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Chapter

Bleeding and Hysteroscopy in

Uterine Myomatosis
Sergio Rosales-Ortiz, Tammy Na Shieli Barrón Martínez,
Diana Sulvaran Victoria, Jocelyn Arias Alarcon,
Janeth Márquez-Acosta and José Fugarolas Marín

Abstract

Uterine leiomyomas are one of the most common diseases in women. However,
there is still much about them we do not know. These tumours, also known as
fibroids or myomas, affect women mainly during their reproductive years, and they
are diagnosed in up to 70% to 80% of women during their lives. The most relevant
part of this disease is the profound impact in the quality of life of women, in the
provision of health services, and on the costs all around the world. Even though, the
majority of women with fibroids are asymptomatic, approximately 30% of them
will present severe symptoms, with a broad range of problems such as: abnormal
uterine bleeding, infertility, and obstetric complications. There are multiple factors
involved in the biology of fibroids: genetic, epigenetic, hormonal, proinflamma-
tory, angiogenic and growth factors, growth factors that are capable of inducing
and promoting de development of fibroids. The leiomyoma is surrounded by a
pseudocapsule generated by compression and ischaemia of the tumour towards the
myometrium and is composed by multiple elements that that promote healing and
tissue repair of the myometrium after myomectomy. Therefore, its conservation in
the myometrium is essential, regardless of the surgical technique used. Resection by
hysteroscopy can be performed in an office or in an operating room, depending on
the characteristics of the fibroid, it is required a good diagnosis and experience.

Keywords: bleeding, hysteroscopy, pseudocapsula, submucosa fobroids

1. Introduction

Uterine leiomyomas are one of the most common diseases in women. However,
there is still much about them we do not know. These tumours, also known as
fibroids or myomas, affect women mainly during their reproductive years, and they
are diagnosed in up to 70% to 80% of women during their lives. The most relevant
part of this disease is the profound impact in the quality of life of women, in the
provision of health services, and on the costs all around the world.
Even though, the majority of women with fibroids are asymptomatic, approxi-
mately 30% of them will present severe symptoms, with a broad range of problems
such as: abnormal uterine bleeding, infertility, and obstetric complications.
There are multiple factors involved in the biology of fibroids: genetic, epigenetic,
hormonal, proinflammatory, angiogenic and growth factors, growth factors that are
capable of inducing and promoting de development of fibroids.

1
Fibroids

The leiomyoma is surrounded by a pseudocapsule generated by compression

and ischaemia of the tumour towards the myometrium and is composed by mul-
tiple elements that that promote healing and tissue repair of the myometrium after
myomectomy. Therefore, its conservation in the myometrium is essential, regard-
less of the surgical technique used.
Resection by hysteroscopy can be performed in an office or in an operating
room, depending on the characteristics of the fibroid, it is required a good diagnosis
and experience.

2. The relevant of fibroids

Abnormal uterine bleeding (AUB) refers to uterine bleeding that, by its charac-
teristics in duration, volume, frequency, and regularity, are outside the 5th and 95th
percentiles for the female population in reproductive age and non-pregnant. In such
manner that range of variation in the menstrual bleeding pattern can be very wide
affecting one or more characteristics at the same time.
The abnormal uterine bleeding is divided into acute and chronic — acute when,
according to a medical evaluation, the amount of bleeding justifies an immediate
intervention to avoid complications secondary to blood loss. It is defined as chronic
when this symptom occurs persistently in last 6 months [1].
The widespread term of heavy menstrual bleeding, refers to a sub-category of
AUB, and it refers to a subjective symptom expressed by the woman as the excessive
loss of blood and impacts her physical, emotional and social well-being as well as
her quality of life. This term moves away from an objective measurement of volume
of more than 80 ml, or a specific score and focuses on the perception of the patient,
therefore, it has a better clinical focus [2].
One important aspect of AUB is that it is one of the main causes for seeking
gynaecological care among 5% and 30% of women in reproductive age, and
approximately one third of that population will suffer from AUB at one moment
in their lives, which represents high direct and indirect costs in their medical
attention [3].
The aetiology of AUB is broad since various pathophysiological mechanisms are
involved, requiring the physician to have an individualised approach and a clear
understanding of the systematised study and treatment options.
In 2011, the International Federation of Gynaecology and Obstetrics (Fédération
Internationale de Gynécologie et d’Obstétrique, FIGO), in contribution with a large
group of clinical and non-clinical researchers of 17 countries of six continents,
published a system and a set of clinical recommendations about AUB to provide
a detailed update with the objective of standardising different terminologies and
definitions used up to that date to refer to symptoms of altered menstrual bleeding
and to establish a correlation with possible underlying causes, so as to facilitate
research, education and standardised and replicable medical care [4].
An AUB classification was introduced, with nine categories based on the
PALM-COEIN acronym, which divides causes into structural and non-structural
pathologies.
Structural pathologies can be evaluated by imaging studies and/or defined
histopathologically (polyps, adenomyosis, leiomyomas and malignancy or atypical
endometrial hyperplasia: PALM).
Regarding non-structural causes, these cannot be detailed by means of
imaging studies, these require a detailed clinical evaluation, and an appropriate
physical examination supported by laboratory tests. In most cases, a diagnosis
can be established, one which corresponds to the COEIN acronym (coagulopathy,

