🔹
Etiology who gets fibroids?
1-Age: 30-40y Incidence increases with age
2- Parity: null Para or low •20% of women in their 20’s
🔹
parity •40% of women in their 40’s
3- Race: negro Genetic predisposition •African-American women at
🔹 Familial tendencies
4- Family history: tve higher risk
5- hyperestrogenaemia.
Corporeal leiomyoma:
uterine:
1)Interstitial 58%.
1)cervical 1-2% & solitary.
2)Subserous18%
2)Corporeal 98% & multiple.
3)submucus 24% & not capsulated.
extrauterine:
1)Round lig
Varieties of leiomyoma 2)brood lig
3)Recto-vog. Sept
4)utero - sacral
Leiomyomotosis:
1)tuinica M
2)extension from myoma
🔻 Subserosal Fibroids
-Develop along outer wall of the uterus
-Unlikely to affect menstrual flow
-source of pelvic or back pain
Types : -Maygrow on a stalk -pedunculated
🔻
1) intramural
-found within the myometrium Intramural Fibroids
2) subserous -Develop in the uterine wall
- externally extending to the serosa -Most common type of fibroid
3) submucous -May cause enlarged uterus, pain,heavy
🔹
CHARACTERISTICS :
The most common solid pelvic tumors in women
- internally impinging on the uterine cavity
4) pedunculated
menstrual bleeding,generalized pressure.
-occurring in 20~40% of women during their
🔹
reproductive years
Benign tumors that originate from smooth muscle cells of the
5) extend through the internal os of the
cervix 🔻 Submucosal Fibroids
-Develop just under the uterine lining
🔹
uterus
Consists of uterine smooth muscle tissue as well as fibrous
-Least common
-Most likely to be symptomatic
🔹
tissues
🔹 Size : seedlings ~ large tumors
-Heavy and prolonged periods
-Associated with infertility
🔹 Multiplicity
Estrogen-dependent tumors - associated with exposure to
circulating estrogen
CONSISTENCY
- decrease in size during menopause *Firm
- maximum growth: when estrogen secretion is maximal,spurt in *Harder (hyaline degeneration).
growth in the decade before menopause(anovulatory cycles with *Soft (pregnancy-cystic degeneration).
unopposed circulation estrogen) *Stony hard (Calcification)
-occasionally grow during pregnancy (caused by estrogen)
CUT SECTION
-Well demarcated surrounding
muscle
-whorly(intermingling muscles fibers and fibrous tissue).
-Paler than surrounding (Ischaemia).
Microscopic Examination
-Smooth muscle cells and fibrous tissue cells.
-Few formed blood vessels.
Pathology: Endometrial carcinoma:
•Macroscopic:
Was the 2nd most common malignancy of the female CLINICAL MANIFESTATION
🔻
genital tract. Now became the first one. 1. Most,patients with uterine myomas are “symptom=free"
-localized -diffuse
Etiologe: Asymptomatic fibroids do not require treatment
🔸
•Microscopic:
adenocarcinoma :
-Age: old one. 2. Excessive menstrual bleeding.
🔻
-Parity: low. - the only symptom produced by myomas
1- endometroid:
-Family history:+ . -obstructive effect on uterine vasculature Fibroids may dramatically increase in size during
Secretory, Ciliated, Papillary and With sq.cell
-Race: white. -> proximal congestion in the myometrium pregnancy.
carcinoma(adenoacanthoma,adenosquamous
-Social class: high. and endometrium -Related to increased estrogen levels
carcinoma)
-Hyperestrogenaemia: association. -> excessive bleeding -Usually shrink to pre-pregnancy size after delivery
2- serous.
3- mucinous
-Smoking: decrease.
-Tamoxifen: trestment after breast cancer
- uterine cavity size & endometrial surfaces are 个 -Fibroids typically improve after menopause.
