STATE UNIVERSITY OF MEDICINE AND
PHARMACY N. TESTEMIANU
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Uterine Leiomyoma.
Endometriosis.
CORINA CARDANIUC
Objectives for Uterine Leiomyoma
Discuss the prevalence of uterine leiomyomas
Describe the symptoms and physical findings in
patients with uterine leiomyomas
Describe the diagnostic methods to confirm uterine
leiomyomas
List the management options for the treatment of
uterine leiomyomas
Synonyms
leiomyoma of uterus
leiomyomas
fibromyomas
myofibromas
fibroids
fibromas
myomas
Definition
Uterine leiomyomas (fibroids) are benign
tumors derived from the smooth muscle cells of
the myometrium
Prevalence
Approximately 45% of women have uterine
leiomyomas by the 5th decade of life
Vast majority are asymptomatic
Primary indication for 200,000 hysterectomies in the
U.S. each year
Sarcomatous changes occur in < 0.1%
Risk Factors
Increasing age during reproductive years
Ethnicity (African American)
Nulliparity
Family history
Pathogenesis of Leiomyomas
Factors that initiate leiomyomas unknown
Estrogen and progesterone important to growth
Increased levels of estrogen and progesterone receptors
present
Estrogen induces proliferation of smooth muscle cells
Progesterone produces proteins which prohibit apoptosis
Increased levels of growth factors produce fibronectin
and collagen
Characteristics of Leiomyomas
Spherical, well-circumscribed, white, firm lesions
Always arise within the myometrium (intramural)
Migrate to various anatomic locations
Submucosal toward endometrium
Intramural within myometrium
Subserosal toward serosal surface
Pedunculated and/or parasitic
Poor internal blood and lymphatic supply
Cystic degeneration
Calcification
Anatomic Locations
Pedunculated Uterus
subserosal
Pedunculated
submucosal
Subserosal
Intramural
Submucosal
Vagina
Clinical Manifestations
Clinical Manifestations
Bleeding symptoms Bulk symptoms
Menorrhagia Pelvic pressure
heavy bleeding
Metrorrhagia Urinary frequency
bleeding between Infertility and/or
menses recurrent
Dysmenorrhea pregnancy loss
painful menses
*Many women are asymptomatic; symptoms depend on size and location of
fibroids
Diagnosis
Bimanual pelvic exam
Transvaginal ultrasound (TVUS)
Sonohysterography
Hysterosalpingography
Diagnostic hysteroscopy
MRI
Physical Exam
Abdominal exam
Palpable mass if uterus > 12-14 wk gestational size
Pelvic exam
Firm, irregularly enlarged uterus
Midline, occasionally adnexal
Mass displaced with cervix
Usually nontender
Physical Exam
Reveals a well-developed, well-nourished
woman in no distress. Vital signs and
general physical exam are unremarkable.
Abdominal examination reveals an irregular-
sized mass into extending halfway between
the pubic symphysis and umbilicus and to
the right of the midline. Pelvic exam reveals
a normal appearing vagina and cervix. The
uterus is markedly enlarged and irregular,
especially on the right side where it appears
to reach the lateral pelvic sidewalls. The
examiner is unable to palpate normal
ovaries due to the mass.
Pathology
Well
circumscribed
white tan firm
masses with a
whorled
appearance
Pathology
Microscopically
leiomyomas are
composed of
bland smooth
muscle.
They can be more
fibrotic than this
example or more
cellular.
Differential Diagnosis
Uterine sarcoma
Ovarian neoplasm
Tubo-ovarian inflammatory mass
Diverticular/inflammatory bowel mass
Colon cancer
Pelvic kidney
Pregnancy
Adenomyosis
Management (Surgical)
Clinical Presentation Nonmedical Options
Desire fertility Myomectomy or UAE
Desire uterine preservation Endometrial ablation or UAE
No desired fertility or uterine preservation Endometrial ablation or Hysterectomy
Rapidly growing uterus Exlap, TAH
*Intervention for patients with leiomyomas not amenable to medial therapy
Management (Surgical)
Desire future fertility
Myomectomy
Laparotomy larger fibroids
Laparoscopic pedunculated or subserosal fibroids
Hysteroscopic submucosal fibroids, >50% in cavity
Desire uterine preservation but not fertility
Endometrial ablation
Uterine artery emboloization (UAE)
No desire for uterine preservation or fertility
Hysterectomy (definitive)
Laparotomy (TAH) larger fibroids
Laparascopic (TVH, TLH) smaller fibroids
Management (Medical)
1st line treatment
NSAIDS
Progestin-only therapies (Depo Provera, Mirena IUD)
Combination therapies (OCPs, patches, vaginal rings)
2nd line treatment
GnRH analog (Lupron) blocks endometrial proliferation, shrinks
myometrium, and reduces leiomyoma volume
Causes vasomotor symptoms (hot flashes) and bone loss
Short courses, used primarily for pre-surgical shrinkage of leiomyoma
GnRH analog + hormonal agents
Minimize adverse hypoestrogenism effects
Mifepristone (RU 486) progesterone receptor antagonist
Still experimental, shown to reduce volume by 50% over 3 months
Management (Conservative)
Treatment is not necessary if.