2
Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

ovulatory dysfunction, primary endometrial dysfunction, iatrogenesis and not

otherwise classified) [4, 5].
In 2018, FIGO recommendations were updated, including clarifications on
terminologies and definitions, as well as modifications in the PALM-COEIN system
which include the reassignment of some entities and orientation for subclasses of
leiomyomas [5].
Leiomyomas are monoclonal tumours comprised of muscle tissue of the uterus,
also referred in literature as fibroids or myomas. These represent the pelvic tumour,
frequently benign, more common in women in reproductive age. At age 50, almost
70% of white women and 80% of African American women will have developed at
least one fibroid [6].
There are many risk factors associated with myomatosis, and these are still
being described. Among these: African American race, age, delayed pregnancy,
nulliparity, early menarche, caffeine, genetic alterations, obesity, a diet rich in red
meat and, recently discovered, the crucial role of progesterone and its receptors in
pathophysiology, growth and development of these tumours [7, 8].
Even though myomatosis has a high prevalence in women, most of them are
asymptomatic and are diagnosed as an incidental finding in a routine gynaecologi-
cal examination. The main symptom of patients with leiomyomas is AUB, referred
by women as profuse and prolonged bleeding, bleeding between periods, and
frequent and irregular periods. These menstrual alterations are frequently used to
being accompanied by the presence of pelvic tumours, dysmenorrhoea, chronic
pelvic pain, infertility, compressive symptoms, and obstetric complications.
Other relevant aspects in the detriment of the quality of life of women with
myomatosis are a negative impact in their sex life (42.9%), bad performance at
work (27.7%), and impaired couple and family relations (27.2%). In this way, a third
of women with leiomyomas will seek medical attention. Symptomatic cases will
depend on size, number, and localisation of these [7, 9].
Several uterine fibroids classifications have been described. Most of them have
considered the degree of extension in the myometrium and/or the distortion of
the uterine cavity. Currently, this has changed, and several factors are considered
in order to establish a better therapeutic approach, its possibility of success, the
complete removal of fibroids and lower risk of complications.
The classification adopted by the ESGE (European Society for Gynaecological
Endoscopy) based on Wamsteker’s, proposes a classification of submucous fibroids
according to the depth within the myometrium, classified as: G−0 is an intrauterine
pedunculated fibroid, G-1 fibroid is majorly in the uterine cavity or has less than
50% of penetration inside of myometrium, and G-2 is mostly (> 50%) inside of the
myometrium [10].
The classification proposed by Lasmar, takes into consideration, the depth of the
fibroid in addition to other characteristics such as size, placement inside of the cavity,
the extension of the injury in the endometrium, and the uterine wall involved, grant-
ing a rating that gives a prognosis on the difficulty or complexity of the removal, as
well as the therapeutic options for its management (Figure 1) [11].
Another classification that also gives a rating according to size, localiza-
tion, myometrium penetration and base extension is the STEPW classification.
(Figure 2).
The FIGO classification considers any location of the fibroids and describes
eight types, as well as a hybrid class (an association of two types of fibroids). It is
common for different types of fibroids to be present at the same time (depending on
the site), and with this classification, a more representative “map” of the distribu-
tion of the fibroids can be made. However, this classification can have difficulties
when applied to very big uteri and with multiple fibroids.