-Estrogen levels decrease dramatically
4- clear cell -> increasing the quantity of menstrual flow
-Corpus cancer syndrome: DM, Obesity and -Hormonal replacement therapy may affect fibroid size/symptoms
🔸
5- undifferentiated
🔸 sq.cell carcinoma
mixed
Hypertension.
-adenoma maligant
3)Pain
- relatively infrequent:
① torsion of the pedicle of a pedunculated myoma 🔻 Pregnancy Complications Due to Leiomyoma:
-Pelvic irradiation. •Abortion •Premature labor
② cervical dilatation by a submucous myoma protruding through the lower uterine •Disturbances in labor •Postpartum hemorrhage
segment •questionable Ectopic pregnancy •Premature rupture of
③ carneous degeneration associate with pregnancy membrane
-->pain is acute and requires immediate attention •Dystocia secondary low segment myoma
4. Pressure and increased abdominal girth •Increase operative deliveries
- develop insidiously, often less apparent symptom •Inversion of uterus
🔻
- urinary tract Sx : frequency, outflow obstruction, compression of the ureter
- G-I Sx : constipation or tenesmus Effects of the Pregnancy on the Myoma
5)Infertility •Degeneration of myomas
- rarely caused by myomas ； •Infection (the process is usually sterile but may be complicated
associated with a submucous myoma interferes with normal implantation or with sperm by secondary infection from uterine cavity)
transport
- implicated in recurrent pregnancy loss
FIGO STAGING OF ENDOMETRIAL CARCINOMA -improvement in reproductive outcome after surgery
6. Malignant transformation
- extremely rare
Degeneration
Leiomyomas enlarge-->outgrow their blood supply--
🔹
>various types of degeneration
Hyaline degeneration :
the presence of homogeneous eosinophilic bands or
🔹 General changes:
-Erythrocytosis Polycythaemia (erythrocytic) 🔹
plaques in the extracellular space.
Myxoid degeneration :
-carbohydrat metabolism (hyperglycaemia). presence of gelatinous intratumoral foci at gross
examination that contain hyaluronic acid–rich
🔹
-Anaemia (hge).
Genital tract:
-Uterus (endomet.-cavity-myomet-uterus as a whole). 🔹
mucopolysaccharides
red degeneration:
-Tubes inflammed (salpingitis) -during pregnancy,
Changes occur with -secondary to venous thrombosis
-ovaries (tunica albuginea-endometriosis-cysts).
benign
(leiomyomas fibroid )
🔹
fibroid
🔹
General
-Blood vessels.
🔹
-Endometriosis (30-40%).
-within the periphery ofthe tumor or rupture of
🔹
intratumoral arteries
Sarcomatoustransformation -less than 3%
🔹
Genital tract Tumor Tumour itself:
itself -Atrophy.
-Degeneration (hayline-red- cystic-fatty-calcerous) 🌟 causes of utrine degeneration:
lesions of the uterus -Necrosis.
-Malignancy (growth after menopause-rapid enlargement-
A.Vascular Insufficiency
-Rapid growth during pregnancy
recurrent fibroid polyp) -Torsion of pedunculated myoma
Endometrial -Vascular (oedema-lymphangectasia -Uterine artery embolization
B.Hypoestrogenic State
-Infection.
carcinoma -Postpartum or postabortal
-GnRH – agonist or antiagonist
-Postmenopausal (perimenopausal)
C. other causes:
-High dosage progestin therapy
-Progesterone receptor modulator
Uterine Adenomyosis
Uterine adenomyosis (the ectopic endometrial tissue) is the presence of
endometrial glands and stroma in the uterine musculature; and cause a
🔸
diffusely enlarged uterus.
Symptoms and Signs
Common symptoms of uterine adenomyosis are:
-Heavy menstrual bleeding.
-Dysmenorrhea, and anemia.
DIFFERENTIAL Dx 🔸
-Chronic pelvic pain.