Asymptomatic
Fibroid small (<12 wk gestational size)
Near menopause
Patient presentation
A 42-year-old G3 P3 female presents with a
history of abnormal bleeding and pelvic pain.
She was well until approximately age 35,
when she began developing dysmenorrhea
and progressive menorrhagia. The
dysmenorrhea was not fully relieved by
NSAIDS. Over the next several years, the
dysmenorrhea and menorrhagia became
more severe. She then developed
intermenstrual bleeding and spotting, as well
as pelvic pain, which she describes as a
constant feeling of pressure. She also
complains of urinary frequency.
Patient presentation
Past gynecological history is otherwise non-
contributory. She delivered three children by
caesarean section, the last with a tubal
ligation at age 30. Her past medical history
is unremarkable.
Patient Presentation
Diagnostic Evaluation
Laboratory
Beta HCG is negative. CBC reveals
hemoglobin of 10.3 and hematocrit of 31.2.
Indices are hypochromic, microcytic. Serum
ferritin confirms mild iron deficiency anemia.
Pap smear is normal with no evidence of
dysplasia. Endometrial biopsy reveals
proliferative endometrium. ECC is negative
for malignancy. Ultrasound shows a large
irregular mass, filling the pelvis and
extending into the lower abdomen. The
mass does extend into the right side of the
pelvis. The ovaries are not visualized.
Patient presentations
42yo P2 s/p BTL with 16 week size uterus,
menorrhagia, anemia, bulk symptoms
Management options?
32yo G0 who desires fertility with otherwise
the same presentation?
Management options?
42yo P3 s/p BTL with bleeding sx, no bulk
sx and a normal size uterus
Could she still have fibroids?
Management options?
Patient presentations
34 yo P1 with menorrhagia and
dysmenorrhea with an 8-10 weeks size
uterus
Management options?
What is this same patient were
asymptomatic?
Bottom Line Concepts
Most uterine leiomyomas are asymptomatic and require no intervention.
Uterine leiomyomas can cause excessive uterine bleeding, pelvic pressure
and pain, and infertility.
Fibroids can be subserosal, intramural, or submucosal. Prolonged or heavy
bleeding may be associated with intramural or submucosal myomas.
Conservative or medical management should be considered prior to
surgical management.
Treatment options for leiomyoma include myomectomy, endometrial
ablation, uterine artery embolization and hysterectomy.
Pregnancies in women with fibroids are usually uneventful.
Fibroids are rarely the cause of infertility. In women who have a
myomectomy in which the endometrial cavity is entered, future deliveries
must be by cesarean birth.
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 53 (p114-115).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 44 (p389-392).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 19 (p241-245).
Endometriosis
Objectives for Endometriosis
Describe the theories of pathogenesis of
endometriosis
List the most common sites of endometriosis
Describe the symptoms and physical exam findings in
a patient with endometriosis
Describe the diagnosis and management of
endometriosis
Definition
Benign condition in which endometrial glands
and stroma are present outside the uterine
cavity and walls.
Occurrence
Prevalence of endometriosis in general population
unknown
Estimated 5-15% of women have some degree of
disease
Found in 1/3rd or more women with chronic pelvic
pain, depending on practice setting
Typical patient is in her 30s, nulliparous, and
infertile, but can present throughout the
reproductive years.
Theories of Pathogenesis
Retrograde menstruation (Sampsons Theory)
Endometrial fragments transported through fallopian tubes at time
of menstruation and implant at intraabdominal sites
Mllerian (Coelomic) metapalasia theory (Meyers Theory)
Metaplastic transformation of pelvic peritoneum
Lymphatic spread (Halbans Theory)
Substances released/shed from endometrium induce formation of
endometriosis
Theories of Pathogenesis
However, since retrograde menstruation is essentially
universal, host factors must impact the development of
disease, such as:
variations in the ability to clean up menstrual
debris, probably reflecting immunologic events.
