MYOMA of UTERUS By Zhengyu Li M.D GYN/OB Department West China Second Univ. Hospital, S.U. zhengyuli@scu.edu.cn
General Consideration Benign neoplasms composed primarily of smooth muscle. Most common solid pelvic tumors, being present in 20-25% women. Ranging in sizes and locations.
Gross appearance Pathology Usually multiple, discrete, and spherical. False capsular covering making clear demarcation and easy removal from the surrounding myometrium. Buff-colored, rounded, smooth, and firm.
Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal myomas of the uterus. Secondary changes
Microscopic Appearance Smooth-muscle cells are markedly elongated and have eosinophilic cytoplasm and elongated, cigarshaped nuclei. Smooth-muscle cells are closely packed than those of the surrounding myometrium, arranged in interlacing bundles. Cytological atypia, necrosis or hemorrhage may be seen.
The nonstriated muscle fibers are arranged in bundles of various sizes that run in multiple directions.
Classification Uterine myomas originate in the myometrium and are classified by anatomic location. Myomas on the cervix of uterus(10%) Myomas on the body of uterus(90%) Submucous (15-20%)- protrude into the uterine cavity Intramural (60-70%) - within the myometrial wall Subserous (20%) - growing toward the serous surface of the uterus! Few myomas are actually of a single pure type. hybrids image
Secondary changes Hyaline generation Mature myoma contains yellow, soft, gelatinous areas of hyaline changes, usually asymptomatic. Cystic generation Liquefaction follows extreme hyalinization, and physical stress may cause fluid contents into the uterus. Result from the diminished vascularity of the connectivetissue element
Red generation Venous thrombosis and congestion with interstitial hemorrhage are responsible for it, most common in pregnancy, accompanied by selflimited pain The cut surface resembles raw meat. Clinical features: acute pain fever rapid growth,tender
Malignant transformation Developed with a 0.1-0.5% frequency Clinical features: More common at 40~ 50 years old Usually occur in intramural fiboids Grow quickly Vaginal bleeding
Clinical findings Menorrhagia and prolonged menstrual period : common Pelvic pain: occurs in pregnancy if undergoing degeneration or torsion of a pedunculated myoma Pelvic pressure: urinary frequency bowel difficulty(constipation) Spontaneous abortion Infertility
Signs A palpable abdominal tumor Pelvic examination: uterus enlarged, irregular and hard
Diagnosis History Bimanual examination Ultrasonography (B ultrasound examination) Hysteroscopy Laparoscopy Hysterography
Differential Diagnosis Pregnancy (menolipsis) Ovarian tumor Adenomyosis (dysmenorrhea) Malignant tumors of uterus sarcoma of uterus endometrial carcinoma cervical cancer
Treatment Observation and Follow Up Small,asymptomatic fibroids need not be treated,especially near menopause. Interval:3~6 months
Medical Treatment Androgenic agents:testosterone propionate GnRH-a: Induce a hypoestrogenic pseudomenopausal state Not recommended for longer than 6 months
Surgery Treatment Indications: greater than 10 weeks gestational size menorrhagia,lead to anemia have pressure symptoms grows rapidly failure of medical treatment
Method: Myomectomy conservative therapy preserve fertility significant risk of recurrence Hysterectomy radical therapy Subtotal hysterectomy
Approach: Trans-abdominal
Trans-vaginal
Laparoscopic or hysteroscopic
Uterine Myomas Complicating Pregnancy Impact on pregnancy:abortion Impact on delivery:premature labour fetal malpresentation retained placenta placenta previa need for operative delivery (birth canal obstruction) postpartum hemorrhage Conservative treatment
Critical Points May be related to superabundant estrogen. Well-circumscribed,nonencapsulated. Have a pseudocapsule. Can be classified into submucosal intramural and subserosal types. Different types have different features. Menorrhagia is common. Four degeneration types Individualized treatment,include observation medical treatment and surgical treatment.