Diagnosis History
🔹 ADEMOMYOSIS:
-presence of ectopic endometrial glands and stroma within the myometrium, which are associated with reactive hypertrophy
-Examination
-Usually ultrasonography or MRI
of the surrounding myometrial smooth muscle
-most commonly a diffuse abnormality but may also occur as a focal mass, which is known as an adenomyoma 🔸
-Definitive diagnosis requires histology after hysterectomy.
Treatment
-Hysterectomy (effective treatment)
-diffuse form of adenomyosis appears as a thickened junctional zone (inner myometrium) on T2-weighted images
-Junctional zone 72mm thick or thicker is highly predictive of adenomyosis -A levonorgestrel-releasing IUD may help control dysmenorrhea and
🔹
bleeding.
🔹
How are fibroids diagnosed? -Small foci of high signal intensity on T2- weighted images represent the endometrial glands
🔹
🔹
Gynecologic exam
Ultrasound
SOLID ADNEXAL MASS:
-If MR imaging can demonstrate continuity of an adnexal mass with the adjacent myometrium, then a diagnosis of leiomyoma
🔹 MRI can be established.
🔸
Endometrial polyp
Uterine polyp is a mass in the inner
🔹
🔹
CT (CAT Scan)
Sonohysterography
-Ovarian fibromas and Brenner tumors are benign ovarian neoplasms that have a large fibrous component and can have
signal intensity similar to that of a pedunculated leiomyoma. fibromas and Brenner tumors surrounded by ovarian stroma and
🔸
lining of the uterus.
Hysteroscopy follicles, thus establishing the ovarian origin of the mass and excluding a diagnosis of leiomyoma
-important in pregnant patients because a confident diagnosis of a uterine leiomyoma may eliminate the need for surgery 🔸They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated)
They range in size from a few millimeters to several centimeters.
They often asymptomatic.
🔹
during pregnancy
UTERINE LEIOMYOSARCOMA
-May arise in a previously existing benign leiomyoma(sarcomatous transformation) or independently from the smooth muscle 🔸 If symptoms :
cells of the myometrium #. Irregular menstrual bleeding.
- A diagnosis of leiomyosarcoma is established histologically by noting the presence of infiltrative margins, nuclear atypia, #. Bleeding between menstrual periods.
and increased mitotic figures #.Excessively heavy menstrual bleeding (menorrhagia),
#.Vaginal bleeding after menopause.
Investigation. #.If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea)
🔸 Screen:
🔸
Etiology
Treatment of endometal -Vag. Smear
-Jet lavage aspiration.
🔸NoButdefinitive cause of endometrial polyps.
they appear to be affected by hormone levels and grow in response to circulating estrogen.
carcinoma
🔸 -Intrauterine brush.
🔸
Diagnosis
🔸
🔸 1- Surgical: (Beast result) -Suction aspiration canula. Endometrial polyps can be detected by:
🔸 2- Radiotherapy.
3- Chemotherapy:
-Kevorkian curette.
- Doppler. 🔸
🔸
vaginal ultrasound (sonohysterography)
Hysteroscopy
Dilation and curettage
Hormonal or cytotoxic agents - hysteroscopy.
-Progestin challenge Detection by ultrasonography alone --difficult
complications
🔸 🔸
P.F., HyperE., liver D., F. OvarianT.
Diagnostic: 🔸Polyps can be surgically removed using curettage with or without hysteroscopy.
Treatment
🔸
🔸
Hematometra, pyometra or phesometra.
Fistula. Examination under anesthesia with fractional
🔸Ureteric comoression.
🔸
curettage.
Prognostic: THERAPY
🔸Perforation
peritonitis. - Tumor markers: Ca125, CEA, TNFa.
- Steroid receptors: E. and P.
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,
-To certify spread.