Genetic differences in the tendency to develop painful
conditions
Medical and psychological comorbidities
Sites of Occurrence
Ovary (most common)
Cul-de-sac
Uterosacral ligaments
Broad ligament
Fallopian tubes
Round ligaments
Vagina
Rectosigmoid and bowel, appendix
Urinary bladder and ureters
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology,
5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel, Chapter
25 (p299).
Symptoms
Classic Triad - dysmenorrhea, dyspareunia, dyschezia
Pain (cyclic and non-cyclic)
Infertility
Secondary dysmenorrhea
Premenstrual and postmenstrual spotting (in about
20%)
Physical Exam
No pathognomonic finding
Dont forget the recto-vaginal exam!
Cul-de-sac nodularity and tenderness
Uterosacral nodularity
Tender, fixed adnexal mass
Uterus fixed and retroverted
Diagnosis
Sine qua non sharp, firm, exquisitely tender barb
(barbed wire) in uterosacral ligaments
Ultrasound adnexal mass of complex echogenicity,
internal echoes consistent with blood
Definitive diagnosis
Direct visualization (via laparotomy or laparoscopy)
Histologic and gross findings consistent with endometrial tissue
Other tests
Ca125 - not specific nor sensitive
Pathology
Appearance of
endometriosis with
back raised lesions of
active endometriosis at
the time of laparascopy
Note: Lesions may be
raised or flat with red,
black or brown
coloration; fibrotic
scarred areas that are
yellow or white in hue;
or vesicle that are pink,
clear, or red.
Pathology
Multiple
endometrial cysts
chocolate cysts
of the ovary
Pathology
Hemorrhage Endometrial gland
Endometrial stroma
Differential Diagnosis
Chronic pelvic inflammatory disease
Recurrent acute salpingitis
Hemorrhagic corpus luteum
Benign or malignant ovarian neoplasm
Ectopic pregnancy
Staging
There is no clear
relationship between
stage and frequency
and severity of pain
symptoms
American Society for Reproductive Medicine revised classification of endometriosis,
1985. (American Fertility Society: Revised American Fertility Society Classification for
Endometriosis. Fertil Steril 43:351,1986)
Management
Key considerations:
Severity of the symptoms
Extent of the disease
Desire for future fertility
Age of the patient
Threat to GI or urinary tract
Management (Medical)
1st line treatment (adequate trial of 3-6 months)
NSAIDS
OCPs , cyclic or continuous
Progestins (i.e. Medroxyprogesterone acetate)
Depression, loss of bone calcium
To move beyond these, strongly consider laparoscopy to both
diagnose and treat the disease.
Medical treatment
2nd line treatment
Mirena IUD (levonorgestrel)
GnRH agonists (Lupron); should not be done without
laparoscopy first; relief of pain does not make the diagnosis of
endometriosis
Cause hot flashes, vaginal dryness, bone loss
High dose progestins suppress gonadotropin release
Cause abnormal bleeding, depression, fluid retention, nausea
Danazol androgenic derivative which suppresses LH and FSH
Pseudomenopause anolvulation and hypergonadism
Cause weight gain, hirsutism, acne, deepening voice
Previously gold standard, used rarely now given side effect profile
Management (Surgical)
Fertility preserving
Laparoscopic (or rarely, laparotomy) with ablation or excision
of endometrial implants and adhesions
Endometriomas >3 cm in diameter should be removed
surgically
Most definitive
Hysterectomy (most often laparoscopic) with ablation or
excision of all endometrial implants and adhesions.
Removal of ovaries has been traditional, but newer studies
suggest retention of ovaries is reasonable in many cases.
Always a risk of recurrence!
Bottom Line Concepts
Typical patient with endometriosis is in her reproductive years, and
sub-fertile.
Pathogenesis of endometriosis is not completely understood and
believed to be a combination of factors.
Characteristic triad of symptoms associated with endometriosis is
dysmenorrhea, dyspareunia, and dyschezia.
Staging of endometriosis is not clearly associated with frequency and
severity of pain symptoms.
Appropriate treatment varies widely and should take into consideration
severity of symptoms, extent of disease, and desire for future fertility.
There is a risk of recurrence of endometriosis throughout a womans
life.
In all women, minimization of menstrual flow and suppression of
ovarian cycling can reduce the risk for endometriosis.
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 38 (p80-81).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 29 (p269-276).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 25 (p298-303).
