UTERINE LEIOMYOMATA

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UTERINE LEIOMYOMATA

• Dr Zeinab Abotalib MD, MRCOG
• Associate Professor Consultant
• Obstetrics Gynecology
• Infertility And Assisted Conception

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Uterine Leiomyomata

• Benign tumor comprised mostly of smooth muscle
  cells
• First described by Reinier De Graff 1641
• Most common tumor of the female pelvis
• Represent 1/3 of all GYN admissions to hospitals

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Incidence

• Usually quoted 50 (Underestimate)
• Cramer and Patel
• 100 serial Uteri
• Sectioned at 2mm
• 77 of 100 had myomas
• 84 had multiple myomas
• 649 myomas found in all
• No difference in incidence within pre or post
  menopausal uteri

Am J Clin Pathol. 1990 Oct94(4)435-8
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Incidence

• More common in African-Americans than white
• Torpin et al. investigated 1741 Uteri
• Overall incidence 3 times higher in blacks
• Also tended to be larger
• Also occurred at a younger age

J Obstet Gynecol 194244569
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Incidence

• Cumulative incidence by age 50, gt 80 for
  African American and nearly 70 for Caucasian
  women.
• One in four women have at least one submucosal
  fibroid.
• Overall prevalence of uterine fibroids increases
  with age from 3.3 in women 25-32 to 7.8 in
  women 33-40 years.

• Baird et al, Am J Obstet Gynecol 2003.
• Borgfeldt et al, Acta Obstet Gynecol Scand 2000.

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Etiology

• Arise from a single muscle cell (monoclonal).
• Proliferate under the influence of sex hormones,
  including estrogen, progesterone androgens.
• Effects of steroids are modulated by local growth
  factors.

• Rein et al, Am J Obst Gyne 1995.
• Ichimura et al, Fertil Steril 1998.
• Stewart et al, Obstet Gynec 1998.
• Wer et al, Fertil Steril 2002.

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Etiology

• Fibroblast growth factor
• Vascular endothelial growth factor
• Heparin-binding epidermal growth factor
• Platelet-derived growth factor
• Transforming growth factor
• Parathyroid hormone-related protein
• Prolactin

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Etiology

• Risk Factors
• Nurses Health Study II
• 95,061 nurses completed questionnaires in 1989,
  1991, 1993
• Obesity
• Early menarche
• Nulliparity

Fertil Steril. 1998 Sep70(3)432-9
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Etiology

• Oral Contraceptives
• High dose pills have been assoc. with stimulation
  of fibroid tumors
• Smoking

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Presentation

• Most fibroids do not cause symptoms.
• 20-50 experience tumor-related symptoms
• Menstrual dysfunction
• Bowel and bladder dysfunction
• Bulk effects
• Such symptoms, account for up to 35 of all
  hysterectomies.

• Lefebvre et al, J Obstet Gynecol Can 2003.
• Myers et al, Agency for Health Care Research and
  Quality, 2001.

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Symptoms

• Pelvic Pain
• Menstrual Irregularities
• GI complaints
• Bladder complaints
• Dyspareunia

• Back pain
• Leg pain
• Vascular symptoms
• Infertility
• Asymptomatic

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Diagnosis

• History
• Bimanual pelvic or abdominal exam
• Pelvic ultrasound - most common
• MRI, HSG, sonohysterogram, hysteroscopy

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Appearance
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Appearance
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Appearance
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Degenerative Changes

• Degenerative changes are reported in
  approximately two-thirds of all specimens, but
  most of them have no clinical significance.
• Hyaline degeneration- It is the most common
• Cystic degeneration
• Mucoid degeneration
• Fatty degeneration
• Carneous degeneration
• Calcification
• Sarcomatous degeneration(malignant
  transformation)

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Uterine Fibroids

• Benign tumour of uterine tissue
• 3 locations
• subserosal
• intramural
• submucosal

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Leiomyomas classified according to their location
in the uterus
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How are they diagnosed?

• Usually detected on an internal gynecological
  exam
• Diagnosis is usually confirmed by ultrasound but
  can also be made with magnetic resonance (MR) or
  computed tomography (CT) scans.