-Preoperative preparation. ▪️
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 myomectomy
1-hysterectomy:
-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 have improvement in life quality for most women who had hysterectomy
-hysterectomy dose not adversely influence sexuality
🔸
-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
⬛
▪️ GROWTH PATTERNS: ② vaginal vault prolapse
🔶
Because malignancy in association with myomas is rare,careful consideration
by fatema okoff
▪️
must be given to specific indications for performing surgery
A historyof rapid growth, especially postmenopausal growth --> should prompt
2. Abdominal Myomectomy
-preferred treatment whenever preservation of uterus is desired
▪️
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
- choice for a solitary pedunculated myoma
-interference with fertility or predisposition to repeated pregnancy loss due to nature or location of myomas
pattern. --> indication for myomectomy
▪️
- if growth pattern is stationary, pelvic exam can be repeated in 4~6 month intervals
USG, Ct, MRI hysterosalpingography ▪️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
▪️
CONCLUSION
Indications for Surgical Management of Uterine ② Hematologic status:
🔹
Myomas:
🔸
🔸 normal Hb --> should have 1 or 2 units of her own blood, obtained 2 weeks before myomectomy
a thorough understanding of the pathogenesis of uterine myomas,
🔹
🔹
Abnormal uterine bleeding not responding to conservative treatments
anemic patient
clinical presentation, and diagnostic tools are the keys to selecting
▪️
High level of suspicion of pelvic malignancy which course to follow in treating patient with myomas
🔹 Growth after menopause --> pretreatment with GnRH analogues or progestational agent surgery for myomas is not always necessary and should be
Treatment 🔹
🔹
Infertility when there is distortion of the endometrial cavity or tubal obstruction
Recurrent pregnancy loss (with distortion of the endometrial cavity)
--> produce and amenorrheic state during which iron
stores can be replenished and anemia corrected to reduce intraoperative blood loss
performed only for appropriate indications
① the use of GnRHa is the achievement of amenorrhea to facilitate
🔷
Treatment of women with uterine Pain or pressure symptoms (that interfere with quality of life) --> pharmacologic vasoconstricting agent and mechanical" vascular occlusion was used correction of IDA before surgery
🔹
leiomyomas must be individualized, based on: THERAPY
-Symptoms,
multiple myomectomy is frequently a more difficult and ② uterine artery embolization is most effective for patients with
Medical management
time-consuming procedure than hysterectomy large symptomatic myomas who are poor surgical candidates and
🔹
-Size and - GnRH analogues, progestational compounds, antiprogestins
- Rate of growth of the uterus, and - morbidity between the 2 procedures (Iverson et al) reluctant to undergo a major surgical procedure
Surgical management
-The woman's desire for fertility. 1•Hysterectomy:(Laparotomy,Laparoscopic) ① hysterectomy group: experienced ureteral, bladder, and bowel injuries ③ gynecologists determine surgical approach, endoscopic or by
② myomectomy group: no intraoperative visceral injuries laparotomy, based on size, number, extent and location of myomas
🔶
2•Myomectomy
(Vaginal,Hysteroscopic,Laparoscopic,Laparotomy) 3. Hysteroscopic Myomectomy ④ all therapeutic measures, and especially invasive techniques,
🔹
should be reserved for patients with symptomatic myomas
🔸
3•Myolysis - Resection of submucosal myomas
🔹 Uterine artery embolization - for asymptomatic women, serial follow-up for growth and
Indication: development of symptoms is generally safe
Others
-high frequency ultrasonography, laser Tx, cryotherapy, thermoablation abnormal bleeding Hx of pregnancy loss, infertility,
🔥 The major indications for aggressive management of 🔸
and pain
Contraindication :
uterine myomas are as follows:
1.Abnormal uterine bleeding Rapid growth
2.Growth after menopause Infertility
🔶
endometrial ca. lower reproductive tract infection, inability to distend the uterine cavity, extension of the tumor deep in to the myometrium
4. Laparoscopic Myomectomy
- performed when myomas are easily accessible, as in
3.Recurrent pregnancy loss Pain or pressuresymptoms superficial subserous or pedunculated myomas
4.Urinary tract symptoms or obstruction
5.Possibility of ovarian neoplasia
6.lron deficiency anemia secondary to chronic blood loss 🔸
- 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
🔶 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
🔸 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
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
-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
Etiology who gets fibroids?
