MYOMA UTERI

Introduction:
Uterine myomas also called “fibroids” are tumors that grow from the wall of the uterus.
The wall of the uterus is made of muscle tissue, so a fibroid is a tumor made of muscle tissue.
The fibroids start off very small, actually from one cell, and generally grow slowly over years
before they cause any problems. Most fibroids are benign; malignant fibroids are rare. The
cause of fibroids is unknown, although it is known that fibroids have a tendency to run in
families. Fibroids are very common, with an estimated 50% of women having them. Fibroids can
be diagnosed by pelvic examination or by ultrasound. Fibroids do not have to be removed
unless they are causing symptoms such as heavy periods, irregular bleeding, or severe cramps
with periods. Also, sometimes the size alone causes enough discomfort so that removal is
necessary. Once women go through menopause, fibroids do not usually cause any further
problems.

Causes of uterine fibroids:

We do not know exactly why women develop these tumors. Genetic abnormalities, alterations in
growth factor (proteins formed in the body that direct the rate and extent of cell proliferation) expression,
abnormalities in the vascular (blood vessel) system, and tissue response to injury have all been
suggested to play a role in the development of fibroids.

Family history is a key factor, since there is often a history of fibroids developing in women of the
same family. Race also appears to play a role. Women of African descent are two to three times more
likely to develop fibroids than women of other races. Women of African ancestry also develop fibroids at a
younger age and may have symptoms from fibroids in their 20s, in contrast to Caucasian women with
fibroids, in whom symptoms typically occur during the 30s and 40s. Pregnancy and taking oral
contraceptives both decrease the likelihood that fibroids will develop. Fibroids have not been observed in
girls who have not reached puberty, but adolescent girls may rarely develop fibroids. Other factors that
researchers have associated with an increased risk of developing fibroids include having the first
menstrual period (menarche) prior to age 10, consumption of alcohol (particularly beer), uterine infections,
and elevated blood pressure (hypertension).
 Estrogen tends to stimulate the growth of fibroids in many cases. During the first trimester of
pregnancy, up to 30% of fibroids will enlarge and then shrink after the birth. In general, fibroids tend to
shrink after menopause, but postmenopausalhormone therapy may cause symptoms to persist.

Overall, these tumors are fairly common and occur in up to 50% of all women. Most of the time,
uterine fibroids do not cause symptoms or problems, and a woman with a fibroid is usually unaware of its
presence.

Complications:
Subfertility: RARE types of ECTOPIC PREGNANCY

o Overactive Bladder Syndrome -- Rare Types

o PCOS -- Rare Types
o Chlamydia -- Rare Types
o Pelvic Inflammatory Disease -- Rare Types
o Cervical Cancer -- Rare Types
o Breast Cancer -- Rare Types
o Ovarian Cancer -- Rare Types
o Von Willebrand Disease -- Rare Types

Signs of uterine fibroids:

(1) Very large fibroids can be palpated abdominally (those smaller than 12-14
gesation Week are usually confined to the pelvis)

 Palpated as irregular, protruding against the anterior abdominal wall.

 Softness, tenderness  suggests presence of edema , sarcoma,
degenerative changes.

(2) Bruits – similar to uterine soufflé of pregnancy may be heard and felt over large
myomas.

(3) Bimanual vaginal examination:

 Enlarged uterus
 Shape  asymmetric and irregular in outline (in submucous Myoma  usually
symmetric enlargement)
 Consistency  firm
 Symptoms of uterine fibroids:
Most women with uterine fibroids have no symptoms.

However, abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are
near the uterine lining, or interfere with the blood flow to the lining, they can cause heavy periods, painful
periods, prolonged periods or spotting between menses. Women with excessive bleeding due to fibroids
may develop iron deficiency anemia. Uterine fibroids that are deteriorating can sometimes cause severe,
localized pain.

Fibroids can also cause a number of symptoms depending on their size, location within the uterus, and
how close they are to adjacent pelvic organs. Large fibroids can cause:

 pressure, 

 pelvic pain, 

 pressure on the bladder with frequent or even obstructed urination, and 

 pressure on the rectum with pain during defecation.