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As seen on ultrasound
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As seen on MRI
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Factors that should be considered prior to
initiating treatment include

• Size of the myoma(s)
• Location of the myoma(s) (Symptoms
• Woman's age (eg, is she near menopause?)
• Reproductive plans

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How are they treated?

• Depends on size and location
• Surgical therapy - hysterectomy, myomectomy
• Drug therapy - pain relievers, hormone therapy
  (to shrink them)
• Uterine artery embolization

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Treatment

• Expectant management - most cases
• Indications for treatment
• Abnormal uterine bleeding, causing anemia
• Severe pelvic pain
• Large or multiple
• Obscuring evaluation of adnexa
• Urinary tract symptoms
• Postmenopausal or rapid growth

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Treatment Choices

• Medical therapies
• Medroxyprogesterone (Provera)
• Danazol
• GnRH agonists (nafarelin acetate, Depot Lupron)

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Treatment

• RU486
• Anti-progestin
• High affinity to Progesterone and glucocorticoid
  receptors
• Murphy et al (1995) showed decrease of volume an
  average 49
• Recent reviews supports usage, but has been
  associated with
• Hot flashes
• Endometrial hyperplasia
• Is not associated with trabecular bone loss

Fertil Steril. 1995 Jul64(1)187-90 Obstet
Gynecol. 2004 Jun103(6)1331-6 Clin Obstet
Gynecol. 1996 Jun39(2)451-60
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Treatment

• Gestrinone
• Antiestrogen/antiprogesterone
• GnRH analogues
• Suppresses pituitary mediated secretion of
  estrogens
• Basically treat 3-6 months
• Expect 50 reduction of uterine volume

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Treatment Choices

• Uterine Artery Embolization (UAE)

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UAE

• Within three months following embolization
• 45 and 55 reduction in total uterine and myoma
  volume.
• Reduction in symptoms in approximately 80 of
  women.
• long- term data on durability and effects on
  fertility and pregnancy outcomes are very limited.

Pron et al, Fertil Steril 2003 Burbank et al, J
Am Assoc Gynecol Laparosc 2000
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What does the doctor see?
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Myomectomy

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Myomectomy

• First performed by Washington and John Atlee,
  1844
• May be approached in a variety of ways
• Abdominally (open)
• Laparoscopic
• Hysteroscopic
• Primarily for submucosal/intramural fibroids
  impacting the endometrial cavity
• Vaginal
• Primarily for pedunculated submucous fibroids

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Myomectomy

• Biggest complication is blood loss

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Myomectomy (local surgical removal of fibroids)

• Sparing the uterus
• Complications significant blood loss  could
  require hysterectomy
• Fibroids can recur20 - 25 will need another
  procedure for treatment of new fibroids

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Myomectomy

• Hysteroscopy for intracavitary / submucous
• Laparotomy

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Myomectomy with hysteroscope
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Myomectomy

• Hysteroscopy for intracavitary / submucous
• Laparotomy

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Treatment Choices

• Hysterectomy
• Vaginal
• Abdominal

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Hysterectomy

• Curative, but irreversible
• Until now, the standard therapy for fibroids 1/3
  of all hysterectomies are performed for fibroids
• Complications bleeding, infection, adhesions,
  risks associated with general anesthetic
• 6 - 8 week recovery

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Comparison of treatment options
Treatment Pros Cons
Pain Medication Reduces Pain Doesn't solve problem, Pain returns
luperon Reduces size Improves symptoms side-effects, Symptoms return on discontinuation
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Comparison of treatment options
Treatment Pros Cons
Hysterectomy Complete cure Major operation cant become pregnant
Myomectomy successful Can still become pregnant surgical procedure Fibroids can recur
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Comparison of treatment options
Treatment Pros Cons
Uterine Artery Embolization Non-surgical treatment Very effective Fibroids may recur

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Goal

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Thanks !
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Method Of Delivery

• Vertex- Vertex (50)
• Vaginal delivery, interval between twins not to
  exceed 20 minutes.
• Vertex- Breech (20)
• Vaginal delivery by senior obstetrician

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Method Of Delivery

• Breech- Vertex( 20)
• Safer to deliver by CS
• Breech-Breech( 10)
• Usually by CS.

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Method Of Delivery

• MONO-MONO
• By C/S
• Why?