Myoma

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 Introduction
• Benign clonal smooth muscle neoplasms that
typically originate from the myometrium
• Arises from smooth muscle cells with increased
amount of extracellular matrix
• Also called
Fibroids
Leiomyoma/Leiomyomata
Uterine myoma
fibromyoma, myofibroma, leiomyofibroma,
fibroleiomyoma, fibroma
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 Introduction …
• Leiomyomata are the most common tumors of
the uterus and the female pelvis
• The most common indication for hysterectomy
• It often grew to enormous size and caused great
suffering from bleeding, pain, and emaciation

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 Epidemiology
• Their incidence among women is generally cited as 20
to 25 percent, but is as high as 70 to 80 percent in
studies using histologic or sonographic examination
• Rare in women < 18 years of age
• Reported case at 1 year of age
• Responsible for one third of gynecologic admissions
• Postmenopausal incidence is not lower than
premenopausal.

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 Etiology
• Unknown
• Estrogen & progestrone may have growth
promoting role on myoma
• Different growth factors (like TGF ß,
FGF,EGF, PGF, VEGF, IGF...) may play
role in the pathogenesis

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• Factors related to tumorogenesis of
leiomyoma classified as:
 Predisposing factors
 Initiators
 Promoters
 Effectors

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 Predisposing factors

• Many of the factors effect is attributed to

their effects on estrogens & progesterone

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 I. Predisposing factors Cont’d
1. Menarche: Early menarche
2. Parity:
 Having one or more pregnancies beyond 20 weeks
decreases the chance
 women at least given birth to 2 children has 2x less
risk
3. Age: Reproductive age
4. Obesity:
 Fibroids increase by 21% for each 10 kg (USA)

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 Cont’d
5.Diet:
 High intake of vegetables = protective effect
 increased risk with high intake of beef, red meat &
ham
 Consumption of alcohol, especially beer, appears to
increase
 Caffeine consumption is not a risk factor
6. Exercise
7. Racial differences: 3-9 x common in blacks
 Myomas in blacks are larger, numerous, more
symptomatic & occur at younger age
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 Cont’d
8. Smoking: Reduces risk of fibroid
10 cigarettes/day-Decreases risk by 18%
20 Cigarettes/ day-Decreases risk by 33%
9. Oral contraceptives:
17 % reduction in risk with each 5 year use
10. Tamoxifen: weak estrogenic effect-20%

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 Relationships of Patients Factors, myoma Risk, & Steroid
Hormones

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 II. Initiators

• The most important piece of fibroid puzzle

remains unsolved
• Three theories:

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1. Increased level of estrogen and progesterone
 Lead to increased mitotic rate that end in increased
somatic mutation
2. A response to injury
 potential injury associated with release of vaso-
constrictve substances (PGs & vasopressin)
 Smooth muscle cells react by changing from
contractile type to proliferative type
3. Theory of genetic and/or epigenetic changes

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 III. Promoters
Evidence of estrogen and progesterone
1. Clinical observations: develop during reproductive years,
shrinkage with GnRH analog Rx, etc
2. Laboratory
 17 estradiol is higher in myoma
 Over expression of aromatase activity
3. Estrogen and progesterone receptors
 Were greater in myoma than myometrium

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 IV. Effectors
 The growth promoting effects of E & P upon myometrium & uterine

myoma

 The growth factors include:

 TFG : Mitogenesis & matrix formation
 Basic fibroblast growth factor: Mitogenesis & angiogenesis
 Epidermal growth factor; Increase during luteal phase
 Platelet derived growth factor
 Vascular endothelial growth factor
 Insulin like growth factor
 prolactin

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 Classification of myomas
• Basis for classification
Site/location
Presence of symptoms
Number

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 FIGO based on location
• 0=pedenculated sub mucosal
• 1=<50% intramural
• 2=>50%intramural
• 3=intramural but incontact with
endometrium
• 4=intramural
• 5=subserosal >50%intramural
• 6=subserosal<50%intramural
• 7=subserosal
• 8=other
02/10/2023
site Cx,adenexa
EYU 17
• Fibroids are often described according to their location in
the uterus and direction of growth
 Intramural fibroids
 Submucosal myomas
 Subserosal myomas
 Intraligamentary
 Cervical fibroids

