UTERINE MYOMAS An Overview of Development, Clinical Features, and Management

1. UTERINE MYOMAS An Overview of Development, Clinical Features, and Management 부산백병원 산부인과 R2 손영실

2. INDEX ◎ Clinical Manifestations ◎ Growth Patterns ◎ Therapy 1. Hysterectomy 2. Abdominal Myomectomy 3. Hysteroscopic Myomectomy 4. Laparoscopic Myomectomy 5. Uterine Artery Embolization 6. Hormone Therapy - Progestins - GnRHa

3. CHARACTERISTICS ◎ The most common solid pelvic tumors in women - occurring in 20~40% of women during their reproductive years ◎ Benign tumors that originate from smooth muscle cells of the uterus ◎ Consists of uterine smooth muscle tissue as well as fibrous tissues ◎ Size : seedlings ~ large tumors

4. CHARACTERISTICS ◎ Types 1) intramural - found within the myometrium 2) subserous - externally extending to the serosa 3) submucous - internally impinging on the uterine cavity 4) pedunculated 5) extend through the internal os of the cervix

5. CHARACTERISTICS ◎ Estrogen-dependent tumors - associated with exposure to circulating estrogen - decrease in size during menopause - maximum growth : when estrogen secretion is maximal, spurt in growth in the decade before menopause (anovulatory cycles with unopposed circulation estrogen) - occasionally grow during pregnancy (caused by estrogen)

6. CLINICAL MANIFESTATION 1. Most patients with uterine myomas are “symptom-free” 2. Excessive menstrual bleeding - the only symptom produced by myomas - obstructive effect on uterine vasculature ⇒ proximal congestion in the myometrium and endometrium ⇒ excessive bleeding - uterine cavity size & endometrial surfaces are ↑ ⇒ increasing the quantity of menstrual flow

7. CLINICAL MANIFESTATION 3. Pain - relatively infrequent ① torsion of the pedicle of a pedunculated myoma ② cervical dilatation by a submucous myoma protruding through the lower uterine segment ③ carneous degeneration associate with pregnancy ⇒ pain is acute and requires immediate attention 4. Pressure and increased abdominal girth - develop insidiously, often less apparent symptom - urinary tract Sx : frequency, outflow obstruction, compression of the ureter - G-I Sx : constipation or tenesmus

8. CLINICAL MANIFESTATION 5. Infertility - rarely caused by myomas - associated with a submucous myoma : interferes with normal implantation or with sperm transport - implicated in recurrent pregnancy loss - improvement in reproductive outcome after surgery 6. Malignant transformation - extremely rare

9. GROWTH PATTERNS ◎ Because malignancy in association with myomas is rare, careful consideration must be given to specific indications for performing surgery ◎ A history of rapid growth, especially postmenopausal growth ⇒ should prompt resection of tumor, even in absence of symptoms ◎ Small asymptomatic myomas require only serial flow-up - initially at 3-month intervals to establish a growth pattern - if growth pattern is stationary, pelvic exam can be repeated in 4~6 month intervals ◎ USG, CT, MRI hysterosalpingography ⇒ assists in documenting growth of myomas

10. GROWTH PATTERNS ◎ Indications for Surgical Management of Uterine Myomas • Abnormal uterine bleeding not responding to conservative treatments • High level of suspicion of pelvic malignancy • Growth after menopause • Infertility when there is distortion of the endometrial cavity or tubal obstruction • Recurrent pregnancy loss (with distortion of the endometrial cavity) • Pain or pressure symptoms (that interfere with quality of life) • Urinary tract symptoms (frequency and/or obstruction) • Iron deficiency anemia secondary to chronic blood loss

11. THERAPY ◎ Medical management - GnRH analogues, progestational compounds, antiprogestins ◎ Surgical management - myomectomy or hysterectomy ◎ Uterine artery embolization ◎ Others - high frequency ultrasonography, laser Tx, cryotherapy, thermoablation

12. THERAPY ◎ The choice should be predicated upon careful consideration of many factors - medical and social : age, parity, childbearing aspirations, extent and severity of symptoms, size, number and location of myoma, associated medical condition, possibility of malignancy, proximity to menopause, desire for uterine preservation ◎ For example, ① multiple myoma & completed childbearing ⇒ benefit from hysterectomy ② nulliparous woman ⇒ myomectomy ③ submucosal myoma ⇒ hysteroscopic resection ④ subserosal pedunculated myoma ⇒ laparoscopic resection

13. THERAPY 1. Hysterectomy - second most frequent major surgical procedure performed in women in the US - indication for hysterectomy ① uterine myoma (33.5%) ② endometriosis (18.2%) ③ uterine prolapse (16.2%) ④ cancer (11.2%)

14. THERAPY - Why do a hysterectomy? Why remove the entire uterus? ⇒ several factors should influence the gynecologist’s judgement, including the age and her childbearing aspirations - for many women, hysterectomy conjures up the specter of loss of sexuality and feminity ⇒ counseling with other women who have undergone hysterectomy can be very constructive before surgery - several recent report ⇒ improvement in life quality for most women who have had hysterectomy hysterectomy dose not adversely influence sexuality

