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UTERINE LEIOMYOMATA

UTERINE LEIOMYOMATA. Dr Zeinab Abotalib MD, MRCOG Associate Professor & Consultant Obstetrics & Gynecology Infertility And Assisted Conception. Uterine Leiomyomata. Benign tumor comprised mostly of smooth muscle cells First described by Reinier De Graff 1641

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UTERINE LEIOMYOMATA

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  1. UTERINE LEIOMYOMATA Dr Zeinab Abotalib MD, MRCOG Associate Professor & Consultant Obstetrics & Gynecology Infertility And Assisted Conception

  2. Uterine Leiomyomata • Benign tumor comprised mostly of smooth muscle cells • First described by Reinier De Graff 1641 • Most common tumor of the female pelvis • Represent 1/3 of all GYN admissions to hospitals

  3. Incidence • Usually quoted 50% (Underestimate) • Cramer and Patel • 100 serial Uteri • Sectioned at 2mm • 77 of 100 had myomas • 84% had multiple myomas • 649 myomas found in all • No difference in incidence within pre or post menopausal uteri Am J Clin Pathol. 1990 Oct;94(4):435-8

  4. Incidence • More common in African-Americans than white • Torpin et al. investigated 1741 Uteri • Overall incidence 3 times higher in blacks • Also tended to be larger • Also occurred at a younger age J Obstet Gynecol 1942;44:569

  5. Incidence • Cumulative incidence by age 50, > 80% for African American and nearly 70% for Caucasian women. • One in four women have at least one submucosal fibroid. • Overall prevalence of uterine fibroids increases with age from 3.3% in women 25-32 to 7.8% in women 33-40 years. • Baird et al, Am J Obstet Gynecol 2003. • Borgfeldt et al, Acta Obstet Gynecol Scand 2000.

  6. Etiology • Arise from a single muscle cell (monoclonal). • Proliferate under the influence of sex hormones, including estrogen, progesterone & androgens. • Effects of steroids are modulated by local growth factors. • Rein et al, Am J Obst Gyne 1995. • Ichimura et al, Fertil Steril 1998. • Stewart et al, Obstet Gynec 1998. • Wer et al, Fertil Steril 2002.

  7. Etiology • Fibroblast growth factor • Vascular endothelial growth factor • Heparin-binding epidermal growth factor • Platelet-derived growth factor • Transforming growth factor • Parathyroid hormone-related protein • Prolactin

  8. Etiology • Risk Factors • Nurses Health Study II • 95,061 nurses completed questionnaires in 1989, 1991, 1993 • Obesity • Early menarche • Nulliparity Fertil Steril. 1998 Sep;70(3):432-9

  9. Etiology • Oral Contraceptives • High dose pills have been assoc. with stimulation of fibroid tumors • Smoking

  10. Presentation • Most fibroids do not cause symptoms. • 20-50% experience tumor-related symptoms: • Menstrual dysfunction • Bowel and bladder dysfunction • Bulk effects • Such symptoms, account for up to 35% of all hysterectomies. • Lefebvre et al, J Obstet Gynecol Can 2003. • Myers et al, Agency for Health Care Research and Quality, 2001.

  11. Pelvic Pain Menstrual Irregularities GI complaints Bladder complaints Dyspareunia Back pain Leg pain Vascular symptoms Infertility Asymptomatic Symptoms

  12. Diagnosis • History • Bimanual pelvic or abdominal exam • Pelvic ultrasound - most common • MRI, HSG, sonohysterogram, hysteroscopy

  13. Appearance

  14. Appearance

  15. Appearance

  16. Degenerative Changes • Degenerative changes are reported in approximately two-thirds of all specimens, but most of them have no clinical significance. • Hyaline degeneration- It is the most common • Cystic degeneration • Mucoid degeneration • Fatty degeneration • Carneous degeneration • Calcification • Sarcomatous degeneration(malignant transformation)

  17. Uterine Fibroids Benign tumour of uterine tissue 3 locations: • subserosal • intramural • submucosal

  18. Leiomyomas classified according to their location in the uterus

  19. How are they diagnosed? • Usually detected on an internal gynecological exam • Diagnosis is usually confirmed by ultrasound but can also be made with magnetic resonance (MR) or computed tomography (CT) scans.

