Uterinemyomas.ppt

Uterine Myoma(leiomyoma,fibroid myoma)Gynecological department of the first affiliatied hospital of Guangxi Medical UniversityGeneral ConsiderationsUterine leiomyomas are benign,composed primarily of smooth muscle.Leiomyomas are present in 20-25%of reproductive-age womenetiology The etiology of this tumor is unknown.steroid hormones,particularly estrogen and progesterone and their receptors in the myometrium maybe the causes of myoma.Myomas are uncommon prior to menarche,regress after menopause,and increase in size during the reproductive years,apparently in response to the estrogenic stimuli.ClassificationvClassified by anatomic location interstitial myoma subserous myoma submucous myoma (Figure)classificationInterstitial myoma:lie within the uterine wallSubserous myoma:lie at the serosal surface of the uterine or may bulge outward from the myometrium(parasitic tumor)Submucous myoma:lie beneath the endometrium and tend to compress it as they grow toward the uterine lumen.they may develop pedicles and protrude fully into the uterine cavity.PathologyLeiomyomas are usually multiple,discrete,and spherical,or irregularly lobulated.Myomas have false capsular covering and can be easily and cleanly enucleated from the surrounding tissue.on gross examination in transverse section,they are buff-colored,rounded,smooth and usually firm.Microscopic StructureNonstriated muscle fibers are arranged in interlacing bundles of varying size running in different directions(whorled appearance).Individual cells are spindleshaped,have elongated nuclei,and are quite uniform in size.varying amounts of connective tissue are intermixed with the smooth muscle bundles.SecondaryChange Due to tumors lack of enough blood supply or malignent transformation1.Benign degeneration a.Hyaline degeneration b.Cystic degeneration c.Calcification d.Red degeneration(Carneous)2.Malignant transformation leiomyosarcomas are reported to develop with a frequency of 0.1-0.5%that of diagnosed myomaBenign degeneration1.Hyaline degeneration:myomas are white but contain yellow,soft and gelatinous areas2.Cystic degeneration:liquefaction follows extreme hyalinization3.Red degeneration:due to venous thrombosis congestion with interstitial hemorrhage Malignant transformation leiomyosarcomas are reported to develop with a frequency of 0.1-0.5%that of diagnosed myomaClinical Findings A.SymptomsSymptoms are present in only 35-50%of patients with myomas and depend on their location,size,state of preservation and whether or not the patient is pregnant.symptomsAbnormal bleeding:being present in 30-70%of patients.The symptoms of submucous and interstitial myomas are menorrhagia,metrorrhagia which are due to an increasing bleeding surface area.Abdominal swelling:when the uterine is larger than 14 gestational size.Pressure effects:intramural or intraligamentos myoma may distort or obstruct other organs.large cervical tumors may fill the true pelvis and compress the ureters,bladder or rectum(urinary retention)Pain:results from vascular occlusion,torsion of a pedunculated tumor or submucous myoma which has a stalk connected with the corpus of uterine.Infertility:myomas as a sole cause of infertility in only 2-10%of patients.Spontaneous abortion:incidence is not certain.possibly 2 times the incidence in normal pregnant women.B.Examination Myomas are easily discovered by routine bimanual examination of the uterus or sometimes by palpation of the lower abdomen.The diagnosis is obvious when the normal uterine contour is distorted by one or more smooth,spherical,firm masses.C.Laboratory Findings Anemia is a most common consequence of leiomyoma which is due to the excessive uterine bleeding and depletion of iron reserves.D.Pelvic imaging Pelvic ultrasound examinations CTMRIE.Special examination Laparoscopy is often definitive in establishing the precise origin of the leiomyomata and is increasingly being used for myomectomy.Hysteroscopy may assist in identification,and be used for removal of a submucous myoma.DiagnosisPatients symptoms:mass,abnormal bleeding,pain,pressurePhysical examination:bimanual examination or sometimes by palpation of the lower abdomenModern imaging techniques:ultrasonography,etcdifferential diagnosisPregnant uterusovarian carcinoma tubo-ovarian abscess endometriosisTreatment The management of myoma will depend essentially on the patients age,symptoms and desire for future fertility.Observation:examination at interval of 36-months small asymptomatic myomas diagnosis during pregnancy Medicine Indications:myoma is small(10 w in size Menorrhagia with annemia Pressure symptoms Fast growth Failed conservative therapy1.Myomectomy:when the uterus need to be preserved(abdominally,laparoscopically,hesteroscopically)2.hysterectomy:when the uterus is too large(more then 12 weeks gestational size)and the patients have no desire for future fertility.Total hysterectomy Subtotal hysterectomySubtotal hysterectomy(abdominally,vaginally,laparoscopically)3.Trans-arterial embolisation