uterine myoma Flashcards
what are uterine leiomyoma’s / fibroids
benign hormone-sensitive smooth muscle tumors of the uterus.
classified as
- submucosal (beneath the endometrium),
- intramural (within the myometrium),
- subserosal (beneath the peritoneum).
Symptoms
depend on the location, size, and number of myomas,
1.menstrual abnormalities (menorrhagia),
2.features of mass effects (back/abdominal/pelvic pain or bladder and bowel dysfunction)
3. infertility.
dg procedures
physical examination and sonohysterography
rx is for symptomatic patients
- surgery (myomectomy or hysterectomy)
- interventional (uterine artery embolization)
- medical therapy (GnRH agonists).
RF of uterine fibroids
Nulliparity Early menarche (< 10 years old) Age: 25–45 years(peak reproductive age) Race: Black women are at increased risk.and have erlier and more severe presentation Obesity Family history
pathophys of fibroids
A leiomyoma originates from a single myometrial cell (monoclonal growth)
causes upregulation of hormone receptors
tumors are referred to as fibroids, b/c they produce excessive amounts of extracellular matrix.
results in overgrowth of smooth muscle cells and connective tissue.
myometrium develops vascular changes, such as increased arterioles and venules, as well as dilated veins.
Classification according to their location within the uterus:
Submucosal leiomyoma
-Localized directly below the endometrial layer
sessile(broad-based) or pedunculated (attached to the submucosal endometrial layer by a narrow stalk)
Intramural leiomyoma (most common) grows from within myometrial wall
Subserosal leiomyoma
- outer uterine wall beneath the peritoneal surface.
- sessile/ pedunculatd
- may attach to various adjacent abdominal structures (e.g., the bowel).
Diffuse uterine leiomyomatosis
-uterus is grossly enlarged due to the presence of numerous fibroids
which type type of fibroid can obstruct the ccervical os
submucosal leimyoma pedunculated type (nascent fibroid)
Leiomyomas that bulge out of the cervical os may undergo torsion and infarction and cxause labor like pain
clinical features
Most women have small, asymptomatic fibroids. Symptoms depend on the number, size, and location of leiomyomas.
1.Abnormal menstruation
Hypermenorrhea, menorrhagia, metrorrhagia (possibly associated anemia)
Dysmenorrhea
2.Features of mass effect
-Enlarged , firm and irregular uterus during bimanual pelvic examination
-Back or pelvic pain/discomfort
-Laborlike pain if fibroid is in cerival os
Urinary tract or bowel symptoms (e.g., urinary frequency/retention, constipation, features of hydronephrosis d/2 compression oof ureter)
- Reproductive abnormalities
- Infertility : caused by an obstructed uterine cavity and/or impaired contractility of the uterus.
- Dyspareunia seen in anterior fibroids
by what mechanism do SUBMUCOSAL fibroids cause abnormal menstruation
increased total surface area as a result of the bulging uterine wall, impaired endometrial wall contractility, or micro/macrovascular abnormalities. The contractility of the uterine wall
define menorrhaggia
abnormally high flow of bleeding (> 80 mL of bleeding volume) or prolonged duration of bleeding (> 7 days of menstruation) during menstrual periods
define metrrorhagia
abnormal bleeding between menstrual periods.
deffine hypermenorrhea
heavy menstrual periods (with bleeding volume > 150 mL possibly with visible blood clots).
dg work up of fibroids
PELCIV EXAM: irregularities in the shape of the uterus
Ultrasound (best initial test)
- Concentric, hypoechoic, heterogeneous tumors
- venetian blind effect: alt hyper & hypo echoic stripes (+ve for adeno myosis and fibroids)
- Calcifications or cystic areas suggest necrosis.
xray: popcorn calcification
MRI: to evaluate the uterus and ovaries for potentially complicated surgical cases
visually differentiate between leiomyomas, adenomyosis and Endometriosis
dx of fibroids
Adenomyosis (Smooth muscle cells and endometrial glandular tissue within the uterine wall)
caused by previous uterine surgery and multiparity
(fibroids is nulliparity)
Uniformly enlarged!! uterus (fibroids uterus is irregularly enlarged )
Endometriosis
(Benign endometrial tissue outside the uterus)
caused by reterograde menstruation
Typically no uterine enlargement
rx criteria of fibroids
goal of rx
perimenopausal women
only in considered in symptomatic patients because of the side effects of medical therapy and surgery.
assx monitired every 6mo
The goal is to relieve symptoms.
Perimenopausal women warrant expectant management in most cases as a decrease in fibroid size and symptoms often occurs after menopause.
goal of med management in fibroids => rx of red degeneration in pregnancy
peri operative medical therapy may help reduce tumor size and decrease tumor vascularization.
types:
Hormone therapy:reducing estrogen levels and increasing progesterone levels to reduce tumor size
NSAIDs: pain relief
Antifibrinolytics to reduce bleeding
Androgenic agonists (danazol): suppress growth of fibroids but has many side effects (acne, edema, hair loss)
hormone therapy agents
Gonadotropin-releasing hormone (GnRH) agonists: e.g., leuprolide, Goserelin
- IM, SC, Depo, or nasal spray
- desensitize the pituitary via overstimulation → diminished release of LH and FSH → reduced estrogen synthesis → volume reduction (deprives fibroid of its growth stimulus) and reduces anemia and promotes amenorhea
Estrogen-progestin contraceptive pills are controversial(sometimes increases risk)
Exogenous progestins (oral contraceotives)
Levonorgestrel-releasing intrauterine devices aid (to control heavy bleeding)
