Uterine Leiomyoma

&
Benign Ovarian Diseases

Dr Howaida Khair
Uterine Leiomyoma
Objectives
❑Identify symptoms and physical findings in patients with uterine
leiomyoma.
❑Describe diagnostic methods to confirm uterine leiomyomas, with
consideration of value-based care.
❑Describe the management options for treatment of uterine
leiomyomas, with consideration of value-based care and the effect of
social and environmental factors on health outcomes.
Uterine leiomyomata
• Known also as fibroids and myomas
• Benign proliferation of smooth muscle cells surrounded by a pseudo -
capsule of compressed muscle fibers
Uterine leiomyomata
Prevalence
➢Clinically apparent in 25 to 50% of women
➢High during the fifth decade of a woman’s life
➢1:4-5 in white women and 1:2 in African women
➢About 80% in pathological exam of the uteus
Size and site:
• Uterine fibroids vary in size and site ,from microscopic to large
multinodular tumors
Uterine leiomyomata
Classification
Classified according to site in the layers of the uterus:
Intramural:
in the muscular wall of the uterus
Subserosal
beneath the uterine serosa and
Submucosal:
beneath the endometrium
A subset of the subserosal category is the pedunculated leiomyoma
• Origin:
Single smooth muscle cell, of the uterine muscle
They usually have moderate growth during pregnancy
Malignant potential:
Usually fibroids regress post menopause.
If a post manuals women presents with rapidly enlarging fibroid they
at increase risk of Leiomyosarcoma
Classification
Classification

May mimic
adnexal mass
Symptoms
❑Menorrhagia : heavy menstrual bleeding lasting more than a week
(menorrhagia is defined as menstrual blood loss of >80 mL), more with
submucous leiomyoma. It can also cause secondary dysmenorrhea
❑Submucosal fibroids are most commonly associated with menorrhagia
❑Iron def anemia:
❑Pelvic pressure :
➢Pressure on urinary balder leading to frequency, , hydroureter ) and
possibly hydronephrosis.
➢Pressure on the rectum leads to constipation.
❑Backache and or leg pains.
Diagnosis
❑Clinical:
Symptoms , signs and physical exam
❑imaging studies:
➢Ultrasound
➢MRI
❑Hysteroscopy
❑Laparoscopy
❑Pathological exam :
❑Diagnosis is often made incidental in pathology exam of uteus removed
for other indications
Pelvic ultrasound

Transabdominal Transvaginal
Normal Transvaginal pelvic ultrasound
Anterior

Myometrium at
uterine fundus

Endometrium
Uterine leiomyomata
Uterine leiomyomata
Hysteroscopy
Hysteroscopy (fibroids)
Fibroids at Laparoscopy
• Can be used for diagnosis and Rx
Diagnosis of Fibroids at Laparoscopy
Rx of Fibroids at Laparoscopy
MRI
May be useful in evaluating extremely large myomas in adjunct to
ultrasound
Rx of Uterine leiomyomata
Depends on the symptoms and he woman desire for future fertility.
Options:
❑Expectant
❑Medical
❑Surgical
❑Uterine artery embolization
❑MRI-guided focused ultrasound surgery
Rx of Uterine leiomyomata
❑Expectant ( observation):

In women near menopause with small scattered fibroids with

menorrhagia and no anemia and no pain can be offer this
treatment
Medical Rx of Uterine leiomyomata
❑ Estrogen-progestin contraceptives
❑Progestin supplementation
❑Progestin-releasing intrauterine devices (IUDs)
❑Tranexamic acid
❑Iron supplementation
❑Gonadotropin-releasing hormone agonists
Estrogen-progestin contraceptives ( oral
contraceptive Pills)
The most common medical therapy utilized by patients with Heavy
menstrual bleeding HMB and fibroids.
Benefits of OCPS :
➢Contraception
➢Reduction of HMB
➢Reduction of iron deficiency anemia
➢Reduction of uterine cancer
➢Reduction of ovarian cancer
➢Inexpensive
➢Widely available
Estrogen-progestin contraceptives ( oral
contraceptive Pills)
Absolute contraindications to OCPS :
breast cancer, history of deep venous thrombosis or pulmonary
embolism, active liver disease, use of rifampicin, familial
hyperlipidemia, previous arterial thrombosis, and pregnancy
Relative contraindications include:
Smoking, age over 35, hypertension etc.
Tranexamic acid
❖Tranexamic acid is an antifibrinolytic agent. It works by blocking the
breakdown of blood clots, which prevents bleeding
❖Can be taken during menses or during the heavy days of menses.
❖For patients who cannot or do not wish to use hormonal
contraceptives.
❖For those who desire a treatment that is used only when symptoms
are present
Gonadotropin-releasing hormone agonists

❑Mode of action:
GnRH agonist is a synthetic form of the natural GnRH secreted by the
hypothalamus. Continuous use lead to down regulation of the pituitary
gland

❑Benefits:
Can reduce HMB.
significantly reduce fibroid volume
Can be use prior to myectomy and hysterectomy to correct anemia and
reduce size of fibroids pre-op
Progestin supplementation

• Oral progestin-only contraceptives, progestin implants, and progestin

injections do not appear to be effective for fibroid-related HMB
Surgical Treatment (Myomectomy or Hysterectomy)