While fibroids do not interfere with ovulation, some studies suggest that they may impair fertility and
lead to poorer pregnancy outcomes. In particular, submucosal fibroids that deform the inner uterine cavity
are most strongly associated with decreases in fertility.

Diagnosing uterine fibroids:

Uterine fibroids are diagnosed by pelvic exam and even more commonly by ultrasound. Often, a
pelvic mass cannot be determined to be a fibroid on pelvic exam alone, and ultrasound is very helpful in
differentiating it from other conditions such as ovarian tumors. MRI and CT scans can also play a role in
diagnosing fibroids, but ultrasound is the simplest, cheapest, and almost without question the best
technique for imaging the pelvis. Occasionally, when trying to determine if a fibroid is present in the
uterine cavity (endometrial cavity), a hysterosalpingogram (HSG) is done. In this procedure, an ultrasound
exam is done while contrast fluid is injected into the uterus from the cervix. The fluid within is visualized in
the endometrial cavity and can outline any masses that are inside, such as submucosal fibroids.

Treatment for uterine fibroids:

Surgical treatments
There are many ways of managing uterine fibroids. Surgical methods are the mainstay of
treatment when treatment is necessary. Possible surgical interventions include hysterectomy, or removal
of the uterus (and the fibroids with it).Myomectomy is the selective removal of just the fibroids within the
uterus. Myomectomy can be done through a laparoscope or with the standard open incision on the
abdominal wall. Some treatments have involved boring holes into the fibroid with laser fibers, freezing
probes (cryosurgery), and other destructive techniques that do not actually remove the tissue but try to
destroy it in place. Surgery is necessary if there is suspicion of malignancy in any case of leiomyoma or
uterine mass.
Another technique for treating fibroids is known as uterine artery embolization (UAE). This technique uses
small beads of a compound called polyvinyl alcohol, which are injected through a catheter into the arteries
that feed the fibroid. These beads obstruct the blood supply to the fibroid and starve it of blood and
oxygen. While this technique has not been in use long enough to evaluate long-term effects of UAE
versus surgery, it is known that women undergoing UAE for fibroids have a shorter hospital stay than
those having surgery but a greater risk of complications and readmissions to the hospital. Studies are
underway to evaluate the long-term outcomes of UAE as opposed to surgical treatment. Uterine artery
occlusion (UAO), which involves clamping the involved uterine arteries as opposed to injecting the
polyvinyl alcohol beads, is currently under investigation as a potential alternative to UAE.

Medical treatments
Non-surgical techniques are usually hormonal in nature and include the use of drugs that turn off
the production of estrogen from the ovaries (GnRH analogs). These medications are given for three to six
months and induce a hypoestrogenic (low estrogen) state. When successful, they can shrink the fibroids
by as much as 50%. Side effects of these drugs are similar to the symptoms of the perimenopause and
can include hot flashes, sleep disturbance, vaginal dryness, and mood changes. Bone loss leading
to osteoporosis after long-term (12+ months) use is the most serious complication. These drugs may also
be used as preoperative treatment prior to undergoing surgical treatment of leiomyoma.

Mifepristone (RU-486) is an antiprogestin drug that can shrink fibroids to an extent comparable to

treatment with the GnRH analogs. This drug, sometimes known as the "morning-after pill" is also used to
terminate early pregnancy. Treatment with mifepristone also reduced the bleeding associated with
fibroids, but this treatment can be associated with adverse side effects such as overgrowth (hyperplasia)
of the endometrium (uterine lining). Mifepristone is not approved by the US Food and Drug Administration
(FDA) for the treatment of uterine leiomyomas, and the required dosages (different from those used for
termination of early pregnancy) have not been determined.

Danazol (Danocrine) is an androgenic steroid hormone that has been used to reduce bleeding in
women with fibroids, since this drug causes menstruation to cease. However, danazol does not appear to
shrink the size of fibroids. Danazol is also associated with significant side effects, including weight
gain, muscle cramps, decreased breast size, acne, hirsutism (inappropriate hair growth), oily skin, mood
changes, depression, decreased high density lipoprotein (HDL or 'good cholesterol') levels, and increased
liver enzyme levels.