3
Fibroids

Figure 1.
Lasmar classification.

Figure 2.
Adapted of STEPW classification. SC: Score. Size: Larger diameter by any image study. Topography: It refers to
where the fibroid is placed in the uterus. Extension of the base: How much of the uterine wall is covered by the
fibroid compared to thirds. Penetration: Depth of the fibroid within the myometrium. Wall: When the fibroid
is in the lateral wall, add one point to the total score.

The FIGO classification updated in 2018 is as follows:

Submucous fibroids — those located exactly below the endometrium and that
protrude, disrupting the uterine cavity in different degrees are types 0, 1, 2 and 3.
Type 0: Pedunculated or with its base on the endometrial wall, but the fibroid is
completely located inside of endometrial cavity.
Types 1 and 2 require that a portion of the injury is intramural (Type 1 < 50% of
the average diameter and Type 2 > 50%).
Type 3 are completely intramural but are also in contact with the endometrium.
Type 3 formally distinguishes itself of Type 2 by means of a hysteroscopy, using the
lowest intrauterine pressure possible to allow visualisation.
Intramural fibroids (Type 4) are completely located inside of the myometrium
without protruding into the endometrial nor the serosal surface.
Subserosal fibroids (Types 5, 6 and 7) represent the mirror image of the sub-
mucousal ones — type 5 with more than 50% of intramural penetration, type 6 less
than 50% intramural and type 7 is attached to the serosal surface by a stalk.
In another place (Type 8): The localization must be specified, for example:
cervical, intraligamentary, and so on.
Hybrid or transmural fibroids are classified by their relation to the endometrial
and serosal surfaces. In these cases, one must refer first to the portion that is in
contact with the endometrium [4, 5, 12].

3. The relation between the fibroid and the bleeding

The relationship between AUB and uterine myomatosis is still not fully
understood, and there is a contradiction that many women with fibroids have a
completely normal bleeding pattern. However, a clear relation between AUB and

4
Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

submucousal fibroids is observed in the context of the degree of distortion and

penetration into the uterine cavity that can generate submucousal fibroids and the
possible occurrence of AUB. According to literature, fibroids (FIGO 0, 1, 2 y 3) are
the most symptomatic [7].
Diverse mechanisms have been proposed to explain the relationship between
the AUB caused by myomatosis, however, these do not explain clearly how all these
facts are intimately involved.
Previously, the most described mechanisms were the increase in the endometrial
surface and the presence of fragile and congested vascularity around the perimy-
ome, currently, it is believed that the effect of fibroids on the endometrial function
represents a change in the surface inside of the uterine cavity that is not limited to
areas that cover the fibroid or fibroids. Some of these changes can have an impact in
the responsiveness and endometrial implantation, as well as in AUB.
An increase in uterine vascularity with larger calibre vessels that can overcome
the action of platelets has also been proposed. As well as changes in the patterns of
myometrial contractility, ulceration of the surface of the fibroid, degeneration of
the fibroid and venous ectasia by due to of compression of the fibroid [3, 13].
In recent years, more knowledge has been gained about complex the cellular
and molecular changes associated with fibroids and the AUB, with an impact in
angiogenesis, alteration of vasoactive substrates and growth factors, as well as
alterations in coagulation, that highlight complex interactions among coagulation,
neoangiogenesis and vasoconstriction [14].
Fibroids will behave as one independent functional unit with the capacity to
secrete different bioactive factors, which generate changes in situ and produce an
effect on the uterus. One of these changes is the increase in the secretion of TGF-β3
(transforming growth factor beta 3), which is involved in the alteration of the homeo-
static and fibrinolytic normal pathways in the endometrium since it reduces the
plasminogen activator-1 (PAI-1), thrombomodulin and antithrombin III, which could
explain one of mechanisms associated with AUB — an increased quantity of TGF-β
has also been related to the remodelling and proliferation of extracellular matrix that
could modulate the growth of fibroids [1, 15].
Regarding the causes related to the increased in bleeding in women with
fibroids, different angiogenic factors have been described, such as the vascular
endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), heparin-
binding epidermal growth factor (HB-EGF), platelet-derived growth factor
(PDGF), parathyroid hormone-related protein (PTHrP) and prolactin [2, 14].
On the other hand, there is an alteration of endothelin-1 (ET-1) and prostaglan-
din F2 alpha (PGF2α), both strong vasoconstrictors that intervene in the amount
of menstrual bleeding by regulating the contractility of the myometrium and the
vasoconstriction of the spiral artery (ET-1) [16].

