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Leiomyoma

The document discusses uterine leiomyomas (fibroids), including their prevalence, types, symptoms, diagnostic methods, and treatment options. It highlights that fibroids are common, particularly among African American women, and can lead to various symptoms such as heavy menstruation and pelvic pressure. The case study presented illustrates a typical patient scenario, emphasizing the importance of differential diagnosis and management strategies for women with fibroids.

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19 views16 pages

Leiomyoma

The document discusses uterine leiomyomas (fibroids), including their prevalence, types, symptoms, diagnostic methods, and treatment options. It highlights that fibroids are common, particularly among African American women, and can lead to various symptoms such as heavy menstruation and pelvic pressure. The case study presented illustrates a typical patient scenario, emphasizing the importance of differential diagnosis and management strategies for women with fibroids.

Uploaded by

48pqcyjrbt
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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LEIOMYOMA (Fibroid)

Case + Video

[email protected]
Objectives

• Identify the prevalence of leiomyomas.


• Describe the clinical picture of patient with leiomyoma.
• List the different types of uterine leiomyoma.
• Describe the diagnostic methods to confirm uterine leiomyoma.
• Discuss the treatment options for leiomyoma (medical and surgical)
• Identify the risk of malignant changes that might occur in leiomyom

Video : https://www.youtube.com/watch?v=2aHCVGeHV1M
Uterine leiomyoma
-Uterine leiomyoma (fibroids)
: benign proliferation of smooth muscle cells

Types of fibroids:
1. Intrmural fibroids (Within the wall of uterus).
2. Subserosal fibroid (beneath serosa or peritoneum).
3. Submucosal fibroid (beneath the endometrium).
• 1 out 4 white woman , 1 out 2 African American Woman

-Most Common indication for hysterectomy (30%)


-hormonal (estrogen) responsive
so it is common in pregnancy.
and menopause will cause Atrophy (Low oestrogen level)
-Symptoms:
Commonly asymptomatic
Or 3 classical symptoms:
1. But mostly bleeding or heavy menstruation (due to invasion the
endometrium).
2. Pelvic pressure or mass.
3. Dysmenorrhea.
-Physical findings:
Depends on its number and sizes.
Large: palpable abdominally
-Note: to comment for size of uterus use word ‘week size uterus’ this
differentiate it from the pregnant uterus or ‘beneath umbilicus’
Intramural : Cant be felt and usually asymptomatic , unless its enlarges
Submucosal: Intermenstrual bleeding (Abnormal Vaginal Bleeding )
SubSerosal : Pressure symptom , Lumpy bumpy (Irregular)
Diagnostic test: by physical examination and imaging studies
1. Pelvic ultrasounds: to quantify the fibroids sizes and numbers.
2. Sonohysterogram.
-Diagnostic test:
1. 3.
PelvicMRI: for
ultrasounds: location
to quantify the fibroidsand size
sizes and numbers.
2. Sonohysterogram.
3. MRI: for location and size.

Treatment:
Mostly women not needed for intervention especially if it is found small or
incidentally (Observation )
- Medical management:
o Oral contraceptive (to reduce bleeding): contraindicated for women over
35 of age, smoke, HTN or with migraine.
o Progestin (for bleeding).
o Prostaglandin synthase inhibitors (NSAID) (for dysmenorrhea).
o GnRH agonist ( to suppress HPO axis) —> can be use for pre surgical
Shrinkage or for premenopausal woman ( until they reach the
menopause )
- Uterine artery embolisation :

Catheter is inserted to femoral artery —> uterine artery —> block the vessels (
fibroid devascularization causing ischemia of myoma)

- Surgical options:
o Myomectomy ( to maintain fertility ): abdominally, hysteroscopically
o Hysterectomy: abdominally or vaginally.
CASE:
A 42-year-old G3P3 woman 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. Past gynecological history is otherwise noncontributory. She
delivered three children by Caesarean delivery, the last with a tubal ligation at
age 30. Her past medical history is unremarkable.
Physical examination: 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 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 side- walls. The adnexae are not palpable given the size of the mass.
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 test is reported negative for malignancy, adequate for
evaluation. Ultrasound shows multiple large intramural fibroids, filling the
pelvis and extending into the lower abdomen. Themass does extend into the
right side of the pelvis. There is mild hydronephrosis on that side. The ovaries
are not visual- ized. Endometrial biopsy reveals proliferative endometrium.
Q1: What are the likely causes of the mass prior to imaging?

The most common cause of a large irregular uterine mass is uterine


leiomyomata. The clinical picture is typical of a patient with fibroids. The
physician must be sure that the patient does not have ovarian neo- plasia. Usually
this is accomplished when the ultrasound confirms the diagnosis of fibroids.

• The differential diagnosis for a pelvic mass includes :


physiologic cysts, infection (tubo-ovarian abscess), benign and malignant
neoplasms, adenomyosis, endometriosis, and masses related to other ab-
dominal/pelvic organ systems.
Q2. What is the prevalence of leiomyoma in different populations of
women?

• Uterine leiomyomas are very common


• Prevalence is high, with up to 70% of Caucasian women and greater than
80% of African American wom-
Q3:Describe the pathological changes of leiomyomata.
• Well-circumscribed, non-encapsulated myometrium confirms the diagnosis
of fibroids. It is a benign neoplasm.

• A leiomyosarcoma will have at least 10 abnormal mitoses per high power


field, and is diagnosed histologically typically after surgical removal by way of
hysterectomy/myomectomy.

• Fibroids are common; leiomyosarcoma is very rare

• Pathological diagnosis is made for a patient who undergoes surgery. Biopsy


for fibroids is not indicated.
Q4. Discuss the appropriate management of women with fibroids.

• Expectant management is acceptable if intervention is not warranted by the


symptoms.
• No intervention is needed for women with asymptomatic fibroids. Many women
with fibroids are asymptomatic.
• Provider should discuss patient’s desire for fertility when planning treatment.

• The most frequent presenting symptoms of uterine fibroids are :


bleeding ,pressure symptoms,pain, and urinary complaints.
Fibroids can be : subserosal,intramuralorsubmucosal.
• Submucosal fibroids are frequently associated with bleeding.
• Pregnancies in women with fibroids are usually uneventful. Fibroids can grow
during pregnancy, which may impact fetal growth and mode of delivery.
• Fibroids are rarely a cause of infertility. There are specific criteria for the use
of myomectomy in infertile patients.
• Oral contraceptives or progestins may be utilized to control bleeding.
• GNRH agonists may be utilized preoperatively.
• • A levonorgestrel containing intrauterine device can be effective for pain and
bleeding in a uterus up to 10 weeks size.
• Hysteroscopic resection
• Uterine ablation
• Uterine artery embolization
• Myomectomy
• Hysterectomy
Q5: What are the indications for hysterectomy in women with
fibroids?
• Failure of prior conservative therapies to relieve symptoms
• When her symptoms have an impact on daily activities
• Excessive uterine bleeding
Profuse bleeding,clots or periods>8days
Symptomatic anemia due to the blood loss
• Pelvic pain caused by the fibroids
Acute and severe Chronic lower abdominal or back pressure Bladder pressure
causing urinary frequency
Done by:
Nouf AlBalla
Revised by:
Razan AlDhahri

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