1-Age: 30-40y Incidence increases with age
2- Parity: null Para or low •20% of women in their 20’s
🔹
parity •40% of women in their 40’s
3- Race: negro Genetic predisposition •African-American women at
🔹 Familial tendencies
4- Family history: tve higher risk
5- hyperestrogenaemia.
Corporeal leiomyoma:
uterine:
1)Interstitial 58%.
1)cervical 1-2% & solitary.
2)Subserous18%
2)Corporeal 98% & multiple.
3)submucus 24% & not capsulated.
extrauterine:
1)Round lig
Varieties of leiomyoma 2)brood lig
3)Recto-vog. Sept
4)utero - sacral
Leiomyomotosis:
1)tuinica M
2)extension from myoma
🔻 Subserosal Fibroids
-Develop along outer wall of the uterus
-Unlikely to affect menstrual flow
-source of pelvic or back pain
Types : -Maygrow on a stalk -pedunculated
🔻
1) intramural
-found within the myometrium Intramural Fibroids
2) subserous -Develop in the uterine wall
- externally extending to the serosa -Most common type of fibroid
3) submucous -May cause enlarged uterus, pain,heavy
🔹
CHARACTERISTICS :
The most common solid pelvic tumors in women
- internally impinging on the uterine cavity
4) pedunculated
menstrual bleeding,generalized pressure.
-occurring in 20~40% of women during their
🔹
reproductive years
Benign tumors that originate from smooth muscle cells of the
5) extend through the internal os of the
cervix 🔻 Submucosal Fibroids
-Develop just under the uterine lining
🔹
uterus
Consists of uterine smooth muscle tissue as well as fibrous
-Least common
-Most likely to be symptomatic
🔹
tissues
🔹 Size : seedlings ~ large tumors
-Heavy and prolonged periods
-Associated with infertility
🔹 Multiplicity
Estrogen-dependent tumors - associated with exposure to
circulating estrogen
CONSISTENCY
- decrease in size during menopause *Firm
- maximum growth: when estrogen secretion is maximal,spurt in *Harder (hyaline degeneration).
growth in the decade before menopause(anovulatory cycles with *Soft (pregnancy-cystic degeneration).
unopposed circulation estrogen) *Stony hard (Calcification)
-occasionally grow during pregnancy (caused by estrogen)
CUT SECTION
-Well demarcated surrounding
muscle
-whorly(intermingling muscles fibers and fibrous tissue).
-Paler than surrounding (Ischaemia).
Microscopic Examination
-Smooth muscle cells and fibrous tissue cells.
-Few formed blood vessels.
Pathology: Endometrial carcinoma:
•Macroscopic:
Was the 2nd most common malignancy of the female CLINICAL MANIFESTATION
🔻
genital tract. Now became the first one. 1. Most,patients with uterine myomas are “symptom=free"
-localized -diffuse
Etiologe: Asymptomatic fibroids do not require treatment
🔸
•Microscopic:
adenocarcinoma :
-Age: old one. 2. Excessive menstrual bleeding.
🔻
-Parity: low. - the only symptom produced by myomas
1- endometroid:
-Family history:+ . -obstructive effect on uterine vasculature Fibroids may dramatically increase in size during
Secretory, Ciliated, Papillary and With sq.cell
-Race: white. -> proximal congestion in the myometrium pregnancy.
carcinoma(adenoacanthoma,adenosquamous
-Social class: high. and endometrium -Related to increased estrogen levels
carcinoma)
-Hyperestrogenaemia: association. -> excessive bleeding -Usually shrink to pre-pregnancy size after delivery
2- serous.
3- mucinous
-Smoking: decrease.
-Tamoxifen: trestment after breast cancer
- uterine cavity size & endometrial surfaces are 个 -Fibroids typically improve after menopause.