The administration of raloxifene (Evista) (a drug used to prevent and treat osteoporosis in

postmenopausal women) has been shown to decrease the size of fibroids in postmenopausal women, but
results with this therapy in premenopausal women have been conflicting.

Low dose formulations of oral contraceptives are also sometimes given to treat the abnormal
bleeding associated with fibroids, but these do not shrink the fibroids themselves. Use of oral
contraceptive pills has been associated with a decreased risk of developing fibroids, so some women may
benefit from their use for this purpose.

Risks of uterine fibroids:

Uterine fibroids are identified in about 10% of pregnant women. Some studies have shown an increased
risk of pregnancy complications in the presence of fibroids, such as first trimester bleeding, breech
presentation, placental abruption, and problems during labor. Fibroids have also been associated with an
increased risk ofcesarean delivery. The size of the fibroid and its precise location within the uterus are
likely to be important factors in determining whether a fibroid causes obstetric complications.
 Uterine Fibroids At A Glance

 Uterine fibroids are benign tumors that originate in the uterus (womb). 

 It is not known exactly why women develop uterine fibroids. 

 Most women with uterine fibroids have no symptoms. However, fibroids can cause a number of
symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic
organs. 

 Uterine fibroids are diagnosed by pelvic exam and even more commonly by ultrasound. 

 If treatment for uterine fibroids is required, both surgical and medical treatment options are
available.
Abnormal Uterine : Bleeding
Pathophysiology and Clinical Management

Abnormal Uterine Bleeding

1/3 of all outpatient gynecologic ‹
visits
#1 reason for urgent hospital ‹
admission for adolescents
Affects 50% of menstruating women ‹
worldwide at some time
4 out of 5 women with AUB have no ‹
anatomic pathologic condition
Accounts for 50% of hysterectomies

Pathophysiology of menstruation
, 6 days - Normal duration 4 ‹
Abnormal if <2 or >7
80) - Normal volume 30cc (10 ‹
Abnormal if >80cc
35 days - Normal cycle length 24 ‹
7 years after - Longer for 5
At least 20% of menarche
cycles. women have irregular
Be sure they are answering the questions you
asked re: LMP and regularity.
Definitions
absence of flow for 3 usual - Amenorrhea ‹
cycle lengths
cycle length >35 days - Oligomenorrhea ‹
cycle length <24 days - Polymenorrhea ‹
regular cycle with heavy - Menorrhagia ‹
volume or duration of flow
irregular intervals of - Metrorrhagia ‹
bleeding but light or normal volume and
duration
irregular interval and - Menometrorrhagia ‹
excessive volume and duration

Causes of AUB
Vary with age of patient ‹
Childhood ‹
Puberty ‹
Reproductive Years ‹
Perimenopause ‹
Postmenopause

Case – childhood
Consulted by NICU for 1 week old ‹
infant with vaginal bleeding
6 year old with vaginal bleeding ‹
12 yo with heavy bleeding, soaking ‹
pads in one hour for 2 day
Infant
Estrogen withdrawal bleed ‹
Sarcoma botryoides (very rare)

6 year old with vaginal bleeding

Foreign body ‹
Infection ‹
Sarcoma botryoides ‹
Trauma ‹
prolapse Urethral ‹
Precocious puberty ‹
tumor, embryonal - Ovarian tumor ‹
, sex cord polyembryoma , choriocarcinoma
any hormonally –– tumors, etc stromal
active tumor

12 year old with menorrhagia

Coagulopathy ‹
Hypothalamic immaturity ‹
Inadequate luteal function ‹
including anorexia and - Psychogenic ‹
bulimia
Ovarian tumors as before
Cases - Reproductive Age
24 yo with oligomenorrhea q 2 ‹
months, with menometrorrhagia
30 yo with menorrhagia for 6 months ‹
associated with new dysmenorrhea
38 yo 2 weeks after a D&C for a ‹
missed AB with persistent heavy bleeding

Reproductive Age

#1 - Anovulation ‹
coagulopathy, - Functional ‹
hypothyroid, luteal phase
dysfunction
anticoagulants, - Iatrogenic ‹
hormonal contraception,
hemodialysi