1 UTERINE LEIOMYOMAS OUYANG,W.X. DEP GYNECOL & OBSTET UNION HOSPITAL TONGJI MEDICAL COLLEGE HUAZHONG UNIV SCIE TECH

2 KEY POINTS 1.Uterine myomas are smooth muscle, nonencapsulated, unicellular,hormone- dependent tumor of the female genitalia. These tumors demonstrate estrogen and progestin receptors.

3 KEY POINTS 2. Uterine myomas decrease in size in response to GnRH agonists. Side effects of this therapy may include myoma degeneration and bleeding, bone loss, and delayed therapy of leiomyoscarcomas. When antagonist therapy is discontinued, regrowth to approximately original size to usually occurs within 6 months.

4 KEY POINTS 3. Hysterectomy is the definitive therapy for symptomatic uterine leiomyomas in a woman who no longer desires the option of bearing children. GnRH therapy is useful in patients with uteri weeks, size to enhance the possibility of vaginal hysterectomy or conversion from vertical to Pfannenstiel incision.

5 ETIOLOGY Steroid hormones, particularly ESTROGEN, in addition, progesterone Peptide growth factors, example GnRH

6 HISTOPATHOLOGY 1. LEIOMYOMAS may be single but are often multiple 2. They vary from less than 1 cm to large tumors 3. They are originally located within the myometrium, submucosa, subserosa, intraligamentum; pedunculated, or parasitic.

7 Location of Myomas

8 HISTOPATHOLOGY 4. On microscopic exam. Mature smooth- muscle cells,

9 LEIOMYOSARCOMAS & UNUSUAL LEIOMYOMAS Leiomyosarcomas are suffered from by women 60 years of age Unusual include epithelioid leiomyoma,which is an unusual smooth- muscle tumor consisting of rounded polygonal cells and multinucleate giant cells.

10 SYMPTOMATIC LEIOMYOMA Abnormal uterine bleeding Pressure and obstructive symptoms Reproductive (spontaneous abortion and fertility problems) Valuation Physical examination may show an enlarged, firm, irregular mass Ultrasonography and/or MRI

11 TREATMENT OPTIONS Treatment options for uterine leiomyomas include expectant, medical, or medical/surgical management

12 Medical Management Testosterone Progesterone Anti-Estrogen Tamoxifen Anti-Progesterone (MifepristoneRu-486) GnRH

13 GnRH AGONISTS Decrease volume of myomas GnRH induce hypoestrogenism. Decrease arterial blood supply to the myoma. Effect of GnRH on Estrogen and Progestin Receptor Status in Leiomyomas Increase the receptor content in short term, decrease it in long term.

14 GnRH AGONISTS Long-term Therapy of myomas with GnRH Agonists to Avoid Hysterectomy Long-term Therapy of myomas with GnRH Agonists cannot apply to reproductive-age women, but to perimenopausal women.

15 GnRH AGONISTS Side effects and Disadvantages Hypo-estronism Menopause Degeneration and blooding Bone loss Possible relation to delayed therapy for leiomyosarcoma

16 Medical/Surgical Therapy Myomectomy versus hysterectomy Whether she desires to maintain the potential for future childbearing or psychological factor

17 Medical/Surgical Therapy Myomectomy

18 Myomectomy

19 Surgical Therapy Hysterectomy Abdominal Hysterectomy (See tape of operation) Vaginal Hysterectomy

20 Medical/Surgical Therapy Endoscopy/Laparoscopy

21 ENDOMETRIOSIS OUYANG,W.X. DEP GYNECOL & OBSTET UNION HOSPITAL TONGJI MEDICAL COLLEGE HUAZHONG UNIV SCIE TECH

22 DEFINITION Endometriosis may be defined as a disorder resulting from the presence of actively growing and functioning endometrial tissue (both glandular and supporting stromal elements are usually found) in aberrant sits outside the uterus.

23 SITES OF OCCURRENCE

24 SITES OF OCCURRENCE

25 Etiology Theory of Tubal Reflux and Direct Implantation Coelomic-Epithelium Metaplasia Theory Theory of Lymphatic Dissemination The Vascular Theory Müllerian Cell Rest Theory

26 PATHOLOGIC FEATURES Endometrial glands Endometrial stroma Evidence of hemorrhage (fresh: red cell and hemosiderin pigment; old: hemosiderin-laden macrophages) Typical lesion — inflammatory cells and fibrous connective tissue

27 PATHOLOGIC FEATURES There is a marked decidual reaction in pregnancy, and lesion of endometriosis became soft and shrink.On this long-known, beneficial effect of pregnancy on endometriosis.

28 CLINICAL MANIFESTATION Symptoms Secondary dysmenorrhea and chronic lower abdominal pain Abnormal uterine bleeding Dyspareunia Rectal tenesmus and symptoms of bowel irritation

29 CLINICAL MANIFESTATION Infertility Inadequate luteal phase Luteinized unruptured follicle symptom Autoimmune mechanisms

30 CLINICAL MANIFESTATION PHYSICAL FINDINGS Tender fibrotic nodule as hard, fixed Fixation of uterus in serious case Cystic ovarian enlargement(s) Visible nodules on other sites.

31 PHYSICAL FINDINGS

32 DIAGNOSIS History Symptoms Physical findings B ultrasonography Laparoscopy

33 ADENOMYOSIS

34 TREATMENT Nonoperative Treatment Simple observation Medical(Hormone) therapy Pseudopregnancy Depo-Provera 100mg im Q2W, ×4,and Q4W, 6 months in all Nemestran 2.5mg twice weekly

35 TREATMENT Pseudomenopause Danazol 200mg twice daily, 6 months in all Nonoperative ovariotomy Goserelin(GnRH-a) 3.6mg ih monthly, 3-6 times in all

36 TREATMENT Radiation therapy

37 TREATMENT Surgical Treatment Conservative surery Resection of endometriomas and reperitonealization of raw area Ovarian-preserved functional surgery Radical extirpative surgery

38 END