o Cryosurgery/Cryomyolysis  Gold standard: hysteroscopic.

Polypectomy
 CT or MRI guided insertion, the tip of the  Good prognosis if benign
probe is frozen and it freezes the tissues
leading to necrosis and atrophy.
o Laser Myolysis
 Cryo and Laser
 Disadvantage: metabolites (products of the
breakdown) may overload the kidneys
 Be careful in treating patients with borderline
kidney function (borderline renal failure)
• Reason for treatment
o Remember that myomas are very common and
not all require treatment. The following are
reasons fro treatment:
 Bleeding
 Pain
 Pressure Symptoms
 Enlargement
 Infertility
• Blockage of the myoma to the passage
of the fallopian tubes
• Posterior wall myoma  may lead to
recurrent abortion
 Possible Sarcoma if the patient still has
growing mass even at menopause

For this case, other work-ups that may be done (for

determination of treatment)
• Combined Transvaginal and Abdominal Mass
o Rule out pregnancy, polyps and etc.
o It will rule out almost every differential diagnosis
o Location of the mass:
 Not that important
 Submucous myoma would bleed.
• Not all myomas would bleed.
• If you find a submucous myoma, you
would be able to explain the reason for
bleeding
o Number of nodules: does not matter
 Location and number of myomas would only
matter if the patient still desires to get
pregnant.
o Measure the thickness of the endometrium
 Hyperplasia may co-exist with myomas since
both are sensitive or affected by estrogen.
 Management may change because of this
finding:
• Endometrial biopsy should be done.
o If normal, treat the myoma only
o But if positive, treat the cancer. The
more serious condition should be
the one treated immediately.
If this case was an adenomyosis, the treatment would be:
• Definitive Treatment: Hysterectomy
o Because the adenomyotic foci are less
responsive.
• BSO depends on the age of the woman.
o But since the age of predilection is usually
multiparous, it no longer needs fertility
preservation.
• READ on the preservation of uterus or nearing
menopause and etc.
o About the medical therapy  levonorgesterol IUD
etc.

Additional Notes from Doc’s Presentation:

• Hallmark of adenomyosis: pinpoint hemorrhages 
active endometrial foci
o Pearl white whorled surface  typical
appearance
o One type of degeneration:
 Cystic degeneration  outgrows blood
supply
 Hyaline change
 Carneous (red) degeneration  looks like
raw meat
• Happens during pregnancy
• Pain  treated symptomatically “Cheaters never win.”
• Endometrial polyps  overgrowth of endometrial
mucosa
o Bleeding pattern: intermenstrual bleeding.
o Saline Infusion Sonography or
sonohysterography These are just notes taken down by a nocturnal medical student at 7 AM in the
o Treatment: Polypectomy morning. Study at your own risk.