-Estrogen levels decrease dramatically
4- clear cell -> increasing the quantity of menstrual flow
-Corpus cancer syndrome: DM, Obesity and -Hormonal replacement therapy may affect fibroid size/symptoms
🔸
5- undifferentiated
🔸 sq.cell carcinoma
mixed
Hypertension.
-adenoma maligant
3)Pain
- relatively infrequent:
① torsion of the pedicle of a pedunculated myoma 🔻 Pregnancy Complications Due to Leiomyoma:
-Pelvic irradiation. •Abortion •Premature labor
② cervical dilatation by a submucous myoma protruding through the lower uterine •Disturbances in labor •Postpartum hemorrhage
segment •questionable Ectopic pregnancy •Premature rupture of
③ carneous degeneration associate with pregnancy membrane
-->pain is acute and requires immediate attention •Dystocia secondary low segment myoma
4. Pressure and increased abdominal girth •Increase operative deliveries
- develop insidiously, often less apparent symptom •Inversion of uterus
🔻
- urinary tract Sx : frequency, outflow obstruction, compression of the ureter
- G-I Sx : constipation or tenesmus Effects of the Pregnancy on the Myoma
5)Infertility •Degeneration of myomas
- rarely caused by myomas ； •Infection (the process is usually sterile but may be complicated
associated with a submucous myoma interferes with normal implantation or with sperm by secondary infection from uterine cavity)
transport
- implicated in recurrent pregnancy loss
FIGO STAGING OF ENDOMETRIAL CARCINOMA -improvement in reproductive outcome after surgery
6. Malignant transformation
- extremely rare
Degeneration
Leiomyomas enlarge-->outgrow their blood supply--
🔹
>various types of degeneration
Hyaline degeneration :
the presence of homogeneous eosinophilic bands or
🔹 General changes:
-Erythrocytosis Polycythaemia (erythrocytic) 🔹
plaques in the extracellular space.
Myxoid degeneration :
-carbohydrat metabolism (hyperglycaemia). presence of gelatinous intratumoral foci at gross
examination that contain hyaluronic acid–rich
🔹
-Anaemia (hge).
Genital tract:
-Uterus (endomet.-cavity-myomet-uterus as a whole). 🔹
mucopolysaccharides
red degeneration:
-Tubes inflammed (salpingitis) -during pregnancy,
Changes occur with -secondary to venous thrombosis
-ovaries (tunica albuginea-endometriosis-cysts).
benign
(leiomyomas fibroid )
🔹
fibroid
🔹
General
-Blood vessels.
🔹
-Endometriosis (30-40%).
-within the periphery ofthe tumor or rupture of
🔹
intratumoral arteries
Sarcomatoustransformation -less than 3%
🔹
Genital tract Tumor Tumour itself:
itself -Atrophy.
-Degeneration (hayline-red- cystic-fatty-calcerous) 🌟 causes of utrine degeneration:
lesions of the uterus -Necrosis.
-Malignancy (growth after menopause-rapid enlargement-
A.Vascular Insufficiency
-Rapid growth during pregnancy
recurrent fibroid polyp) -Torsion of pedunculated myoma
Endometrial -Vascular (oedema-lymphangectasia -Uterine artery embolization
B.Hypoestrogenic State
-Infection.
carcinoma -Postpartum or postabortal
-GnRH – agonist or antiagonist
-Postmenopausal (perimenopausal)
C. other causes:
-High dosage progestin therapy
-Progesterone receptor modulator
Uterine Adenomyosis
Uterine adenomyosis (the ectopic endometrial tissue) is the presence of
endometrial glands and stroma in the uterine musculature; and cause a
🔸
diffusely enlarged uterus.
Symptoms and Signs
Common symptoms of uterine adenomyosis are:
-Heavy menstrual bleeding.
-Dysmenorrhea, and anemia.
DIFFERENTIAL Dx 🔸
-Chronic pelvic pain.