4. Endometrial changes

Understanding changes generated by fibroids at the endometrial level is very

complex, since it is not only a physical effect on the anatomy of the uterus exerted
by intramural and submucosal fibroids, but a significant effect in the endometrial
physiology and the expression and function of endometrial genes [17].
An important phenomenon to understand endometrial changes, is inflammation.
It is well established that an inflammatory component is involved in most physi-
ological processes, specifically in the reproductive process, inflammation has direct
interference with follicular development, ovulation, implantation, pregnancy, labor,
and menstruation are not exempt.

5
Fibroids

Inflammation is understood as the presence of leukocytes (immune cells) of

different within the reproductive tract tissue, without being associated with an
infectious process. This invasion of leukocytes alters function by having specific
role in local regulation.
Specific sequential changes in different kinds of leukocytes can be proven inside
of the human endometrium during the different phases of normal and abnormal
menstrual cycles. Leukocytes are very scarce in number throughout the prolifera-
tive phase, but significantly increase all through the secretory phase, taking into
consideration that around 40% of all stromal cells in the premenstrual phase are
leukocytes, mostly natural killer cells (NK) and granulocytes.
The decrease in progesterone increases the expression of inflammatory media-
tors, including Il-8, MCP-1 and nitric oxide which promote the recruiting of
endometrial leukocytes. Macrophages and neutrophils are important in the defence
of the epithelium when the epithelial barrier is broken because of any reason, for
example, menstrual bleeding.
Leukocytes also have the potential to release regulatory molecules that stimu-
late the mechanisms of endometrial repair, consequently, so the alteration of
immune cells and cytokine mediators are related to the symptoms of abnormal
uterine bleeding and pelvic pain, always starting from the inflammatory process
produced by the menstrual cycle, fibroids, and endometriosis among other
pathologies [18, 19].
Besides endometritis and endometrial micro-erosions, vascular alterations are
another important factor in the causes of bleeding and endometrial alterations [20].
From the complex onset of fibroid tumorigenesis, induced among others by
the t (12-14) translocation, the deletion of 7q, HMGA2 gene of the locus 12q14-q15,
that, under the oestrogen-progesterone promoter stimulus, the micro-environment,
growth factors with mitotic activity such as growth factor 3, fibroblast growth
factor, epidermal growth factor, and insulin-like growth factor, besides promoting
tumour growth, are leukocyte chemoattractans, generating an accumulation of
inflammatory cells inside of the fibroid tissue and the corresponding endometrium
that could affect the function from menstruation to fertility [21, 22].
Another aspect related to leukocytes is the relation between the vascular
endothelial growth factor (VEGF) of intravascular neutrophils and the prolifera-
tion of endometrial cells from the subendometrial capillary plexus that develops
small vessels in the capillary plexus — this angiogenic process is present alongside
functional activity in the proliferative phase and in pathological states [22].
Among the effects that fibroids exert on the endometrium, are the altered
genetic expression and changes in the immune environment and vasoconstrictive
factors, generating from a decrease in production of transcription factors neces-
sary for implantation, within the window of implantation (WOI) to the altered
production of coagulation factors during menstruation [17].
To understand these changes, it is necessary to understand how human endo-
metrial stromal cells (HESC) regulate the expression of the tissue factor (TF),
which is the main promoter of coagulation at this level, complemented by the effect
of progesterone which increases a second haemostatic factor in the HESC, the
plasminogen activator inhibitor-1 (PAI-1) — if this order is altered, the stability
of the stromal endometrial matrix and the vascular extracellular matrix are lost by
the action of the matrix metalloproteinase (MMP) -1, 3 and 9. This increases the
inflammatory activity and an uncontrolled angiogenesis, with an endometrium that
loses its homeostatic and proteolytic ability, and being highly vascularised.
An increase in TF expression accompanied by decreased endometrial blood
flow produces hypoxia and reactive oxygen species (ROS) induce an aberrant

