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Uterine leiomyomas
1. Dr. Yusri Arif Sapaee
Supervised by Dr. Amy Suzanna Annuar
2. Benign tumours of the uterine smooth
muscle (the myometrium)
Also called myomas, fibromyomas
and fibroids
Most common benign tumours of
female genital organs
Major contributor for hyterectomy in
Malaysia ~ 47.8%
3.
4. Exact etiology is UNKNOWN
Possible etiological factors include:
HYPERESTRENISM
GROWTH FACTORS
GENETIC FACTORS
5. Evidenced by the following
Appear only in childbearing period
Commonly associated with endometrial
hyperplasia and/or endometriosis
Increase in size during pregnancy and
during estrogen hormonal therapy
Decrease in size and undergoes atrophy
after menopause with hormonal
depletion or with GnRH agonist therapy
6. Parity
More common in nulliparous and low parity
women
Hereditary
More common in women with positive
family history (mother and sister)
Obesity
More common in obese women
Conversion of circulating androgens to
estrone (E1) by excess adipose tissue
7.
8.
9. Understanding their differences,
how they grow and how they develop
Can help to decide the best treatment
option
To evaluate degree of difficulty during
operation
10. proximate to the endometrium and
grow toward and bulge into the
endometrial cavity
Increase surface area of endometrial
lining
Heavy menstrual bleeding anemia
multiple blood transfusion
Large submucosal fibroid tumors
May block fallopian tubes infertility
11. The growth centered within the
uterine walls
Tends to make uterus feels larger
than normal bulk symptoms
Prolonged heavy menses
Pelvic pain
Pressure on surrounding organs
Inhibit muscle contraction
cramping pain during menses
12. originate from myocytes adjacent to
the uterine serosa, and their growth
is directed outward
Usually cause pelvic pain and
compression symptoms
May extend to lie within the broad
ligaments difficult to remove
during surgery
13. Attached only by a stalk to their
progenitor myometrium
Pedunculated submucosal myoma
Pedunculated subserosal myoma
It can be twisted on their stalk
acute pelvic pain
14.
15. Mostly asymptomatic
Usually accidentally discovered during
routine bimanual examination or on
performing pelvic ultrasound
16. Mostly with submucosal and large
multiple interstitial myomas
Increased surface area of the
endometrium
Mechanical interference with uterine
contraction
Associated endometrial hyperplasia
Increased myometrial vascularity due to
venous congestion
17. At any level within the myometrium, submucous, subserosal, and
intramural leiomyomas can compress adjacent veins and thereby
cause dilatation of distal endometrial venules.
18. Usually painless unless complicated
Dull aching pain: hyaline degeneration,
infection of submucosal fibroid polyp
Acute pain: red degeneration and torsion
of pedunculated myoma
Colicky pelvic pain: extrusion of
pedunculated submucosal myoma
through the cervix
Loin pain: ureteric compression
Congestive or spasmodic dysmenorrhea
19. Urinary bladder frequency, incontinence
Ureter hydronephrosis
Rectum constipation
Cervix dyspareunia
Major veins edema of lower limb(s)
Pelvic nerve back pain and thigh pain
20. Interference with implantation and
distortion of uterine cavity
Tubal obstruction
Interference with ascent of sperm
and fertilization
21. Recurrent miscarriage
Preterm labour
Pre-labour rupture of membrane
Malpresentations
Obstructed labour
Post partum haemorrhage
Abruptio placenta
22.
23. Hyaline degeneration
Occurs in the centre due to poor
vascularity
Becomes larger and softer
Red degeneration
More frequent in pregnancy
Thrombosis of capsular vessels
Rapid uterine growth outgrowth its
blood supply
24.
25. Calcification
Deposition of calcium phosphate and
carbonate along blood vessels in long
standing myomas
Peripheral egg-shell appearance
Diffuse womb stone
Common after menopause
27. Infection
Most frequent at the tip of a submucosal
myoma polyp
Torsion
Pedunculated subserous myoma
Rarely torsion of the whole uterus
Malignant transformation
Very rare
No more than 0.2 – 0.5% of myomas
28.
29. Gold standard in diagnosis
Saline-infusion sonography
Injection of saline to delineate the
endometrial cavity
Improve sensitivity of TVS in diagnosing
submucosal myoma
Also very helpful to exclude
associated pelvic pathology
e.g. Ovarian cyst
30.
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34.
35.
36. Submucous fibroid clearly outlined by saline-infusion
sonography and identified by long white arrows.
37. These tools allow more accurate
assessment of leiomyomas, which
may help identify appropriate patients
for alternatives to hysterectomy
Hysteroscope
Hysterosalpingography (HSG)
Magnetic resonance imaging (MRI)
38.
39. Structural factors
uterine size
size, number and location of the myomas
Desire for fertility
Definitive versus uterus-conserving treatment
General medical health
Age, BMI, co-morbidities, previous treatment,
previous surgery
Preference
Focal versus global uterine treatment
40. NSAIDs
Inhibit prostaglandin synthesis
Reduce menstrual flow (25-35%)
Relieve dysmenorrhea
Progestogens
Given for 21 days
Significant reduction in menstrual blood
loss
41. Danazol
Synthetic steroid
suppress estrogen and progesterone
receptor in endometrium
thinning of lining of endometrium
reduction of blood loss
Disadvantage: masculinizing effect
42. Tranexamic acid
Antifibrinolytic agent
Synthetic derivative of amino acid lysine
Reversible blockage on plasminogen
50% reduction of menstrual blood loss
Levonorgestrel intrauterine system
Reduces blood loss by 80%
Not applicable to all type of fibroid
43. GnRH agonist
Induce a reversible hypoestrogenic state
Reduce uterine volume
Pre-operative use
3-4 months course prior surgery
Reduce fibroid size and uterine volume
Midline vertical laparotomy incision lower
transverse abdominal incision
Improve pre-operative haemoglobin level
Reduce perioperative blood loss and
transfusion requirement
45. Benefits
80% improvement in abnormal
menstrual bleeding
Removal of intracavitary fibroid improves
fertility
Disadvantage
Need another treatment after
myomectomy
20% over 2-5 years
46. Removal of small submucosal myoma
<5cm in diameter which protrude
>50% into uterine cavity
Better preceded by GnRH agonist
preparation to decrease vascularity
and diminish the size of myomas
Advantage:
Significantly less pain
Shorter recovery period
47. Indications
Postmenopausal women with symptomatic
fibroids
Multiple or very large myoma
Future fertility not desired
Patient’s preference
Advantages
Sure relief of symptoms with no recurrence
Less blood loss during surgery
Lower post-operative morbidity
48. Angiographic interventional procedure that
delivers polyvinyl alcohol (PVA)
microspheres or other particulate emboli
into both uterine arteries.
Uterine blood flow is therefore obstructed,
producing ischemia and necrosis
These microspheres are preferentially
directed to the tumors, sparing the
surrounding myometrium