Leiomyoma

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What is the natural history of leiomyomas in postmenopausal women?

At menopause, menstrual cyclicity stops and steroid hormone levels wane, and there is a cessation of the abnormal uterine bleeding symptoms associated with fibroids. Most, but not all, women have shrinkage of leiomyomas at menopause.

What is medical treatment of leiomyomas in women who do not wish to preserve fertility?

Combined estrogen-progestin contraceptives (oral contraceptive pills, vaginal ring, or transdermal patch) are the most common medical therapy utilized by individuals with HMB and fibroids, especially those who desire contraception. For patients who cannot use or do not want estrogen-containing contraceptives, the levonorgestrel (LNG)-releasing IUDs are the main progestin-only contraceptive for fibroid-related HMB.

What is the effect of fibroids on fertility?

Fibroids themselves can contribute to a number of reproductive impairments, including infertility and recurrent pregnancy loss, although the available data often come from observational studies and, in some instances, they conflict. One of the key confounders is that increasing age is associated with increased risk of infertility, fibroids, and miscarriage. Generally, the literature has concluded that fibroids that distort the cavity (International Federation of Gynecology and Obstetrics [FIGO] types 0 to 3) have more of an impact on fertility, and surgical treatment can be effective in reversing that impairment.

What is first-line treatment of leiomyomas in women who do not wish to preserve fertility?

First-tier treatment of HMB includes hysteroscopic fibroid resection, if the fibroids are in an appropriate anatomic location, or medical treatment aimed at reducing HMB for those with fibroids in locations not amenable to hysteroscopic resection.

What is the definitive treatment for leiomyomas in women who wish to preserve fertility?

For individuals desiring fertility who present with heavy menstrual bleeding (HMB) and a submucosal fibroid or fibroids (FIGO type 0, type 1, or some type 2), we recommend hysteroscopic myomectomy both for its minimally invasive relief of symptoms and optimization of fertility. For individuals who desire pregnancy and present with bulk symptoms (with or without bleeding) or whose fibroids are not amenable to hysteroscopic resection, we suggest abdominal myomectomy via either laparoscopy (with or without robotic assistance) or an open incision.

What is the heavy or prolonged bleeding of leiomyomas?

Heavy and/or prolonged menses is the typical bleeding pattern with leiomyomas and the most common fibroid symptom. The presence and degree of uterine bleeding are determined, in large part, by the location of the fibroid; size is of secondary importance: ●Submucosal myomas that protrude into the uterine cavity (eg, types 0 and 1) are most frequently related to significant heavy menstrual bleeding. ●Intramural myomas are also commonly associated with heavy or prolonged menstrual bleeding, but subserosal fibroids are not considered a major risk for heavy menstrual bleeding. ●Cervical fibroids that are close to the endocervical canal may be related to AUB.

What is the definitive treatment for treatment of leiomyomas in women who do not wish to preserve fertility?

Hysterectomy, or complete removal of the fibroid uterus, provides definitive therapy and, thus, has been the mainstay of surgical treatment for a century.

How should symptomatic women desiring definitive treatment be managed?

Hysterectomy. Fibroids are the most common cause for hysterectomy.

How should symptomatic women who desire fertility be managed?

Non-surgical treatment or myomectomy. Leuprolide is the most effective medical treatment but usually used if near menopause or to shrink fibroids prior to hysterectomy or myomectomy. Levonorgestrel-releasing IUD. NSAIDs for dysmenorrhea.

How should symptomatic women who do not desire fertility be managed?

Non-surgical treatment, myomectomy, myolysis or uterine artery embolization.

How should asymptomatic women be managed?

Observation. Majority don't need treatment. Decision to treat is determined by symptoms, size/rate of tumor growth and desire for fertility.

What are protective factors against leiomyoma?

Parity — Parity (having one or more pregnancies extending beyond 20 weeks of gestation) decreases the chance of fibroid formation.

What are pelvic ultrasound findings consistent with leiomyomas?

Pelvic ultrasound is the first-line study used to evaluate for uterine fibroids. Transvaginal ultrasound has high sensitivity (95 to 100 percent) for detecting myomas in uteri less than 10 gestational weeks' size. Fibroids are seen on ultrasound usually as hypoechoic, well-circumscribed round masses, frequently with shadowing; cellular fibroids may appear to be more isoechoic, making differentiation from the normal myometrium difficult, or hyperechoic.

What are risk factors for leiomyomas?

Race — The incidence rates of fibroids are typically found to be two- to threefold greater in black women than in white women. The natural history of leiomyomas also differs by race. Most white women with symptomatic fibroids are in their 30s or 40s; however, black women develop symptoms on average four to six years younger and may even present with disease in their 20s. Early menarche — Early menarche (<10 years old) is associated with an increased risk of developing fibroids. Other endocrine factors — Prenatal exposure to diethylstilbestrol is associated with an increased risk of fibroids, supporting the role of early hormonal exposure in pathogenesis. Obesity — Most studies show a relationship between fibroids and increasing body mass index (BMI). Alcohol - Consumption of alcohol, especially beer, appears to be associated with an increased risk of developing fibroids. Genetics — Studies imply a familial predisposition to leiomyomas in some women. There is also evidence of specific susceptibility genes for fibroids. Other factors — Hypertension is associated with an increased leiomyoma risk. The risk is related to increased duration or severity of hypertension.

What study can be used to evaluate the potential fertility risks presented by leiomyomas?

