1. 8th Edition APGO Objectives for Medical Students
Uterine leiomyomas

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

4. 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

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

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

7. Risk factors
Black
Caucasion
Asian

8. Location
Submucous
Intramural
Subserosal

9. Most common site
corpus

10. 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

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

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

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

14. 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

15. Treatment
Conservative - wait and watch (especially near menopause)

16. 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

17. Treatment
Interventional Radiology
Uterine artery embolization

18. References
Beckmann CRB, Ling FW, et al., Obstetrics and Gynecology, 4th ed., Lippincott Williams and Wilkins, Philadelphia, PA, pp
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:
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

19. Clinical Case
Uterine Leiomyoma

20. 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.

21. 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.

22. 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.

23. Patient presentation Laboratory
Beta HCG is negative. CBC reveals hemoglobin of 10.3 and hematocrit of 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.

24. Diagnosis Uterine leiomyoma (fibroids) Iron deficiency anemia
Mild hydronephrosis

25. 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.