  20. As seen on ultrasound

  21. As seen on MRI

  22. Factors that should be considered prior to initiating treatment include: • Size of the myoma(s) • Location of the myoma(s) (Symptoms • Woman's age (eg, is she near menopause?) • Reproductive plans

  23. How are they treated? • Depends on size and location • Surgical therapy - hysterectomy, myomectomy • Drug therapy - pain relievers, hormone therapy (to shrink them) • Uterine artery embolization

  24. Treatment • Expectant management - most cases • Indications for treatment • Abnormal uterine bleeding, causing anemia • Severe pelvic pain • Large or multiple • Obscuring evaluation of adnexa • Urinary tract symptoms • Postmenopausal or rapid growth

  25. Treatment Choices • Medical therapies • Medroxyprogesterone (Provera) • Danazol • GnRH agonists (nafarelin acetate, Depot Lupron)

  26. Treatment • RU486 • Anti-progestin • High affinity to Progesterone and glucocorticoid receptors • Murphy et al (1995) showed decrease of volume an average 49% • Recent reviews supports usage, but has been associated with • Hot flashes • Endometrial hyperplasia • Is not associated with trabecular bone loss Fertil Steril. 1995 Jul;64(1):187-90 Obstet Gynecol. 2004 Jun;103(6):1331-6 Clin Obstet Gynecol. 1996 Jun;39(2):451-60

  27. Treatment • Gestrinone • Antiestrogen/antiprogesterone • GnRH analogues • Suppresses pituitary mediated secretion of estrogens • Basically treat 3-6 months • Expect 50% reduction of uterine volume

  28. Treatment Choices • Uterine Artery Embolization (UAE)

  29. UAE • Within three months following embolization: • 45% and 55% reduction in total uterine and myoma volume. • Reduction in symptoms in approximately 80% of women. • long- term data on durability and effects on fertility and pregnancy outcomes are very limited. Pron et al, Fertil Steril 2003 Burbank et al, J Am Assoc Gynecol Laparosc 2000

  30. What does the doctor see?

  31. Myomectomy

  32. Myomectomy • First performed by Washington and John Atlee, 1844 • May be approached in a variety of ways • Abdominally (open) • Laparoscopic • Hysteroscopic • Primarily for submucosal/intramural fibroids impacting the endometrial cavity • Vaginal • Primarily for pedunculated submucous fibroids

  33. Myomectomy • Biggest complication is blood loss

  34. Myomectomy (local surgical removal of fibroids) • Sparing the uterus • Complications significant blood loss  could require hysterectomy • Fibroids can recur20 - 25% will need another procedure for treatment of new fibroids

  35. Myomectomy • Hysteroscopy for intracavitary / submucous • Laparotomy

  36. Myomectomy with hysteroscope

  37. Myomectomy • Hysteroscopy for intracavitary / submucous • Laparotomy

  38. Treatment Choices • Hysterectomy • Vaginal • Abdominal

  39. Hysterectomy • Curative, but irreversible • Until now, the standard therapy for fibroids 1/3 of all hysterectomies are performed for fibroids • Complications: bleeding, infection, adhesions, risks associated with general anesthetic • 6 - 8 week recovery

  40. Comparison of treatment options

  41. Comparison of treatment options

  42. Comparison of treatment options

  43. Goal

  44. Thanks !

  45. Method Of Delivery Vertex- Vertex (50%) • Vaginal delivery, interval between twins not to exceed 20 minutes. Vertex- Breech (20%) Vaginal delivery by senior obstetrician

  46. Method Of Delivery Breech- Vertex( 20%) • Safer to deliver by CS Breech-Breech( 10%) • Usually by CS.

  47. Method Of Delivery • MONO-MONO • By C/S • Why?

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