ASSOCIATE PROFESSOR IOLANDA BLIDARU Leiomyoma of the uterus ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

Epidemiology The commonest of all pelvic T. (1/3). 20% of female > 35 years have fibroid. Childbearing life. Often enlarge during pregnancy or during oral contraceptive use, and regress after menopause occur in women of reproductive age, often

Uterus deprived from a baby consoles itself with a fibroid.

Causes Unknown Hyperestrogenemia – E2 / ER, P / PR, GnRH, growth factors (IGF-1, EGF< PDGF< FGF) Race Obesity Chromosomal abnormalities (7, 12, 14)

Pathology MACROSCOPY site shape size consistency cut section capsule number varieties

Uterine leiomyoma Cervical 1-2% solitary Corporeal 98% multiple

Corporeal leiomyoma Subserous 18% submucus 24% not capsulated Interstitial 58%

Cervical leiomyoma Exocervix Supravaginal cervix sessile pedunculated small sessile polypoid Supravaginal cervix sessile pedunculated

CONSISTENCY Firm Harder (hyaline degeneration). Soft (pregnancy-cystic degeneration). Stony hard (Calcification)

Leiomyomata Uterus

CUT SECTION well demarcated surrounding muscle. whorly (intermingling muscle fibers and fibrous tissue). paler than surrounding (ischaemia).

Microscopic Examination Few formed blood vessels (blood lakes). Smooth muscle cells and fibrous tissue cells.

Leiomyoma:

Changes occuring with fibroid General Genital tract Tumor itself

Genital tract Endometrium - hyperplasia Tubes - inflammation (salpingitis) Endometriosis (30-40%)

Tumour itself Benign degeneration Malignant degeneration atrophic hyaline red cystic fatty calcification necrosis with or without infection vascular (edema, lymphangiectasia) Malignant degeneration (0.1-0.5 % - growth after menopause, rapid enlargement, recurrent fibroid polyp).

DIAGNOSIS History Examination. Investigation. D.D.

SYMPTOMS No symptom Bleeding (menorrhagia - metrorrhagia). Pain - uncomplicated → congestion → dysmenorrhea; complicated → degeneration (malignant, infection, torsion) Infertility Mass Discharge Pressure symptoms (urinary, lower limb edema, constipation)

Signs Symmetrically enlarged uterus (submucosal fibroid) Asymmetrically enlarged uterus (subserous fibroid)

Investigations Clinical (examination) Laboratory (Hb, Ht, urinary tests, pregnacy test, Pap test etc) Imaging & instrumental techniques (US, hysteroscopy, hysterography, colposcopy, fractional curettage, Ct scan) Miscellaneous (intravenous urography, etc)

DIFFERENTIAL DIAGNOSIS Pregnancy (normal / abnormal) Ademomyosis. Leiomyomas - myomectomy, adenomyosis - hysterectomy Solid Adnexal Mass (fibromas, Brenner tumors, inflammatory mass) Uterine Leiomyosarcoma ( histologically - the presence of infiltrative margins, nuclear atypia, and increased mitotic figures )

Uterus Adenomyosis:

DIFFERENTIAL DIAGNOSIS

Uterine Leiomyosarcoma

Treatment of Leiomyoma No treatment Conservative Radiological Surgical GnRH agonists Uterine artery embolization. Patient (age, parity, symptoms). Tumor (number, size, type) Complications.

Treatment of Leiomyoma MEDICAL Progesterone / Progestins Selective PR modulator / antagonist (Mifepristone, Ulipristal) GnRH agonists (Buserelin, Triptorelin, Leuprolid, Histerelin, Goserelin)

Myomectomy (Hysteroscopy, laparoscopy, laparotomy) Hysterectomy SURGICAL Myomectomy (Hysteroscopy, laparoscopy, laparotomy) Hysterectomy