ENDOMETRIOSIS
General condition 1. Endometriosis is benign but troublesome gynecological condition. 2. It is characterised by presence of functioning endometrial tissue outside the normal locatioin in uterine cavity. 3. These outside tissue respond to stimulation by ovarian hormones in a similar manner to endometrium. 4. Endometrosis dose not occur before puberty, and tend to regress after the menopause.
Frequency: 1. Endometriosis occurs in 10%- 15% of women in the general population, has a prevalence rate of 20-50% in infertile women and as high as 80% in women with chronic pelvic pain. 2. A familial association exists, with a 10-fold increased incidence in women with an affected first-degree relative. 3. Monozygotic twins are markedly concordant for endometriosis
The commonest sites of these deposits are 1. ovary. 2. peritoneum of culde-sac of the pouch of Douglas 3.Sigmoid colon 4.Broad ligment 5.Uterosacral ligaments Less common are 1. Cervix. 2. Round ligament. 3. Bladder. 4. Laparotomy scars rarely in the bladder, pericardium, and pleura
Pathologic characteristics Red lesion, clear vesicle, white spots powder burns 主要包括红色病变 ( 早 期病变 ) 蓝色病变 ( 典型病变 ) 及白色病变 ( 陈旧病变 )
This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriomas, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black color.
腹膜型内异症
Clinical findings History. 1. The most common symptoms associated with pelvic endometriosis are dysmenorrhea (66%), deep dyspareunia (33%), infertility (60%), and low back pain or chronic pelvic pain that worsens with menses, may have premenstrual spotting and menorrhagia. Dysmenorrhea often precedes menses and lasts throughout the period.
Physical examination Fifty percent of women have a normal clinical examination. Findings will be accentuated in early menses and may include 1. a fixed, tender, retroverted uterus; 2. tender nodules along the uterosacral ligaments (with obliteration of the cul-de-sac); 3. nodules on the back of the uterus and cervix;
4. unilateral or bilateral fixed asymmetric adnexal masses. Rectovaginal exam is important to assess the posterior uterus and culde-sac. Up to 10% of teens with endometriosis have congenital outflow tract obstruction.
Diagnostic aids: 1. Laparoscopy should be done to confirm the diagnosis since the clinical diagnosis may be wrong 30% to 40% of the time.
2. Ultrasound may be helpful with a large pelvic mass, but cannot visualize small implants or differentiate types of cystic lesions.
Treatment of endometriosis This may be medical,surgical or a combination of the tow. Treatment is only necessary if symptoms are present The choice of treatment depends on the age and parity of the patient, her desire for fertility and the extent of disease present.
Medical treatment 1. Medical treatment of endometriosis cannot restore fertility, but may help with pain or dyspareunia. Pain recurs after treatment in 53%. 2. The aim is to induce a hypoestrogenic state or a pseudopregnancy state, both of which suppress endometriotic lesions.
Drugs used to treat endometriosis are: continuous combined oral contraceptive pill Progestogens Danazol Gestrinone Gonadotrophin-releasing hormone analogues
GnRH agonists such as leuprolide acetate (IM), goserelin (SQ implant) or nafarelin (nasal spray) induce an artificial menopausal state. Side effects are similar to menopause, including decreased bone mineral density. Response rate is 90%.
Surgical treatment 1. Conservative surgery Indicated in those patients with symptomatic disease who wish to preserve their fertility. It can be carried out by laparotomy or laparoscopy
Radical surgery. Hysterectomy and bilateral oophorectomy with excision or destruction of all visible endometriotic deposits. In case where chronic pelvic pain persists and childbearing is complete.
Adenomyosis Adnomyosis, also called endometriosis interna, is the presence of endometrial glands and stroma within the myometrium; it is generally thought to be nurelated to endometriosis.
Treatment 1. Surgical treatment 2. Hormonal thearpy : medical treatment with hormones has not been successful in treatment of adenomyosis.