1. UTERINE LEIOMYOMATA Dr Zeinab Abotalib MD, MRCOG Associate Professor & Consultant Obstetrics & Gynecology Infertility And Assisted Conception

2. Uterine Leiomyomata Benign tumor comprised mostly of smooth muscle cells Reinier De Graff 1641First described by Reinier De Graff 1641 Most common tumor of the female pelvis Represent 1/3 of all GYN admissions to hospitals

3. Incidence Usually quoted 50% (Underestimate) –Cramer and Patel 100 serial Uteri Sectioned at 2mm 77 of 100 had myomas –84% had multiple myomas –649 myomas found in all No difference in incidence within pre or post menopausal uteri Am J Clin Pathol. 1990 Oct;94(4):435-8

4. Incidence More common in African-Americans than whiteMore common in African-Americans than white –Torpin et al. investigated 1741 Uteri Overall incidence 3 times higher in blacksOverall incidence 3 times higher in blacks Also tended to be largerAlso tended to be larger Also occurred at a younger ageAlso occurred at a younger age J Obstet Gynecol 1942;44:569

5. Incidence Cumulative incidence by age 50, > 80% for African American and nearly 70% for Caucasian women. One in four women have at least one submucosal fibroid. Overall prevalence of uterine fibroids increases with age from 3.3% in women 25-32 to 7.8% in women 33-40 years. - Baird et al, Am J Obstet Gynecol 2003. - Borgfeldt et al, Acta Obstet Gynecol Scand 2000.

6. Etiology Arise from a single muscle cell (monoclonal). Proliferate under the influence of sex hormones, including estrogen, progesterone & androgens. Effects of steroids are modulated by local growth factors. - Rein et al, Am J Obst Gyne 1995. - Ichimura et al, Fertil Steril 1998. - Stewart et al, Obstet Gynec 1998. - Wer et al, Fertil Steril 2002.

7. Etiology Fibroblast growth factor Vascular endothelial growth factor Heparin-binding epidermal growth factor Platelet-derived growth factor Transforming growth factor Parathyroid hormone-related protein Prolactin

8. Etiology Risk Factors –Nurses Health Study II 95,061 nurses completed questionnaires in 1989, 1991, 1993 –Obesity –Early menarche –Nulliparity Fertil Steril. 1998 Sep;70(3):432-9

9. Etiology Oral Contraceptives –High dose pills have been assoc. with stimulation of fibroid tumors Smoking

10. Presentation Most fibroids do not cause symptoms. 20-50% experience tumor-related symptoms: -Menstrual dysfunction -Bowel and bladder dysfunction -Bulk effects Such symptoms, account for up to 35% of all hysterectomies. - Lefebvre et al, J Obstet Gynecol Can 2003. - Myers et al, Agency for Health Care Research and Quality, 2001.

11. Symptoms Pelvic Pain Menstrual Irregularities GI complaints Bladder complaints Dyspareunia Back pain Leg pain Vascular symptoms Infertility Asymptomatic

12. Diagnosis History Bimanual pelvic or abdominal exam Pelvic ultrasound - most common MRI, HSG, sonohysterogram, hysteroscopy

13. Appearance

16. Degenerative Changes Degenerative changes are reported in approximately two-thirds of all specimens, but most of them have no clinical significance. 1.Hyaline degeneration- It is the most common 2.Cystic degeneration 3.Mucoid degeneration 4.Fatty degeneration 5.Carneous degeneration 6.Calcification 7.Sarcomatous degeneration(malignant transformation)

17. Uterine Fibroids Benign tumour of uterine tissue 3 locations: subserosal intramural submucosal

18. Leiomyomas classified according to their location in the uterus

20. How are they diagnosed? Usually detected on an internal gynecological exam Diagnosis is usually confirmed by ultrasound but can also be made with magnetic resonance (MR) or computed tomography (CT) scans.

