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Uterine leiomyoma

Last updated: June 9, 2021

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Uterine leiomyomas (fibroids) are benign, hormone-sensitive uterine neoplasms. These tumors are classified as either submucosal (beneath the endometrium), intramural (within the muscular uterine wall of the uterus), or subserosal (beneath the peritoneum). Symptoms depend on the location, size, and number of myomas, and include menstrual abnormalities (menorrhagia), features of mass effects (e.g., back/abdominal/pelvic pain or bladder and bowel dysfunction), and infertility. Physical examination and sonohysterography are used to establish the diagnosis. Treatment for symptomatic patients includes surgery (myomectomy or hysterectomy) as well as interventional (uterine artery embolization) and/or medical therapy (GnRH agonists).

Predisposing factors

References:[1][2][3]

Leiomyomas are classified according to their location within the uterus:

  • Subserosal leiomyoma: localized in the outer uterine wall beneath the peritoneal surface
  • Intramural leiomyoma (most common): growing from within the myometrium wall
  • Submucosal leiomyoma: localized directly below the endometrial layer (uterine mucosa)
  • Diffuse uterine leiomyomatosis: The uterus is grossly enlarged due to the presence of numerous fibroids.

References:[1]

Most women have small, asymptomatic fibroids. Symptoms depend on the number, size, and location of leiomyomas.

  1. Abnormal menstruation
  2. Features of mass effect
  3. Reproductive abnormalities

References:[1]

References:[1][4]

  • Macroscopic
    • Grayish-white surface
    • Homogeneous; tissue bundles on cross-section partly in a whorled pattern
    • Some leiomyomas may involve regressive changes: scar formation, calcification, and cysts
  • Microscopic: Smooth muscle tissue in a whorled pattern with well-demarcated borders, consisting of monoclonal cells interspersed with connective tissue

References:[5]

Differential diagnosis of uterine leiomyoma
Factors Uterine leiomyoma (fibroids) Adenomyosis Endometriosis Uterine polyps Uterine leiomyosarcoma [6][7]
Definition
  • Overgrowth of localized endometrial tissue attached to the inner wall of the uterus, usually benign [8]
Risk factors
Clinical features
  • Symptoms similar to uterine fibroids
  • Menstrual irregularities
  • Postmenopausal bleeding
  • Pelvic pain
Uterine findings
  • Irregularly enlarged, firm
  • Uniformly enlarged
  • Typically not enlarged
  • Typically not enlarged
  • Rapidly enlarging
Pathology

The differential diagnoses listed here are not exhaustive.

Treatment should only be considered in symptomatic patients because of the side effects of medical therapy and surgery. The goal is to relieve symptoms. Perimenopausal women warrant expectant management in most cases.

Asymptomatic fibroids

  • Do not require treatment
  • Frequent follow-ups (approx. every 6–12 months) with pelvic ultrasonography; and symptom monitoring
  • Patients should be counseled to contact their physician if new symptoms develop.

Symptomatic fibroids

Medical therapy

Preoperative medical therapy may help reduce tumor size and decrease tumor vascularization.

Interventional therapy

  • Uterine fibroid embolization: uterine artery embolization
    • Procedure: injection of polyvinyl alcohol (PVA) into the arteries that supply blood to the fibroid, causing it to shrink; ¼ of patients may require further invasive treatment
    • Indications:
      • Continued heavy bleeding and/or severe pain with insufficient response to medical treatment
      • Contraindications to surgery or personal preference to avoid surgery
      • No wish to conceive in the future

Surgical therapy

  • Indications: rapidly growing fibroid, recurrent refractory bleeding: secondary to medical therapy, severe symptoms
  • Procedures

References:[10]

References:[1]

We list the most important complications. The selection is not exhaustive.

Uterine leiomyomas during pregnancy

References:[11]

  1. Stewart EA, Laughlin-Tommaso SK. Uterine leiomyomas (fibroids): Epidemiology, clinical features, diagnosis, and natural history. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/uterine-leiomyomas-fibroids-epidemiology-clinical-features-diagnosis-and-natural-history.Last updated: December 21, 2016. Accessed: February 17, 2017.
  2. Malik M, Norian J, McCarthy-Keith D, Britten J, Catherino WH. Why leiomyomas are called fibroids: the central role of extracellular matrix in symptomatic women.. Semin Reprod Med. 2010; 28 (3): p.169-179. doi: 10.1055/s-0030-1251475 . | Open in Read by QxMD
  3. Ciavattini A, Di Giuseppe J, Stortoni P, et al. Uterine fibroids: Pathogenesis and interactions with endometrium and endomyometrial junction. Obstet Gynecol Int. 2013; 2013 : p.1-11. doi: 10.1155/2013/173184 . | Open in Read by QxMD
  4. Uterine leiomyoma. https://radiopaedia.org/articles/uterine-leiomyoma. Updated: February 17, 2017. Accessed: February 17, 2017.
  5. Uterus Stromal tumors Leiomyoma. http://www.pathologyoutlines.com/topic/uterusleiomyoma.html. Updated: February 9, 2017. Accessed: March 14, 2017.
  6. Memarzadeh S, Berek JS. Uterine sarcoma: Classification, epidemiology, clinical manifestations, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-sarcoma-classification-epidemiology-clinical-manifestations-and-diagnosis.Last updated: November 1, 2019. Accessed: June 22, 2020.
  7. Roberts ME, Aynardi JT, Chu CS. Uterine leiomyosarcoma: A review of the literature and update on management options. Gynecol Oncol. 2018; 151 (3): p.562-572. doi: 10.1016/j.ygyno.2018.09.010 . | Open in Read by QxMD
  8. Wethington SL, Herzog TJ, Burke WM, et al. Risk and Predictors of Malignancy in Women with Endometrial Polyps. Ann Surg Oncol. 2011; 18 (13): p.3819-3823. doi: 10.1245/s10434-011-1815-z . | Open in Read by QxMD
  9. Stewart E. Uterine adenomyosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-adenomyosis?source=search_result&search=adenomyosis&selectedTitle=1~51#H6.Last updated: February 9, 2017. Accessed: February 17, 2017.
  10. Stewart EA. Overview of treatment of uterine leiomyomas (fibroids). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-treatment-of-uterine-leiomyomas-fibroids.Last updated: May 27, 2016. Accessed: February 17, 2017.
  11. Ouyang DW, Norwitz ER. Pregnancy in Women with Uterine Leiomyomas (Fibroids). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pregnancy-in-women-with-uterine-leiomyomas-fibroids.Last updated: December 19, 2017. Accessed: February 21, 2018.
  12. Stewart EA. Histology and pathogenesis of uterine leiomyomas (fibroids). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/histology-and-pathogenesis-of-uterine-leiomyomas-fibroids?source=search_result&search=uterine+leiomyoma&selectedTitle=9~150.Last updated: June 5, 2014. Accessed: March 14, 2017.
  13. Bharambe BM, Deshpande KA, Surase SG, Ajmera AP. Malignant transformation of leiomyoma of uterus to leiomyosarcoma with metastasis to ovary. J Obstet Gynaecol India. 2012; 64 (1): p.68-69. doi: 10.1007/s13224-012-0202-4 . | Open in Read by QxMD