Diagnosis History
🔹 ADEMOMYOSIS:
-presence of ectopic endometrial glands and stroma within the myometrium, which are associated with reactive hypertrophy
-Examination
-Usually ultrasonography or MRI
of the surrounding myometrial smooth muscle
-most commonly a diffuse abnormality but may also occur as a focal mass, which is known as an adenomyoma 🔸
-Definitive diagnosis requires histology after hysterectomy.
Treatment
-Hysterectomy (effective treatment)
-diffuse form of adenomyosis appears as a thickened junctional zone (inner myometrium) on T2-weighted images
-Junctional zone 72mm thick or thicker is highly predictive of adenomyosis -A levonorgestrel-releasing IUD may help control dysmenorrhea and
🔹
bleeding.
🔹
How are fibroids diagnosed? -Small foci of high signal intensity on T2- weighted images represent the endometrial glands
🔹
🔹
Gynecologic exam
Ultrasound
SOLID ADNEXAL MASS:
-If MR imaging can demonstrate continuity of an adnexal mass with the adjacent myometrium, then a diagnosis of leiomyoma
🔹 MRI can be established.
🔸
Endometrial polyp
Uterine polyp is a mass in the inner
🔹
🔹
CT (CAT Scan)
Sonohysterography
-Ovarian fibromas and Brenner tumors are benign ovarian neoplasms that have a large fibrous component and can have
signal intensity similar to that of a pedunculated leiomyoma. fibromas and Brenner tumors surrounded by ovarian stroma and
🔸
lining of the uterus.
Hysteroscopy follicles, thus establishing the ovarian origin of the mass and excluding a diagnosis of leiomyoma
-important in pregnant patients because a confident diagnosis of a uterine leiomyoma may eliminate the need for surgery 🔸They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated)
They range in size from a few millimeters to several centimeters.
They often asymptomatic.
🔹
during pregnancy
UTERINE LEIOMYOSARCOMA
-May arise in a previously existing benign leiomyoma(sarcomatous transformation) or independently from the smooth muscle 🔸 If symptoms :
cells of the myometrium #. Irregular menstrual bleeding.
- A diagnosis of leiomyosarcoma is established histologically by noting the presence of infiltrative margins, nuclear atypia, #. Bleeding between menstrual periods.
and increased mitotic figures #.Excessively heavy menstrual bleeding (menorrhagia),
#.Vaginal bleeding after menopause.
Investigation. #.If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea)
🔸 Screen:
🔸
Etiology
Treatment of endometal -Vag. Smear
-Jet lavage aspiration.
🔸NoButdefinitive cause of endometrial polyps.
they appear to be affected by hormone levels and grow in response to circulating estrogen.
carcinoma
🔸 -Intrauterine brush.
🔸
Diagnosis
🔸
🔸 1- Surgical: (Beast result) -Suction aspiration canula. Endometrial polyps can be detected by:
🔸 2- Radiotherapy.
3- Chemotherapy:
-Kevorkian curette.
- Doppler. 🔸
🔸
vaginal ultrasound (sonohysterography)
Hysteroscopy
Dilation and curettage
Hormonal or cytotoxic agents - hysteroscopy.
-Progestin challenge Detection by ultrasonography alone --difficult
complications
🔸 🔸
P.F., HyperE., liver D., F. OvarianT.
Diagnostic: 🔸Polyps can be surgically removed using curettage with or without hysteroscopy.
Treatment
🔸
🔸
Hematometra, pyometra or phesometra.
Fistula. Examination under anesthesia with fractional
🔸Ureteric comoression.
🔸
curettage.
Prognostic: THERAPY
🔸Perforation
peritonitis. - Tumor markers: Ca125, CEA, TNFa.
- Steroid receptors: E. and P.
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,
-To certify spread.