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 Uterine leiomyomas in various anatomic locations

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 Types of myoma
• Intramural : Develop within the uterine wall
 the commonest type, 70%
• Subserous : if projecting from the peritoneal surface of the
uterus
• Submucus : if projecting in to the cavity
• Intraligamentary : if projecting between the layers of the
broad ligament
• Cervical myomas : Are located in the cervix, rather than
the uterine corpus
• Parasitic myoma : pedunculated subserous myoma
acquires an extrauterine blood supply from omental
vessels, its pedicles atrophy and resorb
• Delivered myoma – pedunculated submucous myoma
passing through the cervix EYU
02/10/2023 20
 Uterine leiomyomas in various anatomic
locations

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 Delivered myoma

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 Single myoma

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 Multiple myoma

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 Multiple myoma

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 Secondary/Degenerative changes

• The very poor vascularity of fibroids encourages the

degenerative changes that are common in big myomas
• Have more of histologic importance
• Can be
 Benign degenerations
Atrophic, hyaline, cystic, calcific, septic, carneous
(red) , myxomatous (fatty) degenarations
 Malignant degeneration

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 Hyaline degeneration
• The most common of all secondary
changes
• Asymptomatic
• Yellowish, soft and often gelatinous area is
seen

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 Cystic Degeneration

• Formation of multiple small cystic spaces,

giving a sponge-like appearance and soft
consistency to the tumor
• Some times mimic cystic ovarian tumor

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 Partial cystic degeneration in pedunculated myoma

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 Calcific (Calcareous)Degeneration

• Occurs when there is some circulatory

disturbance.
• This is seen most often in pedunculated myoma.
• Ca carbonate & phospate deposits over the
tumor
• Can be seen using X- Ray

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 Necrosis
• May occur in any tumor.
• This is commonly due to impairement of the
blood supply or severe infection.
Eg. Torsion of a pedunculated myoma.

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 Carneous (red) degeneration
• Commonly seen during pregnancy or near the
menopause, but can occur any time.
• Venous thrombosis and congestion with interstitial
hemorrhage are responsible for the color of the myoma
undergoing red degeneration.
• The process is usually associated with extreme pain but is
always self limited.
• Its exact mechanism is not known
• sometimes Preterm labour can occur

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 Fatty degeneration
•  Is rare and asymtomatic
• Follows hyaline and cystic degeneration

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 Septic degeneration
• Infection may follow necrosis due to
circulatory inadequecy
• Common in submucous myoma especially
postabortally or post delivery

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 Atrophic degeneration
• Signs and symptoms regress or disappear
as tumor size decreases
• Seen in menopause or after pregnancy

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 Sarcomatous degeneration
• Malignanat transformation is quite rare
• 0.1 - 0.5% of myomas

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 Clinical feature
• Variable
• Often asymptomatic
• Symptoms are present in only 35–50%
• Symptoms can generally be classified into three
distinct categories:
1) Abnormal uterine bleeding
2) Pelvic pressure and pain
3) Reproductive dysfunction
• It is extremely rare for myoma to cause
symptoms after the menopause due to atrophy
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1. Increased uterine bleeding/AUB
• The most common symptom = 1/3rd
• Menorrhagia or hypermenorrhea
 Is the typical bleeding pattern of myomas;
• Intermenstrual bleeding and postmenopausal
bleeding are NOT characteristic of myoma

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 several mechanisms of bleeding
 The surface area 15 cm2 to 200 cm2
 Irregular ulceration of endometrium overlying
submucous myoma
 Endometrial congestion
 Local hyperestrogenemia leading to endometrial
hyperplasia
 Interfere with myometrial contractility
 Interfere with contractility of the spiral arterioles
 Anovulation and DUB

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 uterine vasculature in normal and
myomatous uterus

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 AUB…

• Problems:-
Iron deficiency anemia
Social embarrassment
Lost productivity in the work force.

