UTERINE MYOMAS

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UTERINE MYOMAS An Overview of Development,
Clinical Features, and Management
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INDEX
? Clinical Manifestations ? Growth Patterns ?
Therapy 1. Hysterectomy 2. Abdominal
Myomectomy 3. Hysteroscopic Myomectomy
4. Laparoscopic Myomectomy 5. Uterine Artery
Embolization 6. Hormone Therapy -
Progestins - GnRHa
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CHARACTERISTICS
? The most common solid pelvic tumors in women
- occurring in 2040 of women during their
reproductive years ? Benign tumors that
originate from smooth muscle cells of the
uterus ? Consists of uterine smooth muscle
tissue as well as fibrous tissues ? Size
seedlings large tumors
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CHARACTERISTICS
? Types 1) intramural - found
within the myometrium 2) subserous
- externally extending to the serosa 3)
submucous - internally impinging on the
uterine cavity 4) pedunculated 5)
extend through the internal os of the cervix
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CHARACTERISTICS
? Estrogen-dependent tumors - associated
with exposure to circulating estrogen -
decrease in size during menopause - maximum
growth when estrogen secretion is
maximal, spurt in growth in the decade
before menopause (anovulatory cycles
with unopposed circulation estrogen)
- occasionally grow during pregnancy
(caused by estrogen)
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CLINICAL MANIFESTATION
1. Most patients with uterine myomas are
symptom-free 2. Excessive menstrual bleeding
- the only symptom produced by myomas -
obstructive effect on uterine vasculature
? proximal congestion in the myometrium
and endometrium ? excessive
bleeding - uterine cavity size endometrial
surfaces are ? ? increasing the quantity
of menstrual flow
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CLINICAL MANIFESTATION
3. Pain - relatively infrequent ?
torsion of the pedicle of a pedunculated myoma
? cervical dilatation by a submucous myoma
protruding through the lower uterine
segment ? carneous degeneration associate
with pregnancy ? pain is acute and requires
immediate attention 4. Pressure and increased
abdominal girth - develop insidiously, often
less apparent symptom - urinary tract Sx
frequency, outflow obstruction,
compression of the ureter - G-I
Sx constipation or tenesmus
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CLINICAL MANIFESTATION
5. Infertility - rarely caused by myomas
- associated with a submucous myoma
interferes with normal implantation or with
sperm transport - implicated in
recurrent pregnancy loss - improvement in
reproductive outcome after surgery 6. Malignant
transformation - extremely rare
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GROWTH PATTERNS
? Because malignancy in association with myomas
is rare, careful consideration must be given
to specific indications for performing
surgery ? A history of rapid growth, especially
postmenopausal growth ? should prompt
resection of tumor, even in absence of
symptoms ? Small asymptomatic myomas require only
serial flow-up - initially at 3-month
intervals to establish a growth pattern - if
growth pattern is stationary, pelvic exam can be
repeated in 46 month intervals ? USG, CT,
MRI hysterosalpingography ? assists in
documenting growth of myomas
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GROWTH PATTERNS
? Indications for Surgical Management of Uterine
Myomas Abnormal uterine bleeding not
responding to conservative treatments
High level of suspicion of pelvic malignancy
Growth after menopause Infertility when
there is distortion of the endometrial cavity
or tubal obstruction Recurrent pregnancy
loss (with distortion of the endometrial
cavity) Pain or pressure symptoms (that
interfere with quality of life) Urinary
tract symptoms (frequency and/or obstruction)
Iron deficiency anemia secondary to chronic
blood loss
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THERAPY
? Medical management - GnRH analogues,
progestational compounds,
antiprogestins ? Surgical management -
myomectomy or hysterectomy ? Uterine artery
embolization ? Others - high frequency
ultrasonography, laser Tx, cryotherapy,
thermoablation
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THERAPY
? The choice should be predicated upon careful
consideration of many factors - medical and
social age, parity, childbearing aspirations,
extent and severity of symptoms,
size, number and location of
myoma, associated medical condition,
possibility of malignancy, proximity to
menopause, desire for uterine
preservation ? For example, ? multiple myoma
completed childbearing ? benefit from
hysterectomy ? nulliparous woman ?
myomectomy ? submucosal myoma ? hysteroscopic
resection ? subserosal pedunculated myoma ?
laparoscopic resection
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THERAPY
1. Hysterectomy - second most frequent
major surgical procedure performed in
women in the US - indication for
hysterectomy ? uterine myoma (33.5)
? endometriosis (18.2) ? uterine
prolapse (16.2) ? cancer (11.2)
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THERAPY
- Why do a hysterectomy? Why remove the
entire uterus? ? several factors should
influence the gynecologists
judgement, including the age and her
childbearing aspirations - for
many women, hysterectomy conjures up the specter
of loss of sexuality and feminity ?