-Preoperative preparation. ▪️
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 myomectomy
1-hysterectomy:
-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 have improvement in life quality for most women who had hysterectomy
-hysterectomy dose not adversely influence sexuality
🔸
-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
⬛
▪️ GROWTH PATTERNS: ② vaginal vault prolapse
🔶
Because malignancy in association with myomas is rare,careful consideration
by fatema okoff
▪️
must be given to specific indications for performing surgery
A historyof rapid growth, especially postmenopausal growth --> should prompt
2. Abdominal Myomectomy
-preferred treatment whenever preservation of uterus is desired
▪️
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
- choice for a solitary pedunculated myoma
-interference with fertility or predisposition to repeated pregnancy loss due to nature or location of myomas
pattern. --> indication for myomectomy
▪️
- if growth pattern is stationary, pelvic exam can be repeated in 4~6 month intervals
USG, Ct, MRI hysterosalpingography ▪️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
▪️
CONCLUSION
Indications for Surgical Management of Uterine ② Hematologic status:
🔹
Myomas:
🔸
🔸 normal Hb --> should have 1 or 2 units of her own blood, obtained 2 weeks before myomectomy
a thorough understanding of the pathogenesis of uterine myomas,
🔹
🔹
Abnormal uterine bleeding not responding to conservative treatments
anemic patient
clinical presentation, and diagnostic tools are the keys to selecting
▪️
High level of suspicion of pelvic malignancy which course to follow in treating patient with myomas
🔹 Growth after menopause --> pretreatment with GnRH analogues or progestational agent surgery for myomas is not always necessary and should be
Treatment 🔹
🔹
Infertility when there is distortion of the endometrial cavity or tubal obstruction
Recurrent pregnancy loss (with distortion of the endometrial cavity)
--> produce and amenorrheic state during which iron
stores can be replenished and anemia corrected to reduce intraoperative blood loss
performed only for appropriate indications
① the use of GnRHa is the achievement of amenorrhea to facilitate
🔷
Treatment of women with uterine Pain or pressure symptoms (that interfere with quality of life) --> pharmacologic vasoconstricting agent and mechanical" vascular occlusion was used correction of IDA before surgery
🔹
leiomyomas must be individualized, based on: THERAPY
-Symptoms,
multiple myomectomy is frequently a more difficult and ② uterine artery embolization is most effective for patients with
Medical management
time-consuming procedure than hysterectomy large symptomatic myomas who are poor surgical candidates and
🔹
-Size and - GnRH analogues, progestational compounds, antiprogestins
- Rate of growth of the uterus, and - morbidity between the 2 procedures (Iverson et al) reluctant to undergo a major surgical procedure
Surgical management
-The woman's desire for fertility. 1•Hysterectomy:(Laparotomy,Laparoscopic) ① hysterectomy group: experienced ureteral, bladder, and bowel injuries ③ gynecologists determine surgical approach, endoscopic or by
② myomectomy group: no intraoperative visceral injuries laparotomy, based on size, number, extent and location of myomas
🔶
2•Myomectomy
(Vaginal,Hysteroscopic,Laparoscopic,Laparotomy) 3. Hysteroscopic Myomectomy ④ all therapeutic measures, and especially invasive techniques,
🔹
should be reserved for patients with symptomatic myomas
🔸
3•Myolysis - Resection of submucosal myomas
🔹 Uterine artery embolization - for asymptomatic women, serial follow-up for growth and
Indication: development of symptoms is generally safe
Others
-high frequency ultrasonography, laser Tx, cryotherapy, thermoablation abnormal bleeding Hx of pregnancy loss, infertility,
🔥 The major indications for aggressive management of 🔸
and pain
Contraindication :
uterine myomas are as follows:
1.Abnormal uterine bleeding Rapid growth
2.Growth after menopause Infertility
🔶
endometrial ca. lower reproductive tract infection, inability to distend the uterine cavity, extension of the tumor deep in to the myometrium
4. Laparoscopic Myomectomy
- performed when myomas are easily accessible, as in
3.Recurrent pregnancy loss Pain or pressuresymptoms superficial subserous or pedunculated myomas
4.Urinary tract symptoms or obstruction
5.Possibility of ovarian neoplasia
6.lron deficiency anemia secondary to chronic blood loss 🔸
- 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
🔶 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
🔸 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
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
-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