15. THERAPY - surgery to relieve bleeding, pain, pelvic pressure, and urinary tract symptoms may lead to improvement in sexual satisfaction and quality of life - complication ① risk of damage to adjacent structure urinary tract : uriteral injury, vesicovaginal fistula, stress incontinence bowel ② vaginal vault prolapse

16. THERAPY - supracervical hysterectomy : associated with a decreased risk of urinary tract injury, less operating time, less vault prolapse (by preservation of uterosacral and cardinal ligament) : recent studies, there was no difference in pelvic relaxation symptoms after 2 years follow-up ⇒ Hysterectomy is an acceptable choice for symptomatic myomas in patients who have significant bleeding, pain, pressure or anemia for whom fertility is not an issue

17. THERAPY 2. Abdominal Myomectomy - preferred treatment whenever preservation of uterus is desired - choice for a solitary pedunculated myoma - interference with fertility or predisposition to repeated pregnancy loss due to nature or location of myomas ⇒ indication for myomectomy

18. THERAPY - To perform myomectomy, the surgeon must carry out a thorough preoperative appraisal ① Hypermenorrhea and abnormal bleeding ⇒ required endometrial evaluation in a patient aged more than 35 years ② Hematologic status normal Hb ⇒ should have 1 or 2 units of her own blood, obtained 2 weeks before myomectomy anemic patient ⇒ pretreatment with GnRH analogues or progestational agent ⇒ produce and amenorrheic state during which iron stores can be replenished and anemia corrected to reduce intraoperative blood loss ⇒ pharmacologic vasoconstricting agent and mechanical vascular occlusion was used

19. THERAPY - multiple myomectomy is frequently a more difficult and time-consuming procedure than hysterectomy - morbidity between the 2 procedures (Iverson et al) ① hysterectomy group : experienced ureteral, bladder, and bowel injuries ② myomectomy group : no intraoperative visceral injuries

20. THERAPY 3. Hysteroscopic Myomectomy - Resection of submucosal myomas - Indication : abnormal bleeding Hx of pregnancy loss, infertility, and pain - Contraindication : endometrial ca. lower reproductive tract infection, inability to distend the uterine cavity, extension of the tumor deep into the myometrium

21. THERAPY 4. Laparoscopic Myomectomy - performed when myomas are easily accessible, as in superficial subserous or pedunculated myomas - these can be morcellated and removed through the laparoscopic cannula or placed in the cul-de-sac and removed via a colpotomy incision - laparoscopic coagulation of a myoma, or myolysis ① conservative alternative to myomectomy in women wishing to preserve fertility ② Nd:YAG laser via degeneration of protein and destruction of vascularity

22. THERAPY - laparoscopic assisted myomectomy involves laparoscopic dissection of the myomas from the uterine wall and their extraction through a minilaparotomy incision, thus sparing a large abdominal incision - these procedures have not been standarized, so, the surgeon who undertakes them should be skilled in operative endoscopy

23. THERAPY 5. Uterine Artery Embolization - this approach had been used for many years to control pelvic hemorrhage, for treatment of myomas was first described in 1995 - principle : limiting blood supply to the myomas (infarction) ⇒ their volume may be reduced - performed under conscious sedation by an interventional radiologist - minimally invasive procedure ⇒ shortened hospital stay

24. THERAPY • - recommended for patients with large myomas who are • symptomatic, women who do not want extirpative therapy • - In a series of 80 patients with myoma related • hypermenorrhea, 90% reported complete cessation of • symptoms after embolization • - complication • ① pain : persist and last for more than 2 weeks • ② postembolization fever, postembolization syndrome, • pyometra, failure of satisfactory regression of • myomas, • sepsis, hysterectomy, and death

25. THERAPY 6. Hormone Therapy ◎ Progestins - Norethindrone, medrogestone, medroxyprogesterone acetate - produce a hypoestrogenic effect by inhibiting gonadotropin secretion and suppressing ovarian function - exert a direct antiestrogenic effect

26. THERAPY ◎ Gonadotropin-Releasing Hormone Analogues - used to achieve hypoestrogenism in various estrogen-dependent conditions ( ex. Endometriosis, precocious puberty, and uterine myomas) - transient effect - within several cycles after discontinuing administration, myomas tend to return to their pretherapy size

27. THERAPY - adjuvantive therapy with 3~4 month course of GnRHa should reduce myoma size and render surgery easier, accompanied by less blood loss - use of GnRHa has been associated with significant short- and long-term side effect, such as postmenopausal symptoms and osteoporosis - severe pelvic pain occasionally will accompany shrinkage of myomas during GnRHa treatment

28. CONCLUSION • a thorough understanding of the pathogenesis of uterine myomas, clinical presentation, and diagnostic tools are the keys to selecting which course to follow in treating patient with myomas • surgery for myomas is not always necessary and should be performed only for appropriate indications ① the use of GnRHa is the achievement of amenorrhea to facilitate correction of IDA before surgery

29. CONCLUSION ② uterine artery embolization is most effective for patients with large symptomatic myomas who are poor surgical candidates and reluctant to undergo a major surgical procedure ③ gynecologists determine surgical approach, endoscopic or by laparotomy, based on size, number, extent and location of myomas ④ all therapeutic measures, and especially invasive techniques, should be reserved for patients with symptomatic myomas - for asymptomatic women, serial follow-up for growth and development of symptoms is generally safe

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