore the
abdomen and sample commonly affected node chains.

49. LEIOMYOSARCOMA
The staging for uterine sarcoma is surgical and identical to that for endometrial adenocarcinoma.
The overall rate of survival is considerable worse than that for those with endometrial adenocarcinoma.
Only 50% patients survive 5 years.

50. LEIOMYOSARCOMA Surgical removal is the method of most reliable
diagnosis.
Adjunctive radiation therapy and chemotherapy provide
little additional benefit.
Uterine sarcoma is not responsive to hormonal treatment
with high-dose progestins.