Myomectomy: Can be done as laparotomy of minimal invasive

procedure( hysteroscopy or laparoscopy ) according to the skill of the
operator, size of fibroid and site
Hysterectomy:
Can be done as laparotomy of minimal invasive procedure(
(laparoscopy )
Myomectomy
In patients who desire to retain childbearing potential or whose fertility is compromised by
the myomas, creating significant intracavitary distortion.
Indications
rapidly enlarging pelvic mass,
symptoms unrelieved with medical management,
and enlargement of an asymptomatic myoma to the point of causing hydronephrosis.
Contraindications:
Pregnancy
Advanced adnexal disease
Malignancy
complications
excessive intraoperative blood loss or postoperative hemorrhage and even the need for
emergency hysterectomy
infection, and pelvic adhesions etc.
Hysterectomy
Indication:
Definitive treatment in symptomatic women who have completed childbearing and opt
for the procedure.
Indicated also in case of menopausal women with severe pelvis pain with rapidly
increasing in size of fibroids
Complications:
➢General anesthetic complications.
➢Bleeding intra or postoperative.
➢Damage to ureter , bladder or intestine
➢Infection.
➢DVT
➢Ovarian failure
Uterine artery embolization (UAE)
✓UAE is a minimally invasive option for management of fibroid-related
symptom

✓The procedure involves inserting a catheter

through the groin injecting the embolic agent
into the uterine arteries that supply blood to
the uterus and fibroids.
✓ As the fibroids die and begin to shrink,
the uterus fully recovers.
Benign Ovarian Diseases
Case

A25-year-old woman, presented to the ER with right sided lower

abdominal pain. She had her LMP 20 days ago and her urine pregnancy
test was negative. She is never been pregnant before.
How would you approach her
Clinical assessment
• History:
Analysis of pain. Associated symptoms ( bowel urinary), Fever, previous
similar attacks. Detailed Gyne, medical, surgical, etc… histories.
Physical exam:
General. Abdominal and ? Pelvic exam
Investigations:
➢Urine
➢Blood
➢Imaging
Differential Diagnosis
Adnexal space:
The area between the lateral pelvic wall and the cornu of the uterus.
The adnexa structures in this space.
Adnexa include the ovaries, fallopian tubes, upper portion of the broad
ligament and mesosalpinx, and remnants of the embryonic Müllerian
duct.
DD of adnexal pain also includes urinary and bowel disorders because
of proximity with adnexal space
Benign Ovarian Cysts
Benign Ovarian Cysts:
❖Follicular Cyst
❖Corpus Luteum Cysts
❖Theca Lutein Cyst
Benign Ovarian tumors:
❖Epithelial cell tumors, the largest class of ovarian neoplasm
❖Germ cell tumors, the most common ovarian neoplasm in reproductive-age
women, the benign cystic teratoma or dermoid
❖Stromal cell tumors, some of the rarer types
Follicular Cysts
• Develop when an ovarian follicle fails to rupture during follicular
maturation and ovulation does not occur.
• A cyst may enlarge beyond 5 cm and continue to fill with follicular
fluid
• Symptoms associated with a follicular cyst may include mild to
moderate unilateral lower abdominal pain and alteration of the
menstrual interval.
• Most follicular cysts spontaneously resolve within 6 -10 weeks.
• Accidental rupture may cause acute unilateral pelvic pain , respnd to
analgesia rarely surgical intervention is needed
Follicular Cysts
• On pelvic ultrasound:
tends to appear as a unilocular simple cyst
without any of the following:
solid components:
thick septations
soft tissue elements
evidence of internal or
external excrescences, and papillations
Corpus Luteum Cysts

❖Its diameter exceeds approximately 3 cm

❖ It is related to the postovulatory (increased progesterone
level) phase of the menstrual cycle
❖Symptoms: pain , adnexal mass and amenorrhea.
❖DD: Ectopic pregnancy
Theca Lutein Cyst

• The least common, the theca lutein cyst, which is associated with
pregnancy.
• Usually bilateral, they are most common in multiple gestations,
trophoblastic disease, and ovulation induction .
• They may not only become large and multicystic but also regress
spontaneously in most cases without intervention.
Theca Lutein Cyst
Benign Epithelial Cell Neoplasms
3 groups serous, mucinous, and endometrioid neoplasm
I. Serous cystadenoma : most common epithelial cell neoplasm is 70%
benign; 10% of low malignant potential, and 20% are frankly malignant.
Benign Epithelial Cell Neoplasms

II. Mucinous cystadenoma:

❖ Second most common epithelial cell tumor of the ovary. The

malignancy rate of 15%
❖These cystic tumors can become quite large, sometimes filling the
entire pelvis and extending into the abdominal cavity
❖Ultrasound assessment will often reveal multilocular septations.
Surgery is the treatment of choice
Mucinous cystadenoma
Benign Germ Cell Neoplasms

• They arise in the ovary and may contain relatively differentiated

structures, such as the hair and bone. The most common tumor
found in women of all ages is benign cystic teratoma, also called a
dermoid cyst or dermoid
Key Points of benign ovarian neoplasms:

✓The following are the key points that can be made regarding They are
more common than malignant tumors of the ovary in all age groups
✓The risk of malignant transformation increases with increasing age.
✓Surgical treatment should be considered if there is high potential for
malignancy or torsion
✓Preoperative assessment with pelvic imaging techniques such as
ultrasound is necessary
✓Surgical treatment may be conservative for benign tumors, especially
if future reproduction is desired