Uterine Leiomyoma

1. Uterine Leiomyoma Brought to you by: Bani and Siddhi

2. Objectives Describe the gross and histologic appearance of uterine leiomyomaand state their clinical significance. Describe anatomic classification, etiology, risk factors, signs and symptoms, physical examination findings, investigations and management of benignuterine neoplasia

3. Definitions Uterine Leiomyomas • Also known as fibroids/myomas • Most common pelvic tumor in women - Benign fibromusculartumors of the myometrium • Epidemiology Clinical manifestations seen in 12-25% of reproductive aged women. Pathologic evidence seen in 80% of these women.

5. Differential Diagnosis of Leiomyomas Benign Condition • Adenomyosis • Leiomyoma variant • Polyp Malignant Disease • Sarcoma • Carcinoma • Endometrial Carcinoma

6. Classification

8. FIGO Classification Subserous outer wall of uteris [55%] Intramural within muscular wall [40%] Submucosal protrude into the uterine cavity [5%] Pedunculated connected to uterus via stock

9. Gross Appearance

11. Histologic Appearance: Typical Leiomyoma • Monoclonal tumors • Arise from smooth muscle cells of myometrium • Benign lesions • Large amount of extracellular matrix, that is surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers. • - Can be variable in appearance

12. Histologic Appearance: atypical/variant leiomyoma Atypical Leiomyoma features Nuclear Atypia Comprised of Pleomorphism Hyperchromasia Multinucleation

13. Clinical presentation • Majority are ASYMPOTMATIC • Only 1/3 of women have symptoms Related to NUMBER, SIZE, LOCATION of fibroids • Abnormal uterine bleeding Most common symptom and main reason women seek treatment 2. Pelvic pain Dysmenorrhea, Dysparunia, pain with BMs 3. “Bulk-related” symptoms Urinary frequency, urinary obstruction, constipation, hydronephrosis/kidney damage 4. Reproductive dysfunction Fibroids are found in 5-10% of infertile women

14. Clinical presentation ABNORMAL UTERINE BLEEDING * Typical bleeding pattern: Heavy/Prolonged Menstrual bleeding * Not associated with post menopausal or intermenstrual bleeding

15. Clinical presentation Pelvic Pressure and Pain -Dysmenorrhea: correlated with heavy menstrual flow and passage of clots -Dyspareunia: Maybe associated with certain location of fibroids such as anterior or fundal fibroids. -Leiomyoma degeneration/torsion (rare): maybe associated with low grade fever, elevated WBC, peritoneal signs

16. Diagnosis Physical examination • Speculum exam Often normal, rarely can have prolapsed fibroid visible in the cervical os May see anteriorly displaced cervix 2. Bi-manual exam Uterus: -SIZE enlarged uterus -CONTOUR irregular -MOBILITY  mobile Assess for Adnexal masses 3. Rectal exam

17. Diagnosis Imaging Transvaginal ultrasound confirms dx and excludes possibility of another type of uterine or adnexal mass Sonohysterography saline infusion into uterine cavity; best for identification of intracavitary lesions

18. Diagnosis Hysterosalpingography used to visualize fibroids when assessing tubal patency in women with infertility Diagnostic hysteroscopy best for determining the presence of submucosal fibroids. Hysteroscope is inserted in the vagina.

19. Ancillary Investigations • Rule out pregnancy/ectopic pregnancy • BhcG • Rule out other causes of vaginal bleeding • FSH/LH, TSH, PRL • Rule out other causes for an enlarged uterus • Assess presence of anemia, coagulation status • CBC, INR, pTT

20. Management ASYMPTOMATIC WOMEN Expectant management SYMPTOMATIC WOMEN PHARMACOLOGICAL SURGICAL √ Fertility X Fertility Done Childbearing but want to retain uterus Hormonal Non-hormonal

21. Note on post-menopausal women -In the absence of post-menopausal hormonal therapy, leimoyomas generally become smaller and asymptomatic - Investigate women with new or enlarging pelvic mass rule out leiomyosarcoma (1-2%)

22. Case Case • A 40 yo G5P5 woman complains of menorrhagia of 2 years duration. She sates that several years ago a doctor had told her that her uterus was enlarged. Her records indicate that 1 year ago she underwent a uterine dilatation and curettage, with the tissue showing benign pathology. She takes ibuprofen but obtains no relief of her vaginal bleeding. On examination, her blood pressure is 135/80, heart rate 80 bpm, and temperature 37.6 degrees Celcius. Abdominal examination reveals a lower abdominal midline irregular mass. On pelvic examination, the cervix is anteriorly displaced. An irregular midline mass approximately 18 weeks size seems to move in conjunction with the cervix. No adnexal masses are palpated. Her pregnancy test is negative. Her hemoglobin is 86, wbc 10 and plt 160.

23. Case • A 40 yo G5P5 woman complains of menorrhagia of 2 years duration. She sates that several years ago a doctor had told her that her uterus was enlarged. Her records indicate that 1 year ago she underwent a uterine dilatation and curettage, with the tissue showing benign pathology. She takes ibuprofen but obtains no relief of her vaginal bleeding. On examination, her blood pressure is 135/80, heart rate 80 bpm, and temperature 37.6 degrees Celcius. Abdominal examination reveals a lower abdominal midline irregular mass. On pelvic examination, the cervix is anteriorly displaced. An irregular midline mass approximately 18 weeks size seems to move in conjunction with the cervix. No adnexal masses are palpated. Her pregnancy test is negative. Her hemoglobin is 86, wbc 10 and plt 160.