21. As seen on ultrasound

22. As seen on MRI

23. Factors that should be considered prior to initiating treatment include: Size of the myoma(s) Location of the myoma(s) (Symptoms Woman's age (eg, is she near menopause?) Reproductive plans

24. How are they treated? Depends on size and location Surgical therapy - hysterectomy, myomectomy Drug therapy - pain relievers, hormone therapy (to shrink them) Uterine artery embolization

25. Treatment Expectant management - most cases Indications for treatment –Abnormal uterine bleeding, causing anemia –Severe pelvic pain –Large or multiple –Obscuring evaluation of adnexa –Urinary tract symptoms –Postmenopausal or rapid growth

26. Treatment Choices Medical therapies –Medroxyprogesterone (Provera) –Danazol –GnRH agonists (nafarelin acetate, Depot Lupron)

27. Treatment –RU486 Anti-progestin –High affinity to Progesterone and glucocorticoid receptors Murphy et al (1995) showed decrease of volume an average 49% Recent reviews supports usage, but has been associated with –Hot flashes –Endometrial hyperplasia –Is not associated with trabecular bone loss Fertil Steril. 1995 Jul;64(1):187-90 Obstet Gynecol. 2004 Jun;103(6):1331-6 Clin Obstet Gynecol. 1996 Jun;39(2):451-60

28. Treatment Gestrinone –Antiestrogen/antiprogesterone GnRH analogues –Suppresses pituitary mediated secretion of estrogens –Basically treat 3-6 months –Expect 50% reduction of uterine volume

29. Treatment Choices Uterine Artery Embolization (UAE)

30. UAE Within three months following embolization: -45% and 55% reduction in total uterine and myoma volume. -Reduction in symptoms in approximately 80% of women. long- term data on durability and effects on fertility and pregnancy outcomes are very limited. Pron et al, Fertil Steril 2003 Burbank et al, J Am Assoc Gynecol Laparosc 2000

31. What does the doctor see?

32. Myomectomy

33. First performed by Washington and John Atlee, 1844 May be approached in a variety of ways –Abdominally (open) –Laparoscopic –Hysteroscopic Primarily for submucosal/intramural fibroids impacting the endometrial cavity –Vaginal Primarily for pedunculated submucous fibroids

34. Myomectomy Biggest complication is blood loss

35. Myomectomy (local surgical removal of fibroids) Sparing the uterus Complications significant blood loss could require hysterectomy Fibroids can recur 20 - 25% will need another procedure for treatment of new fibroids

36. Myomectomy Hysteroscopyfor intracavitary / submucous Laparotomy

38. Myomectomy with hysteroscope

40. Myomectomy Hysteroscopyfor intracavitary / submucous Laparotomy

41. Treatment Choices Hysterectomy –Vaginal –Abdominal

42. Hysterectomy Curative, but irreversible Until now, the standard therapy for fibroids 1/3 of all hysterectomies are performed for fibroids Complications: bleeding, infection, adhesions, risks associated with general anesthetic 6 - 8 week recovery

43. Comparison of treatment options TreatmentProsCons Pain Medication Reduces Pain Doesn't solve problem, Pain returns luperon Reduces size Improves symptoms side-effects, Symptoms return on discontinuation

44. Comparison of treatment options TreatmentProsCons Hysterectomy Complete cure Major operation can’t become pregnant Myomectomy successful Can still become pregnant surgical procedure Fibroids can recur

45. Comparison of treatment options TreatmentProsCons Uterine Artery Embolization Non-surgical treatment Very effective Fibroids may recur

46. Goal

47. Thanks !

48. Method Of Delivery Vertex- Vertex (50%) Vaginal delivery, interval between twins not to exceed 20 minutes. Vertex- Breech (20%) Vaginal delivery by senior obstetrician

49. Method Of Delivery Breech- Vertex( 20%) Safer to deliver by CS Breech-Breech( 10%) Usually by CS.

50. Method Of Delivery MONO-MONO By C/S Why?