Saline infusion sonography (sonohysterography) is an imaging study in which pelvic ultrasound is performed while saline is infused into the uterine cavity. Use of this technique allows identification of submucosal lesions (some of which may not be seen on routine ultrasonography) and intramural myomas that protrude into the cavity and characterizes the extent of protrusion into the endometrial cavity. Saline infusion sonography is helpful when planning a hysteroscopic resection of a fibroid or evaluating the potential risks of fertility associated with a fibroid.

How are symptoms of leiomyomas classified?

Symptoms are classified into three categories: ●Heavy or prolonged menstrual bleeding ●Bulk-related symptoms, such as pelvic pressure and pain ●Reproductive dysfunction (ie, infertility or obstetric complications) Among symptomatic women with uterine fibroids, abnormal uterine bleeding (AUB) and menstrual cramps are the most common symptoms occurring in approximately 26 to 29 percent of all women.

How are leiomyomas diagnosed?

The clinical diagnosis of uterine leiomyomas is made based upon a pelvic examination and pelvic ultrasound findings consistent with a uterine leiomyoma. Characteristic symptoms further support the clinical diagnosis, although many women are asymptomatic. Transvaginal ultrasound: most widely used initial imaging test for suspected fibroids.

What differential diagnoses should be considered when evaluating a patient for leiomyomas?

The differential diagnosis of an enlarged uterus includes both benign and malignant conditions: ●Pregnancy ●Myometrial lesions: •Benign leiomyoma •Adenomyosis (diffuse infiltration of the myometrium) or adenomyoma •Leiomyoma variant •Leiomyosarcoma •Metastatic disease - This is very rarely the cause of an enlarged uterus and typically from another reproductive tract primary; these lesions are likely to be myometrial but may invade the endometrium ●Endometrial lesions: •Endometrial polyp - These tend to be small and are unlikely to cause an enlarged uterus •Endometrial carcinoma (may invade into the myometrium) or hyperplasia •Carcinosarcoma - Considered an epithelial neoplasm •Endometrial stromal sarcoma (mimics endometrium but invades the myometrium) ●Hematometra (blood within the uterine cavity, usually following an intrauterine procedure [eg, dilation and curettage])

How do leiomyomas present clinically?

The majority of myomas are small and asymptomatic, but many women with fibroids have significant problems that interfere with some aspect of their lives and warrant therapy. These symptoms are related to the number, size, and location of the tumors.

What are bulk-related symptoms of leiomyomas?

The myomatous uterus is enlarged and irregularly shaped and can cause specific symptoms due to pressure from myomas at particular locations. These symptoms and findings include pelvic pain or pressure, urinary tract or bowel obstruction, or venous compression. Pelvic pressure or pain — In general, pelvic discomfort is common in women with fibroids but less common than AUB. Urinary tract or bowel issues — A heterogeneous group of urinary symptoms including frequency, difficulty emptying the bladder, or, rarely, complete urinary obstruction may all occur in up to 60 percent of women with fibroids. Fibroids that place pressure on the rectum can result in constipation. Venous compression — Very large uteri may compress the vena cava and lead to an increase in thromboembolic risk.

What are pelvic examination findings consistent with leiomyomas?

The pelvic examination findings are typically of an enlarged, mobile uterus with an irregular contour on bimanual pelvic examination; however, small submucosal or intramural fibroids will not produce a noticeably enlarged uterus or an irregular contour. The most common symptoms are heavy or prolonged menstrual bleeding, and fibroids may be associated with pelvic pain, infertility, or other symptoms. The size is described in terms of the fundal height in the superior-inferior axis in comparison to a gravid uterus: Twelve weeks is palpable just above the pubic symphysis, 16 weeks is midway between the symphysis and umbilicus, and 20 weeks is at the umbilicus.

How are leiomyomas classified?

Uterine fibroids are described according to their location in the uterus although many fibroids have more than one location designation. The International Federation of Gynecology and Obstetrics (FIGO) classification system for fibroid location is as follows. Intramural myomas (FIGO type 3, 4, 5) - These leiomyomas are located within the uterine wall. Submucosal myomas (FIGO type 0, 1, 2) - These leiomyomas derive from myometrial cells just below the endometrium (lining of the uterine cavity). These neoplasms protrude into the uterine cavity. Subserosal myomas (FIGO type 6, 7) - These leiomyomas originate from the myometrium at the serosal surface of the uterus. Cervical myomas (FIGO type 8) - These leiomyomas are located in the cervix rather than the uterine corpus.

What are leiomyomas?

Uterine leiomyomas (also referred to as fibroids or myomas) are the most common pelvic tumor in women. They are noncancerous monoclonal tumors arising from the smooth muscle cells and fibroblasts of the myometrium. Growth is estrogen dependent - may increase in size with relation to the menstrual cycle, anovulatory states and during pregnancy (may regress after menopause).

What is the prevalence of leiomyomas?

Uterine leiomyomas are the most common pelvic tumor in women. Incidence is difficult to determine since there are few longitudinal studies. In addition, the actual prevalence in the female population is unknown since studies have been conducted mainly in symptomatic women or following hysterectomy. The prevalence of leiomyomas increases with age during the reproductive years (especially >35 years of age). 5 times more common in African-Americans. Nulliparity, obesity, family history and hypertension.

What is the natural history of leiomyomas in premenopausal women?

With modern pelvic imaging, we have achieved an increased appreciation of the variability of growth and shrinkage of leiomyomas during the reproductive years. Prospective studies have found that between 7 to 40 percent of fibroids regress over six months to three years. There is also an increased appreciation of postpartum regression of fibroids.


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