Uterine Leiomyoma

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APGO educational topic number 53
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uterine leiomyoma uterine liya my Omata
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or fibroids are proliferations of smooth
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muscle cells they are very common and by
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the fifth decade of a woman’s life they
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may be present in 1 out of 4 white women
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and one out of two african-american
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women fibroids are the most common
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indication for hysterectomy accounting
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for approximately 30% for this operation
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the objectives of this video are to cite
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the prevalence of uterine lion myoma to
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identify symptoms and physical findings
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in patients with uterine leiomyoma
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describe the diagnostic methods to
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confirm uterine leiomyoma and finally
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describe the management options for the
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treatment of uterine leiomyoma we
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classify fibroids into three groups
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based on their anatomic location here is
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the uterus cervix and endometrium the
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first type of fibroid is an intramural
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fibroid which is entirely within the
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wall of the uterus the second type of
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fibroid is a sub serosa fibroid which is
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located beneath the serosa layer of the
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uterus the third type of fibroid is a
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sub mucosal fibroid which is located
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just beneath the endometrium this is a
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photograph of a uterus with multiple
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intramural fibroids this next photograph
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also shows a uterus with multiple
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fibroids and the arrow points to a large
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sub serosa fibroid this last photograph
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is a history scopic view of the
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endometrial cavity and shows three sub
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mucosal fibroids they are considered
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benign hormonal irresponsive tumors and
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estrogen stimulates growth and the high
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estrogen state of pregnancy fibroids can
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induce rapid growth when a woman goes
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through menopause and is in a low
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estrogen state there will be cessation
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of growth and even some atrophy the
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important message to remember is that
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for most women fibroids are asymptomatic
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and cause no or minimal problems when
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fibroids cause symptoms the symptoms are
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usually related to bleeding the type of
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bleeding can vary but the classic
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presentation of abnormal bleeding
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related to fibroids is heavy periods the
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simplest way of thinking about why
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fibroids cause heavy periods is to
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envision the fibroids distorting the
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endometrial cavity a sub mucosal fibroid
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will obviously
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the most likely type of fibroid to
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distort the endometrial cavity
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intramural fibroids can distort the
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endometrial cavity if they are of
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significant size or quantity some serosa
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fibroids are the least likely type of
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fibroid to cause bleeding problems again
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unless they are big enough or if there
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are enough of them
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the second classic symptom of fibroids
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is pelvic pressure or the sensation of a
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pelvic mass fibroids can attain a
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massive size and here’s a photograph of
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a large sub serosa fibroid growing on
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the posterior wall of the uterus
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this second photograph illustrates
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another example of a uterus that has
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multiple fibroids of significant size
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and we refer to this as a large my
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amitis uterus the third classic symptom
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of fibroids is dysmenorrhea or painful
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menses let’s now move to physical
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examination
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you may remember dr. pom Cohen from the
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Affco abnormal uterine bleeding video
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remember that the L of the pom Cohen
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abnormal uterine bleeding classification
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system stands for leiomyoma physical
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examination findings depend on the size
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and number of the fibroids if the uterus
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is large then it can be palpated
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abdominally and since we are
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obstetrician gynecologists we often
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describe the size of the uterus in terms
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of week size compared to the pregnant
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uterus you have a twenty week sized
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uterus or we will describe the number of
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finger breasts beneath the unbel a cos
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you’ll either respond Papes to two
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finger breasts below the umbilicus
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smaller fibroids or fibers that are
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submucosal or intramural may not be
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palpable on physical examination the
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diagnosis is made through physical
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examination and imaging studies pelvic
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ultrasound can have quantify the number
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and size of the fibroids here is an
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ultrasound with a sagittal view of the
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uterus the hyper akoha Karia is the
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endometrial cavity and the arrow points
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to a small intramural fibroid a Sano
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histogram can better visualize the
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endometrial cavity saline is instilled
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through the cervix into the endometrial
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cavity and this image shows a normal non
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distorted cavity a sauna history cam can
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help to characterize the percent of a
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fibroid that is in the endometrial
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cavity in order to determine whether
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history or scopic
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are a can be useful to better visualize
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the exact size and location of the
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fibroids let’s now move to manage
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options and remember that most women do
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not require any treatment especially if
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the fiber it is small and found
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incidentally on imaging study when
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bleeding is the main symptom that the
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patient is experiencing the medical
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therapy can be used to try to minimize
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the abnormal bleeding
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this can be estrogen and progesterone
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usually with oral contraception since
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fibroids often become symptomatic and
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women in their fifth decade of life
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remember that oral contraception should
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not be given to women over age 35 with
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hypertension who’s smoked or who have
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migraines progestins are another option
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to help temper eyes bleeding
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prostaglandin synthesis inhibitors such
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as ibuprofen can decrease the amount of
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dysmenorrhea and the amount of menstrual
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flow and finally GnRH agonist suppress
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the hpo axis and thus produce a false
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menopause and this can lead to a
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reduction at fibroid size this can be
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used as a temporary measure in women to
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boost their red blood cell counts prior
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to definitive surgery or short-term and
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women who are close to getting to
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menopause it is a short-term solution
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since it does cause a false menopause
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and thus will have the detrimental
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effect of the hypo estrogen state on
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bone and cardiovascular health uterine
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artery embolization is a procedure
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performed by interventional radiologists
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a catheter is inserted into the femoral
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artery to the uterine arteries which are
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then embolized
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with tiny microspheres this results in a
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fibroid avascular is a ssin and
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involution there is short and long-term
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data that supports that uterine artery
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embolisation is a safe and effective
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management option for fibroids for
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appropriately selected women who wish to
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retain their uteri let’s now move to
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surgical options myomectomy is another
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option for women who desire to preserve
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their uteri
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the myomectomy can be performed either
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abdominally either via laparoscopy or
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laparotomy approach hysteroscopic
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myomectomy can be performed if there is
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a distinct submucosal fibroid the
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following video will demonstrate a
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history or scopic myomectomy you can see
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the small submucosa library that is
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being removed with a history scopic
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instrument at the completion of the
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procedure the endometrial cavity has
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been restored to normal anatomy
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and finally hysterectomy is definitive
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therapy for fibroids indications should
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be specific and well-documented it can
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be performed vaginally or abdominally
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depending on the size and location of
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the fibroids this concludes the aapko
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video on uterine Leah my OMA we have
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discussed the prevalence symptoms
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physical exam findings and diagnostic
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methods and management options for this
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common finding in women
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[Music]