Uterine Leiomyomas

• LU is a 32 y/o G1P1001 LMP 2 wks ago who presents with a complaint of heavy vaginal bleeding at each menstrual cycle which began 6 months ago. She reports that her menses were initially 3 days in length but are now 5 days. She is using 6 sanitary napkins per day. She also reports a feeling of “pressure and something moving in her pelvis” especially after she urinates. She has no pain with sexual intercourse. On bimanual pelvic examination she has an enlarged firm uterus with multiple smooth irregularities on the surface. The uterus is the size of a 12 week pregnancy. A urine pregnancy test is negative.
  • Typical presentation of a patient with leiomyoma (fibroids)
    • A very common smooth muscle tumor
      • 20-25% of women of reproductive age
      • >80% of women will get this in their lifetime
      • usually very small and asymptomatic
      • more common in AA females for unknown reasons
      • No one knows why it develops; we only know that it’s a clonal expansion that is Estrogen dependent!!
    • There are many Types each with the same clinical picture:
      • Intramural
        • Lies entirely between layers of the myometrium
      • Submucosal
        • Lies under the endometrium
      • Subserosal
        • Starts out just under the level of the serosa and is asymptomatic unless it grows out to cause pressure effects
      • Parasitic
        • Starts as pedunculated (attached to serosa by a stalk) then grows vascular connection to other structures (omentum or bowel), doesn’t grow de novo, can occur in almost any location of smooth muscle

o        Symptoms of Leiomyomas

o        Majority of patients are asymptomatic even with very large fibroids – especially in obese women.

o        Often discovered on routine exam as an enlarged uterus without pain

o        Symptoms depend on location, size, stage and pregnancy status

§         Abnormal menstrual bleeding – most commonly

·         there are many different mechanisms by which fibroids can cause bleeding of variable flow

·         Intramenstrual bleeding (bleeding between periods) can be due to pressure effects on opposite site of endometrium causing denuding

·         Can lead to Fe-deficiency anemia if flow of menses is too high

§         Pain

·         Variable degree, depends on patient

·         If occurs, usually localized to pelvic area

·         Can be due to vascular compromise to the fibroid growth beyond its blood supply leading to necrosis (white degeneration) or necrosis and bleed into the fibroid and seem to grow (red degeneration).

§         Pressure effects

·         Could cause radiation of pelvic pain to the back or as Dr. Pompeo noted she had a patient who had felt pressure effects all the way up to the xyphoid when bending over

·         Patient can have dyspareunia (pain with intercourse) due to pressure of penetration against the cervix or vaginal wall; it all depends on location of fibroids.

§         Infertility

·         Cause of infertility in about 25% of women and is due to blockage of the sperm from getting to the fallopian tubes again depends on location of fibroids.

§         Spontaneous Abortion

·         Most commonly due to submucosal fibroids  via mass effect à just no room for the fetus to grow

o        Occurs in 2^nd or early 3^rd trimester

·         Other cause is due to implantation of the placenta over the fibroidà compromises the blood supply to the placenta à low blood flow and oxygen to baby

o        Diagnosis of Leiomyomas

o        History:  always important

o        Physical Exam: the bimanual exam = “mainstay” of diagnostic procedures

§         Uterus will be firm, mobile and smooth with irregular contours (she drew a picture on the board that I can’t seem to reproduce here because my computer skills are lacking)à in other words each discrete fibroid will have a smooth surface but will give the uterus an overall lumpy texture not nodularity.

§         Fibroids will move with the uterus in contrast to other pelvic masses which move independently of the cervix/uterus

o        Ultrasound: an adjunct test to quantify and guide therapy

o        MRI: can distinguish between two different tissues that are physically next to each other.

o        Catscans: not performed

§         Only indicated if the uterus is fixed in the pelvis and you fear mass effect of the uterus on the ureters at the pelvic brim (the only place where the ureter is pressed up against a bony prominence) or laterally at the cervix where ureters are going into the trigone of the bladder at this site a cervical fibroid can compress the ureter which will impede urine flow.

o        Treatment of Leiomyomas

o        Observation: if asymptomatic

o        Medical:

§         NSAIDs (anti-inflamm) – decreases pain with periods and bleeding in some

§         Oral Contraceptives – decrease menstrual flow

§         Progestins – stop periods altogether

§         GnRH agonists – stops menses and induce menopausal state and causes a 40% reduction in uterus size

o        Surgical:

§         Myomectomy – removal of just the fibroid, done in females who would like to continue child bearing

·         Most women deliver by C-section afterwards due to uncertainty of the integrity of uterus, though no evidence supports this concern, it’s just anecdotal

§         Hysterectomy – only done if there are significant symptoms

·         At one point was the predominant treatment and was the most common surgical procedure, now is #2, the new #1 is C-Section!!

o        New procedure

§         Uterine artery embolization

Physician cannulates the femoral artery and snake the instrument around toward the uterine artery where it injects pellets that will cut off the blood supply to the fibroid à shrinkage/degeneration

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