6
Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

angiogenesis and inflammation. Hypoxia produces the release of endometrial cells’

apoptosis inducers secreted by human endometrial stromal cells (HESC) [23].
An altered angiogenesis due to the presence of fibroids produces fragile, hyper
dilated, thinned vessels that bleed easily. The alteration of endometrial blood flow
produces local hypoxia and the generation of ROS that increase the production of
angiogenic factors such as the vascular endothelial growth factor (VEGF) in human
endometrial stromal cells and Angiopoietin-2 (Ang-2) in endometrial cells with a
decrease in HESC of angiostatic (Ang-1) [24].

5. The pseudo-capsule

In order to understand more about fibroids, it is essential to understand the

myometium as a structure comprised of bundles of smooth muscle fibres sur-
rounded by connective tissue with a network of blood and lymphatic vessels — this
is the place where fibroids grow, comprised of intertwined fascicles of disor-
dered smooth muscle cells, abundant fibrous tissue with type I and III collagen
(Figure 3).
During its growth, fibroids compress the myometrium forming a pseudo-
capsule composed of collagen fibres, neurofibres and blood vessels. Occasionally,
bridges of collagen fibres and vessels that join the myometrium with the fibroid can
be formed (Figures 4 and 5) [25].
The pseudocapsule vessels that come from the surrounding myometrium are
grouped in a vascular network and the veins surrounding the fibroid in the shape
of a plexus forming the image of a “ring of fire”, easily detectable with a Doppler
ultrasound (Figure 6) [26].

Figure 3.
Showing the uterine wall (UW) with th dissected pseudocapsule (PS) and the myoma at the bottom.

7
Fibroids

Figure 4.
Image with two fibroids at the ends (F), two pseudocapsules (PC) and the myometrium in the center (my).

Figure 5.
Magnified image of the pseudocapsule (PC) and fibroid (F).

Angiogenesis of the fibroid’s pseudo-capsule leads to the formation of a

protective vascular capsule, in addition, to being responsible for the blood supply
to the central nucleus of the tumour.
The biological genesis of the pseudo-capsule is not well described, however,
there is evidence that is originated from the myometrium that surrounds the
fibroid, therefore, the fibroid is not originated from the pseudo-capsule, but it is
part of the myometrium that compresses it [27].
The pseudo-capsule is a structure rich in neuropeptides and neurotransmit-
ters, which have a very important role in wound healing and innervation repair-
ing besides being key in sexual and reproductive functions and being the study
objective for new future treatments.

8
Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

Figure 6.
Ultrasound with a fibroid in the center, with peripheral Doppler showing the ring of fire, the arrows delimit
the pseudocapsule.

Neurotransmitters such as: Substance P (SP), Vasoactive Intestinal Peptide

(VIP), Neuropeptide Y, Oxytocin, Vasopressin, PGP 9.5, calcitonin gene-related
peptide and Growth hormone releasing hormone play an important role in the
wounds’ inflammatory and healing cascades [28].
The neurofibres of the pseudo-capsule contain SP and VIP just as the myome-
trium without pregnancy.
It is possible that these neuropeptides have influence in the physiology of the
uterine contraction, cervix dilation and during labour [29].
Other research focused on the opioid neuropeptides enkephalin (ENK) and
oxytocin (OXT). The study revealed the lack of positive ENK neurofibres at the
bottom of the uterus and in the fibroid’s pseudo-capsule in the body of the uterus,
and presence of these in the isthmic-cervical area. Fibres positive for OXT were
observed in the pseudo-capsule in all uterine regions, lesser at the bottom, and a
higher quantity in the cervical isthmus. This indicates a larger research of neuro-
peptides about the impact in neurofibres in obstetric complications such as sponta-
neous miscarriage and cervical dystocia during labour [30].
Literature mentions the importance of knowing the fibroid’s pseudo-capsule
during a myomectomy, since performing a correct technique enhances the progno-
sis of quality of life and fertility rate in women affected by uterine myomatosis [31].
The objective of the myomectomy is to enucleate the fibroid, always preserv-
ing the pseudo-capsule. Myomectomy’s technique takes prostate cancer surgery
as a base, a procedure that preserves the neurovascular bundles that surround the
prostate with the objective of reducing the probability of post-operative impotence
and incontinence.
Taking into account these findings according to the prostatic capsule and the
importance of nerve-spearing surgery, these were implemented in the surgery known
as intracapsular myomectomy, preserving the fibroid’s pseudo-capsule and neurovas-
cular bundle with the objective of improving reproductive function. It is performed
by coagulating, cutting, and breaking the pseudo-capsule’s fibrous bridges, then
extracting the fibroid directly dissecting the fibromuscular skeleton that surrounds
it, always using low energy instruments (less than 30 watts). The closing of the