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Case 13 – Benign Lesions of the Uterus
Notes from Discussion of Dr. Gil Gonzalez
A 45 year old G3P3 (3003) complained of progressive
increase in the amount and duration of her menses since 2
years ago. LMP – 1 week ago; Menses still regular. Abdominal
examination: (+) firm, nodular, non-tender movable mass in the
hypogastric area, the upper pole of which is halfway between
the symphisis pubis and umbilicus. Speculum examination:
cervix was pink, smooth, with minimal bloody-mucoid
discharge from the os. Internal examination: cervix – firm, long,
closed, movable not tender; uterus – nodular, firm, enlarged to
about 3 months size, movable, non-tender; adnexa – no mass
nor tenderness.
What is wrong with the patient?
• Increased in amount and duration of menses 
Menorrhagia or heavy menstrual bleeding
o The bleeding comes concurrent with the
expected menses (cyclic/periodic)
Additional data that may be elicited:
• History:
o Does the patient also experience pain during
coitus?
 Consider the possibility of endometriosis
o If ever she noticed the mass, ask her when it
started?
 The rate of growth would suggest a benign
or malignant lesion.
o Ask for urinary symptoms:
 Frequency with nocturia
• It may be a mass compressing the
urinary organs
o Ask for gastrointestinal symptoms:
 Constipation
• It may be a mass compressing the GI
tract
What other symptom would you asking for in this patient?
• If there is pain in the mass?
o There might be nerve compression
• What complication can cause pain in a myoma?
o Compression of the nerve?
• Check for signs and symptoms of anemia since she
has been bleeding:
o Easy fatigability
o Pallor
o Palpitations
• Is she taking any medication since she bled?
From PE, you would be able to determine the following and
work-up a diagnosis:
• Size of uterus
• Nodular
Impression:
• Leiomyoma
o Most common mass
o PE: There will be distortion of the uterus and it is
usually asymmetrical
o All myomas at one point in time are intramural
since the origin is the muscle layer. So even if
they present as a submucous or a subserous
myoma, they all have an intramural compartment.
 Thus, the enlargement would be
asymmetrical.
o Sensitive to estrogen
o If submucous  presents with bleeding
o If subserous  asymmetric mass
o Intramural may also cause an Abnormal Uterine
Bleeding
o Review of Physiology:
 Hemostatic mechanisms to stop the bleeding
• Contraction of the myometrium
o Myometrial fibers have no pattern
and they intertwine with no
directions
o The blood vessels are intertwined
with it and when the muscles
contract, they also constrict
• Platelet plug
• Clotting time and bleeding time
o Mechanism of Pathology
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 Intramural myomas may still cause bleeding
because they prevent the adequate
contraction of the uterine musculature
preventing the normal constricting
mechanism of the myometrium.
 The uterus is also enlarged, thus, there will
be more surface area covered with
endometrium. The expanded endometrial
lining to be sloughed off may lead to
increased bleeding.
Differential Diagnosis:
• Hematometra
• Endometrial Polyp
o PE: no uterine enlargement
• Adenomyosis
o The closest differential for this case.
o PE: the enlargement is symmetrical and firm. The
shape would be retained. It would be felt as
tender or inflamed and felt as doughy (between
firm and soft)/ boggy at the time of menstruation.
o There is presence of inflammation and
endometriotic focus there.
 There is no limit to the inflammation and the
involvement is mostly symmetrical since the
inflammation would be generally.
• Pregnancy
o If in case, you should rule it out by asking for the
presumptive, possible, and positive signs of
pregnancy
 Color: Violaceous cervix (Chadwick’s Sign)
 Nausea and vomiting
 Weight gain
o BUT in this case, the LMP was just 1 week ago.
She is so not pregnant! (No amenorrhea)
o Upon PE, the cervix would be soft.
• Endometrial Cancer
Treatment:
• Medical
o GnRH AGONIST
 Duration: 3 or 4-6 months only since
osteoporosis is a side effect.
rd
 The maximum effect is seen on the 3
month.
 Window of intervention: right after the
myoma shrunk and about 3-4 months after.
o Pre-operative treatment
 Medicate to shrink the myoma and make it
less vascular
• Less prone to bleeding because of
decreased vascularity
• Shrink to have a smaller incision site
and more room for the surgeon to work
on.
 Poor surgical risk patients are:
• Diabetic
• Cardiac condition
• Surgical
o Definitive: Hysterectomy (TAH with or without
BSO)
o Myomectomy for younger women who are
symptomatic but would like to preserve fertility
 Myoma has a pseudocapsule which outlines
it. Just open it up and the myoma can be
easily scooped/taken out.
• This would leave a large defect in the
myometrium. This is closed properly to
avoid retaining a space when the uterus
is repaired.
• The presence of a pseudocapsule
differentiates myoma from an
adenomyosis
o Myoma – has a pseudocapsule
o Adenomyosis – no pseudocapsule
o Uterine Artery Embolization
 Fine catheter inserted to the femoral artery
and retrograde insertion  instill alcohol
 The uterus has collateral blood supply. The
uterine artery is not its sole blood supply.
However, the myomas are mainly supplied
by the uterine artery. Thus, uterine artery
embolization will cease the blood flow to the
myomas but the uterus won’t necrotize since
it has other blood supply.