Women’s Hospital, School of Medicine Zhejiang University Prof. Lin Jun Uterine Myoma Women’s Hospital, School of Medicine Zhejiang University Prof. Lin Jun

Introduction Most common benign tumor of female reproductive system Benign neoplasm composed primarily of smooth muscle and connectives tissue Common in women 30-50y Usually asymptomatic

Etiology Estrogen and ER ↑ Progestin may promote mitosis of myoma Not detectable before puberty and after menopause Probably relates to female hormones Estrogen and ER ↑ Progestin may promote mitosis of myoma

Classification According to the location： Uterine body myoma 90% Cervical myoma 10%

Classification According to the relationship between myoma and uterine myometrium ： intramural myoma 60%-70%  subserous myoma 20% submucous myoma 10%-15%

Classification

Classification multiple myoma

Pathology Gross Appearance： round, smooth, and usually firm false capsular covering ——pseudocapsule can be clearly demarcated from the surrounding myometrium

Pathology Gross Appearance： Transverse section : light gray a whorl-like arrangement or an intertwining pattern

Pathology Microscopic examination： composed of smooth muscle cells and varying amounts of connectives tissue Individual cells are quite uniform in size, spindle shaped, have elongated nuclei. Nonstriated muscle fibers are arranged in interlacing bundles of varying size running in different directions.

Degeneration Hyaline degeneration Cystic degeneration Red degeneration Sarcomatous change Degeneration with calcification

Degeneration Red degeneration most common during pregnancy and puerperium venous thrombosis and congestion with interstitial hemorrhage

Degeneration ← Red degeneration ← Hyaline degeneration

Degeneration Sarcomatous change malignant rare, 0.4-0.8% old women enlarge rapidly with irregular vaginal bleeding

Degeneration Sarcomatous change

Symptoms Usually no symptoms Associate with location, and degenerations Not associate with the size and the number

Symptoms 1. menorrhagia and prolonged menses large intramural myoma submucous myoma 2. abdominal mass 3. leukorrhagia

Symptoms 4. pressure effects 5.others pressure bladder or rectum → urinary frequency, constipation intraligamentous myoma and large cervical myoma → obstruct ureter 5.others infertility spontaneous abortion abdominal pain

Sign associated with： size location number degeneration large myoma→ palpable abdominal mass Pelvic examination： uterus —— enlarged，irregular and hard

Diagnosis Typical symptoms and signs Ultrasound Hysteroscopy Laparoscopy

Ultrasound

Ultrasound

Diagnosis Hysteroscopy

Diagnosis Laparoscopy

Differential diagnosis Pregnancy Ovarian neoplasms Adenomyosis Malignant tumors of uterus uterine sarcoma endometrial carcinoma cervical cancer

Treatment According to : age desire for childbearing symptoms location , size and amount of myoma

Treatment Observation and Follow Up Small，asymptomatic，especially near menopause Interval：3～6 months

Medical measure Indications： smaller than 2 months in size slight symptoms near menopause

Medical measure GnRH-a LH、FSH↓ E2↓ shrinkage of myoma 1.Androgenic agents： testosterone propionate 2.Gonadotropin-releasing hormone agonist, （GnRH-a） GnRH-a LH、FSH↓ E2↓ shrinkage of myoma leuprorilin goserelin

Medical measure 2.GnRH-a 3.Mifepristone Side effects: Hypoestrogenic side effects Osteoporosis 3.Mifepristone

Surgical measures Indications： greater than 10 weeks in size menorrhagia→ anemia pressure effects grows rapidly failure in medical treatment infertility or recurrent abortion

Surgical measures Approaches： laparotomy hystereoscopy laparoscopy

Surgical measures Myomectomy 2. Hysterectomy preserve fertility, <35 years old 2. Hysterectomy Large myoma Numerous tumors Obviously symptomatic patient No wish of preserving fertility Suspected to malignant transformation

Myomas during pregnancy Impact on pregnancy and delivery ： abortion preterm labor fetal malpresentation placenta previa birth canal obstruction postpartum hemorrhage

Myomas during pregnancy Red degeneration Clinical finding: rapid growth of myoma pain, fever, WBC↑ Conservative treatment

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