9
Fibroids

Figure 7.
Miomectomy image with dissection of fibroma (F), pseudocapsule (PC) and between fibroconnective
bridges (FB).

myometrium is performed depending on the type of fibroid found — in subserosal

fibroids it is performed in one plane, and in intramuscular fibroids two planes are
closed (Figure 7). This surgical principle can be applied to all myomectomies: lapa-
rotomy, laparoscopy, and caesarean myomectomy. In comparison with intracapsular
myomectomy through laparotomy or laparoscopy, laparoscopic myomectomy proved
to have more benefits: lesser intraoperative and postoperative bleeding, reduced
bladder pain after the removal of the Foley catheter, less use of analgesic medication
and a shorter hospital stay — reduced appearance of fever, myometrial scar, bruising,
ileus, and use of antibiotics were also observed during the post-operative period in
comparison with laparotomy [32].

6. Leiomyomatosis and infertility

Most of leiomyomas are asymptomatic, symptoms are usually correlated with

the number, size, location, and degenerative changes that these suffer — these are
considered hormone-dependent. It is estimated that 30% of cases cause abnormal
uterine bleeding, chronic pelvic pain and other symptoms that can affect the
patients’ quality of life. Leiomyomas also cause anaemia, recurrent pregnancy loss,
preterm birth, urinary incontinence, subfertility, and infertility [33, 34].
The relation between leiomyomas and infertility has been a concern for a
long time. The American Society for Reproductive Medicine (ASRM) mentions that
these uterine tumours are associated with infertility from 5% to 10% of cases and
are catalogued as directly responsible for infertility from 2% to 3% of patients.
However, the exact mechanism, by which these cause infertility, is still in debate.
Consequently, several mechanisms have been proposed to explain the possible