counseling with other women who have undergone
hysterectomy can be very constructive
before surgery - several recent report
? improvement in life quality for most
women who have had hysterectomy
hysterectomy dose not adversely
influence sexuality
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THERAPY
- surgery to relieve bleeding, pain, pelvic
pressure, and urinary tract symptoms may
lead to improvement in sexual
satisfaction and quality of life -
complication ? risk of damage to adjacent
structure urinary tract uriteral
injury, vesicovaginal fistula,
stress incontinence
bowel ? vaginal vault prolapse
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THERAPY
- supracervical hysterectomy
associated with a decreased risk of urinary tract
injury, less operating time, less
vault prolapse (by preservation of
uterosacral and cardinal ligament)
recent studies, there was no difference in
pelvic relaxation symptoms after 2
years follow-up ? Hysterectomy is an
acceptable choice for symptomatic myomas in
patients who have significant bleeding,
pain, pressure or anemia for whom fertility is
not an issue
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THERAPY
2. Abdominal Myomectomy - preferred
treatment whenever preservation of uterus
is desired - choice for a solitary
pedunculated myoma - interference with
fertility or predisposition to repeated
pregnancy loss due to nature or location of
myomas ? indication for myomectomy
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THERAPY
- To perform myomectomy, the surgeon must
carry out a thorough preoperative
appraisal ? Hypermenorrhea and abnormal
bleeding ? required endometrial
evaluation in a patient aged more
than 35 years ? Hematologic status
normal Hb ? should have 1 or 2 units of
her own blood,
obtained 2 weeks before myomectomy
anemic patient ? pretreatment
with GnRH analogues or progestational agent
? produce and amenorrheic state during
which iron stores can be
replenished and anemia corrected
to reduce intraoperative blood loss
? pharmacologic vasoconstricting agent and
mechanical vascular
occlusion was used
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THERAPY
- multiple myomectomy is frequently a more
difficult and time-consuming procedure
than hysterectomy - morbidity between the 2
procedures (Iverson et al) ? hysterectomy
group experienced ureteral,
bladder, and bowel injuries ? myomectomy
group no intraoperative visceral
injuries
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THERAPY
3. Hysteroscopic Myomectomy - Resection of
submucosal myomas - Indication
abnormal bleeding Hx of pregnancy loss,
infertility, and pain -
Contraindication endometrial ca. lower
reproductive tract infection,
inability to distend the uterine cavity,
extension of the tumor deep into the
myometrium
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THERAPY
4. Laparoscopic Myomectomy - performed when
myomas are easily accessible, as in
superficial subserous or pedunculated myomas
- these can be morcellated and removed through
the laparoscopic cannula or placed in the
cul-de-sac and removed via a colpotomy
incision - laparoscopic coagulation of a
myoma, or myolysis ? conservative
alternative to myomectomy in women
wishing to preserve fertility ? NdYAG
laser via degeneration of protein and
destruction of vascularity
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THERAPY
- laparoscopic assisted myomectomy involves
laparoscopic dissection of the myomas from
the uterine wall and their extraction
through a minilaparotomy incision, thus sparing
a large abdominal incision - these
procedures have not been standarized, so, the
surgeon who undertakes them should be skilled
in operative endoscopy
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THERAPY
5. Uterine Artery Embolization - this
approach had been used for many years to control
pelvic hemorrhage, for treatment of myomas
was first described in 1995 -
principle limiting blood supply to the myomas
(infarction)
? their volume may be reduced -
performed under conscious sedation by an
interventional radiologist -
minimally invasive procedure ? shortened hospital
stay
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THERAPY
- recommended for patients with large myomas
who are symptomatic, women who do not
want extirpative therapy - In a series of 80
patients with myoma related
hypermenorrhea, 90 reported complete cessation
of symptoms after embolization -
complication ? pain persist and last for
more than 2 weeks ? postembolization
fever, postembolization syndrome,
pyometra, failure of satisfactory regression of
myomas, sepsis, hysterectomy, and
death
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THERAPY
6. Hormone Therapy ? Progestins -
Norethindrone, medrogestone, medroxyprogesterone
acetate - produce a hypoestrogenic
effect by inhibiting gonadotropin
secretion and suppressing ovarian
function - exert a direct antiestrogenic
effect
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THERAPY
? Gonadotropin-Releasing Hormone Analogues
- used to achieve hypoestrogenism in various
estrogen-dependent conditions ( ex.
Endometriosis, precocious puberty, and uterine
myomas) - transient effect -
within several cycles after discontinuing
administration, myomas tend to return to
their pretherapy size
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THERAPY
- adjuvantive therapy with 34 month course
of GnRHa should reduce myoma size and
render surgery easier, accompanied by
less blood loss - use of GnRHa has been
associated with significant short- and
long-term side effect, such as
postmenopausal symptoms and osteoporosis -
severe pelvic pain occasionally will accompany
shrinkage of myomas during GnRHa
treatment
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CONCLUSION
a thorough understanding of the pathogenesis
of uterine myomas, clinical presentation, and
diagnostic tools are the keys to selecting
which course to follow in treating patient
with myomas surgery for myomas is not always
necessary and should be performed only for
appropriate indications ? the use of GnRHa is
the achievement of amenorrhea to
facilitate correction of IDA before surgery
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CONCLUSION
? uterine artery embolization is most
effective for patients with large
symptomatic myomas who are poor surgical
candidates and reluctant to undergo a major
surgical procedure ? gynecologists
determine surgical approach, endoscopic
or by laparotomy, based on size, number, extent
and location of myomas ? all
therapeutic measures, and especially invasive
techniques, should be reserved for patients
with symptomatic myomas - for
asymptomatic women, serial follow-up for growth
and development of symptoms is generally
safe
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