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 Pelvic pressure and pain
Bladder - urinary frequency, difficulty emptying
the bladder
Rectum - constipation.
Ureter - ureteric compression leading to renal
hydronephrosis is rare
Pelvic Pain
Dysmenorrhea
Dysparunia
Acute/Chronic pain = Degeneration

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 Causes of pain in myoma
a) Pressure effect
b) Myometrial contraction
c) Torsion
d) Infection
e) Decreased perfusion versus rapid growth
f) Release of prostaglandins

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Reproductive dysfunction
• Do not interfere with ovulation
• Associated with subfertility
• Features that may contribute to subfertility/infertility
Cavity distorsion
Size larger than 4 to 5 cm, which might affect
uterine contractility or impair normal endometrial
function thereby impairing implantation
Location near the tubal ostia or cervix, which
could potentially impede gamete transport

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 Adverse pregnancy outcomes of myoma
1) First trimester bleeding/miscarriage
2) Preterm labour
3) PROM
4) preeclampsia
5) Placental abruption, placenta previa
6) IUGR, IUFD
7) Breech presentation / malpresentation
8) Dysfunctional labor
9) Increased risk of cesarean delivery
10)PPH
11) Endomyometritis

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 Less common symptoms of fibroid:-
Prolapse into the vagina resulting in ulceration
or infection
Polycythemia from autonomous production of
erythropoietin
Hypercalcemia from autonomous production
of PTHrP

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 Infected delivered myoma

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Effect of Pregnancy on Myoma:-
1) Increase in size
2) Red degeneration

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    DDX

Related to the symptoms:-

 Pregnancy (normal, GTD)
 Ovarian tumor
 Cervical polyps
 Adenomyosis
 Full blader
 

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Diagnosis
• History and P/E
• Imaging
Ultrasound
saline Sonohysterography
 Hysterosalpingography
Diagnostic hysteroscopy
MRI
• Plain abdominal film

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 Managment
• Depend on:-
1) Age
2) Fertility goal
3) Symptoms
4) Availability of options
• Asymptomatic ones managed expectantly

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 Management
Management could be:
a) Expectant / follow up
b) Medical
c) surgical
d) Immunotherapy

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 Management…
• Expectant/ follow up
a) When the tumors are small
b) When the diagnosis is certain
c) When there are no symptoms
d) Near menopause
 Patient may be reassured but kept under
regular supervision

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 Medical treatment
1. GNRH analogues: shrink size
 By creating artificial menopause
 Indications
Preoperative restoration of the Hct concentration in
severely anemic women
Near menopause
 Disadvantage
Signs and symptoms of menopause
Bone loss if use > 6 months
Expensive
 E.g. . Leuprolide, goserelin
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 Medical treatment….

• Medical treatment
2. GNRH antagonists(cetrorelix and ganirelix)
3. Antiprogestins e.g. Mifepristone
4. Androgenes e.g. Danazole
5. Nonsteroidal antiinflammatory drugs
6. combination oral contraceptive pills

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 Surgical management
• Surgical
1) Myomectomy(Open/Laparscopic/Hysterescopic)
2) Hysterectomy I,definitive
3) Uterine artery embolization
4) Myolysis
5) Endometrial Ablation

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 Surgical management…
• Surgery
 Indication for operative intervention
1) When fibrois are causing symptoms
2) Rapid growth of the tumor
3) Myoma > 12 weeks sized gravid uterus
4) If the DDX is ovarian tumor
5) Highly mobile pedunculated subserous myoma
6) Infertility due to myoma

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 Surgical management…
Myomectomy
Indication is need of further fertility
Rupture of the scar during subsequent
pregnancy is the danger, especially if the
cavity was entered
There is a possibility of recurrence

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 Surgical management…

• Hysterectomy
Indication
If no need for further pregnancy,
Myomectomy is technically difficult
Definitive treatment
It eliminates current symptoms & risk of
recurrence

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 Uterine Artery Embolization
e.g.. By polyvinyl alcohol

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