10
Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

adverse effects of fibroids on fertility, such as: alteration of the endometrial

contour that interferes with implantation, alteration of endometrial blood flow
that affects endometrial responsiveness, ulceration, thinning, endometrial inflam-
mation and atrophy, endometrial biochemical alterations, triggering of uterine
contractility dysfunction that alters the embryonic movement and tube obstruc-
tion. According to the American Fertility Society Guideline for Practice, fibroids can
be associated with 5% to 10% of infertility cases, although as a sole factor, these
only influence from 2% to 3% [35].
Normally, the uterus presents uterine contractions, these begins in the uterine
fundus and continue towards the cervix, and their frequency increases in the early
follicular phase. In the periovulatory and luteal phase, the direction of contractions
is inverted, that is to say, from the cervix to the fundus, favouring the fertilisation
process [36].
Fibroids as a mechanical factor is one of the simplest mechanisms that would
explain infertility in this group of patients with larger and intracavitary fibroids
being those that interfere in the process of transporting eggs and sperm, as well as
implantation [37]. Another mechanism is through the production of cytokines and
chronic inflammation — these underlying mechanisms are the ones that increase the
uterine contractility mainly due by overproduction of cytokines. One study showed a
considerable increase in uterine peristalsis in the presence of fibroids and after myo-
mectomy in this group of patients, a pregnancy rate of 40% was obtained [38, 39].
The implantation process is one of the most complex and perfectly orchestrated
processes in the human being. The foetal success depends on immunological
changes in the mother, and it is based on modifications in the innate and adaptive
immune system, in which embryo implantation and placenta development are
presented thanks to immune reactions mediated by the following cytokines: TNF
(tumour necrosis factor) -α and β, interleukin 1, 2, 10 and 6, among others [40].
In patients with submucous fibroids, it has been proven that a significant decrease
in IL-10 and glycodelin levels, the latter being a key protein to promote angiogenesis
and supress NK (natural killer) cells in the implantation process [41]. The presence
of fibroids has shown alterations in the subendometrial area, a region highly rich in
macrophages and NK cells. In patients with leiomyomatosis, a decrease in concentra-
tions of these two cell populations has been proven, altering the steroid receptors at
the endometrial level that are essential for the implantation process [42].
Pregnancy, live births, and implantation rates are significantly lower in
patients with leiomyomatosis [43]. The presence of submucosal leiomyomas
decreases the birth rate by 70%, while intramural fibroids show a decrease in the
birth rate by 30% [44].
It is known that the presence of fibroids shows a deleterious effect upon the uter-
ine contractility, depending on its location and size, particularly those that distort
the submucosal and intramural uterine cavity in 60% of women younger than
40 years of age, and in 80% of women younger than 50 years of age.
One of fibroids subtypes tha most affects fertility is leiomyoma with bizarre
nuclei (LBNs) which, in turn, is linked with higher concentrations of MIB1 (mind-
bomb E3 ubiquitin protein ligase 1, which is an apoptosis regulator, also known as
Ki-67) in the endometrium. This means, that not only the size and location of the
fibroid plays a role in the subfertility observed in patients withe leiomyomatosis,
but also the morphological subtype of fibroids. Furthermore, this shows that
regardless of the location of the fibroids, the fertility rate was lower compared
with the controls. Showing a relative risk of clinical pregnancy of 0.85 with CI
95%: 0.73–0.98 and a live birth rate with a RR: 0.69 with CI 95% 0.59–0.82 and
an increase in the abortion rate with a RR 1.68 CI 95%: 1.37–2.05, in patients with
uterine leiomyomatosis [45].

11
Fibroids

7. Hysteroscopical management of submucous fibroids

The coming of hysteroscopy in gynaecologic surgery has offered a new conser-

vative approach to the treatment of pathologies of the uterine cavity.
Going back to the FIGO classification adopted by ESGE (European Society
of Gynaecological Endoscopy) of submucous fibroids, describing the extent
of miometrial involvement of submucosal fibroids visualised by hysteroscopy.
According to the degree of myometrial penetration: submucosal fibroids grade 0,
grade 1 and sometimes grade 2 submucous fibroids are candidates for this
management (Figure 8).
The criteria for scheduling the surgical procedure must be clear, and these
include a pre-operative evaluation that considers in detail the size, location, myo-
metrial depth, distance from the fibroid to the serosa layer of the uterus, and the
number of fibroids with possible degree of tissue degeneration with ultrasound or
MRI, knowledge of the management of electrolytic or non-electrolytic distension
fluids, and hysteroscopic irrigation pump, experience in the use of monopolar or
bipolar resectoscopes, diode laser or mechanic resectors and when to select each one
of them, and surgical judgement to use different techniques and to know when to
stop the procedure or program it in two sessions [46].
Contraindications for a resectoscopy are: pelvic inflammatory disease or herpes
infection, a distance of less than 5 mm from the fibroid to the uterine serosa, large
size uterine cavity that does not allow the suitable distension and view of tumours,
and a lack of surgical ability of the surgeon.
The success rate of 90% in myomectomies depends on the appropriate selection
of the patient and being within the range of possible complications — from 1% to
5% in fibroids of less than 3 cm in diameter.
The entire fibroid must be removed without leaving any residual tissue and
respecting the dissection plane of the pseudocapsule, which is part of the myome-
trium and favours the appropriate healing of the uterine wall.
The myomectomy can be performed in the office or in the operating the-
atre according to patient’s characteristics, intra-wall extension of the tumour,

Figure 8.
ESGE classification of submucous leiomyomas.

