Myoma Uteri/Fibroids/ Leiomyomata a benign (not recurring or progressive) tumor grows in the muscles of the uterus tumors can

an grow very large, sometimes growing as large as a melon typical Myoma, however, is around the size of an egg when the Myoma penetrates the entire wall of the uterus, it is referred to as uterus myomatosus. In certain very rare cases (less than 1/2 of 1% of the time) the tumors can become malignant. When this happens, it is known as sarcoma When the Myoma pushes on the intestines or the bladder, it can result in constipation, pain of the bladder, or a constant need to urinate. If the tumor pushes on the nerves in the spinal cord, it can result in pain of the back or the legs. The causes of uterine Myoma are not fully understood. Some research suggests that Uterine Myoma is less common in women who have had at least two children. For at least one form of uterine Myoma, there seems to be a genetic predisposition. Uterine Myoma often goes undetected. Ultrasounds, CT Scans, or MRIs may be necessary to fully diagnose uterine Myoma. If you have symptoms of Uterine Myoma, your health care provider will help you determine the best way to diagnose the problem. Once it is diagnosed, Uterine Myoma can be treated through hormonal and/or herbal treatments. Hormonal treatment typically do not cure the Uterine Myoma. Rather, they give a temporary relief of the symptoms of Uterine Myoma. In addition, these hormones may have certain side effects. If these hormone treatments do not work, surgery is typically an option. Surgical options include the surgical removal of the Myoma tumors (known as an enucleation) or a complete hysterectomy. Recent advances in laser surgery may make this an option also. If this is the case, the surgery can become much less invasive, and can be done laparoscopically.

Symptoms of Uterine Myoma may include: hyper menorrhea lower abdominal pain dysmenorrhea irregular vaginal bleeding dizziness anemia Epidemiology o o o o o o o o The most common non-cancerous tumours in women The most common indication for hysterectomy Apparent in up to 25% of women More common in a higher body mass index women 3 times more common in black American women than white women Asian women have a lower incidence Symptoms appear at age of 30s or 40s The incidence increases with age up to the menopause Pathophysiology o Leiomyomas grossly appear as round, well circumscribed (but not encapsulated), solid nodules that are white or tan, and show whorled appearance on histological section. The size varies, from microscopic to lesions of considerable size. Typically lesions the size of a grapefruit or bigger are felt by the patient herself through the abdominal wall.

Microscopically, tumor cells resemble normal cells (elongated, spindle-shaped, with a cigar-shaped nucleus) and form bundles with different directions (whorled). These cells are uniform in size and shape, with scarce mitoses. There are three benign variants: bizarre (atypical); cellular; and mitotically active. Classification o According to position o 70% Intramural (in uterine wall) o 20% Subserosal (beneath serosa) o 10% Submucosal (beneath endometrium) pedunculated submucosal or pedunculated vaginal Symptoms o Half of women with fibroids have no symptoms o symptoms depends on their size, position and condition Hypermenorrhea (submucosal are more likely) Persistent intermenstrual bleeding (cause by pedunculated submucosal fibroid) Dyspareunia (cause by torsion of a pedunculated fibroid) abdominal cramps, discomfort, and heaviness( cause by large uterus) Constipation and urinary frequency (cause by pressure) Recurrent miscarriage or infertility Clinical Findings Palpable abdominal mass PV examination irregularly enlarged and asymmetrical tender and large sizes u nlike the soft uterus containing a pregnancy o Signs of anaemia due to menorrhagia o o Differential diagnosis o Chronic pelvic inflammatory disease o Tubo-ovarian abscess o Ovarian tumour o Uterine sarcoma o Endometrial polyps, endometrial carcinoma o Endometriosis o Dysfunctional uterine bleeding o Other causes of a pelvic mass include tumour of large bowel, appendix abscess, diverticular abscess o Pregnancy Investigation o Pregnancy test may be indicated o Full blood count o Pelvic ultrasound: o Transvaginal ultrasound is more accurate o MRI: occasionally required if ultrasound not definitive in assessing depth o Endometrial sampling for histology in the assessment of abnormal uterine bleeding o Hysteroscopy with biopsies Treatment o Medical o Surgical

Medicine o NSAID to reduce menstrual blood loss and dysmenorrhea o Antifibrinolytic agents , e.g. tranexamic acid to reduce menorrhagia o Combined oral contraceptive if women also requires effective contraception o Danazol reduces menorrhagia by suppressing gonadotropin secretion and abolishing cyclical ovarian function o GnRH agonists: R educ e size of fibroid 50% within 3 months but once discontinued, fibroids regrow to their former size within about 2 months; therefore mainly useful preoperatively Beware of side effects including amenorrhoea, menopausal symptoms and osteoporosis in long term use Surgery o Indication excessively enlarged uterine size ( > 12 wks gestation ) pressure symptoms ( urinary frequency or retentio n etc.) abnormal uterine bleeding causing anemia severe pelvic pain secondary to amenorrhea growth after menopause infertility rapid increase in size (r/o leiomyosarcoma) o Oophorectomy if ovaries are damaged or age > 45 Surgical option o Myomectomy for patients who want to preserve their fertility Laparoscopic myomectomy for subserous fibroids Hysteroscopic myomectomy for submucosal fibroids Vaginal myomectomy for Pedunculated vaginal recur in 50% of patients o Hysteroscopic endometrial ablation for menorrhagia Total hysterectomy technique o Abdominal hysterectomy o Vaginal hysterectomy most often used in cases of uterine prolapsed o L aparoscope-assisted vaginal hysterectomy Vaginal hysterectomy performed with laparoscope , th e uterus is removed in sections through the laparoscope tube or through the vagina Abdominal hysterectomy Vaginal hysterectomy 1. cervix prolapsing through vaginal introitus grasped by tenaculi 2. cervix being bivalved with scalpel 3. uterine corpus being bivalved after separation of cervix has been completed 4. uterus halved after bivalving procedure to facilitate its removal 5. after half of uterus is removed. cervix is grasped with uterine corpus below 6. bladder is drained with foley catheter revealing non-bloody urine LAVH (laparoscopically assisted vaginal hysterectomy) Surgical procedure using a laparoscope to remove the uterus and/or f allopian tubes and ovaries through the vagina o Not all hysterectomies can or should be done by LAVH o