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Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

estimated surgical time since office procedures should not exceed more than
20 minutes, the diameter of the instrument, and if anaesthesia is required to
improve the conditions and results of the surgery [47].
As decision criteria G-0 and G-1 fibroids with a minimum myometrial compo-
nent and smaller than 15 mm can be treated in the office. Hysteroscopic resections
can still be attempted in G-1 fibroids of less than from 4 to 5 cm and G-2 fibroids of
less than from 5 to 6 cm of diameter in the operating theatre and with anaesthesia
since pain occurs when surgically working in the myometrium that has sensory
innervation.
In order to calculate the volume of the fibroid, the V = 4/3πr [3] formula must
be used.
Using a 4 mm resectoscope loop, 0.5 cm [3] is removed per minute and a 5 cm
diameter fibroid has 65.4 cm [3], so on average the procedure will require two
hours, being within the pertinent time limit for a hysteroscopy [48].
In the office, scissors and 5 Fr grasper clamps can be used in fibroids of less than
15 mm, sectioning the pedicle in order to extract it and, if it is not possible to, wait
from 30 to 45 days for the uterus to spontaneously expel it, or the tumour can also
be divided into two parts in order to extract fragments.
There is the, OPPIuM technique in G2 myomas, consisting in performing a
cut with monopolar energy alongside the intracavitary fibroid’s peripheral line of
reflection, and in a second surgery in 30 days, resecting the leiomyoma that has
emerged into the uterine cavity with a resectoscope, facilitating the procedure.
There is also the possibility of using a 45-watt diode laser with wavelengths
of 980 nm and 1470 nm to cut or vaporise the fibroid with a lower rate of com-
plications and a better vision without generating bubbles. The cutting depth is
1 mm and with special fibres, vaporisation and selective clotting of the tissue are
achieved.
The gold standard is the resection with 15 Fr bipolar loop mini-resectoscope and
3 mm loop in the office and in the operating theatre, 27 Fr bipolar resectoscope with
a 4 mm loop in order to completely the fibroid, while preserving the pseudocapsule.
The “cut” must be programmed from 60 Watt to 70 Watt to avoid post-operative
adherences. It is convenient to have the Collins loop and the cold Mazzon loops
to enucleate the residual tissue, complete the surgery, and completely remove the
leiomyoma.
There are mechanic tissue resection devices of different thicknesses — 15 Fr to
24 Fr with a reciprocating cutting blade and a 0 degree vision with better liquid
control, that cut and aspirate the tissue by using saline solution, avoiding thermal
damage to endometrium/myometrium and fluid overload. The surgeon must have
the experience to align the instrument which is straight and does not allow much
mobilitiy, with the fibroid in a peripheric way, and in case any vein or artery pres-
ents haemorrhage, remove the device a few millimetres from the surgical site and
wait that the continuous flow clears the vision and then directs it towards the vessel
and completely resects it towards its origin.
No prophylactic or post-operative antibiotic is needed, it is only used if there is a
history of pelvic inflammatory disease.
The success of the hysteroscopic myomectomy depends on a personalised
study of each patient and its therapeutic goals, performing a complete diagnosis
both clinical and with laboratory and imaging studies including an ultrasound or
magnetic resonance to perfectly locate the type and number of fibroids, their depth
within the myometrium, and the distance to the serosa layer of the uterus.
Correctly selecting if the procedure can be performed in an office or in an
operating theatre, because one of the main goals is the complete removal of all the

13
Fibroids

tumour tissue in one or two surgical sessions, remembering that the office surgery
limit is 25 minutes and that the ability to work comfortably depends on the patient’s
pain threshold, in addition the use of the appropriate 5 mm surgical material.
Both in the case of surgery in an office and in an operating theatre, being familiar
with more than one instrument allows a better selection of the type of energy to use
and guarantee the safety of the patient and avoid possible complications [49].

Author details

Sergio Rosales-Ortiz*, Tammy Na Shieli Barrón Martínez, Diana Sulvaran Victoria,

Jocelyn Arias Alarcon, Janeth Márquez-Acosta and José Fugarolas Marín
UMAE, Hospital de Gineco Obstetricia No. 4 “Luis Castelazo Ayala”,
Mexican Institute of Social Security, Mexico City, Mexico

*Address all correspondence to: [email protected]

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

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Bleeding and Hysteroscopy in Uterine Myomatosis
DOI: http://dx.doi.org/10.5772/intechopen.94174

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