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Benign uterine tumor

first work

dya tayfur

on 24 December 2013

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Transcript of Benign uterine tumor

Iron-deficiency anaemia
Bladder frequency, constipation (due to increased pelvic pressure)
Hyaline degeneration (asymptomatic)
Torsion of pedunculated fibroid
Ureteral obstruction causing hydronephrosis
Infertility; may occur as a result of narrowing of the isthmic portion of the fallopian tube or as a consequence of interference with implantation (especially with submucosal fibroids)
In pregnancy:-----
Recurrent miscarriage
Fetal malpresentation
Red degeneration: presents with fever, pain and vomiting
Intrauterine growth retardation
Premature labour
Postpartum haemorrhage

Exact aetiology is not clearly understood, but the current working hypothesis is that genetic predispositions, prenatal hormone exposure and the effects of hormones, growth factors and xenoestrogens cause fibroid growth
Leiomyomas have increased levels of estrogen and progesterone receptors compared to other smooth muscle cells.
Estrogen stimulates the proliferation of smooth muscle cell, whereas progesterone increases the production of proteins that interfere with programmed cell death (or apoptosis).

Leiomyomas also have higher levels of growth factors that stimulate the production of fibronectin and collagen, major components of the extracellular matrix that characterizes these lesions.

Fibroids (Uterine Leiomyoma)
Benign Uterine Disease
Fibroids (uterine leiomyomas) are benign tumours mainly compose of smooth muscle cells &fibroblast , with a thin capsular covering. They start as multiple, single cell seedlings distributed throughout the uterine wall. These then increase in size very slowly over many years, stimulated by oestrogens. As the fibroid grows, the central areas may not receive an adequate blood supply and undergo benign degeneration often followed by calcification
They are clinically apparent in 20% of women of reproductive age and maybe present in as many as 70% of uteri removed at hysterectomy

* Their incidence is increased in women of Afro-Caribbean origin ,while decreased with prolonged use of the oral contraceptive pill as well as with increasing numbers of term

Benign disease of the uterus is an important problem for many women and their gynaecologists.

The commonest condition in this category is fibroids but uterine polyps are also of importance.

Both fibroids and endometrial polyps are very common and although asymptomatic in many women, they can cause considerable morbidity for others.

1-Intramural (70%)
2-Growing into the uterine cavity; either submucosal, pedunculated submucosal or pedunculated vaginal (10%)
3-Growing outwards from the uterus (20%); can be:
Pedunculated subserous (abdominal)

sub mucous fibroid classification
Symptoms associated with uterine fibroids
1 – The majority of uterine leiomyomas cause no symptoms(50%) ( Asymptomatic).
2 – Uterine fibroids commonly present with menstrual problems
particularly heavy menstrual bleeding.
Menorrhagia may be associated with intramural or submucosal tumor.

been associated with submucous
myomas ulcerating
through the endometrial lining.
Excessive bleeding
may result in anemia, weakness,
, and even congestive heart failure.

Recently it has been shown that Menorrhagia is not just confined to those who have submucous fibroids but can also be associated with subserosal lesions.
3 – Dysmenorrhoea can be an additional problem leading to misery for the women affected.
There is an increased incidence of secondary dysmenorrhea in women with uterine myomas, generally caused by the increased blood loss.

4 – Symptoms related purely to the size of the fibroid.
This may be a feeling of dragging or pressure in the pelvis or simply that of abdominal swelling.

She may complain of :
a-pelvic pressure,
c- bloating,
d-a feeling of heaviness in the lower abdomen, or lower back pain.

6 – Subfertility ,
Difficulty in conceiving ,
Pregnancy loss ,
Intrapartum bleeding (particularly Caesarian section), are other problems that may be caused by fibriod.

Sign of Uterine Fbroid
Very large fibroids can be palpated abdominally. Those smaller than a 12- to 14-week gestational size are usually confined to the pelvis.

The bladder should be emptied before examination to avoid the confusion of urinary retention. Although submucous fibroids may not be palpable
bimanual pelvic examination a firm, irregularly enlarged uterus with smoothly rounded or bosselated protrusions may be felt if the tumors are subserosal or intramural.

The tumors are usually non tender.

Their consistency may vary from rock hard, as in the case of a calcified postmenopausal leiomyoma, to soft or even cystic, as in the case of cystic degeneration of the tumor.

In general, the myomatous masses are in the midline, but sometimes a large portion of the tumor lies in the lateral aspect of the pelvis and may be indistinguishable from an adnexal mass.

If the mass moves with the cervix, it is suggestive of a leiomyoma.
Diagnosis :-
1 – Ultrasonography is very useful as first line investigation.
2 – MRI scan can give excellent visualization of the uterus and ovaries. In addition, enhancement with gadolinium gives an information of the vascularity of the uterus.

-Biopsy of the fibroid is not commonly undertaken.

Deffrential diagnosis
The most common differential diagnoses are
1 – An ovarian neoplasm,
2 – A tubo-ovarian inflammatory mass,
3 – A pelvic kidney,
4 – A diverticular or inflammatory bowel mass,or cancer of the colon.

Typically regression at the menopause and so symptoms then resolve, but will continue if on hormone replacement therapy.

Menorrhagia caused by fibroids may be managed hormonally in many cases.

Progestin-only therapies (oral or injected medroxyprogesterone acetate, progestin-only oral contraceptive pills, or levonorgestrel-releasing intrauterine devices) or

combination hormonal contraceptive methods
(oral contraceptive pills, vaginal rings, or patches) are usually a first therapeutic option.

The goal of hormonal treatment may be to reduce monthly menstrual blood loss with cyclic hormonal methods or to eliminate menses with extended or continuous use of these methods

3-GnRH agonists have demonstrated considerable efficacy in blocking ovarian steroidogenesis, which halts endometrial proliferation.
GnRH agonists reduce the volume of the myometrium and the leiomyomas. This allows for correction of anemia and reduces intraoperative blood loss.

The effects of GnRH-agonist therapy disappear soon after the drug is stopped.
because of the intense vasomotor symptoms and the deleterious effect on the bone mineral density, only short courses of these agonists can be administered, usually in preparation for myomectomy or hysterectomy.

Intermittent GnRH- agonist administration has been shown to reduce side effects while achieving therapeutic goals longer term.

Combining GnRH agonists with hormonal agents, such as low-dose progesterone or estrogen/progestin combinations, may minimize some adverse effects of hypoestrogenism (such as osteoporosis), but long-term data are not available.

Clinical trials using:
the selective antiprogesterone receptor antagonist, mifepristone , to reduce the size of uterine myomas have shown a reduction of 50% over a 3-month period.

Surgical Managment
1 – Myomectomy is the preferred surgical procedure for women with a limited number of tumors who desire uterine preservation.

Myomectomy occasionally can be performed hysteroscopically for submucous masses or transabdominally (either laparoscopically or with laparotomy) for other leiomyomas.

Pretreatment for 3 months with GnRH agonists and the use of vasoconstrictive agents intraoperatively may improve surgical outcomes whatever surgical approach is used
2 – Hysterectomy provides definitive therapy. If the uterus is large (>12 to 14 cm), laparotomy is generally the preferred approach.
Vaginal hysterectomy is generally preferred if the uterus is not bulky and the vagina is not constricted.

Laparoscopically assisted vaginal hysterectomy permits excellent visualization of the adnexae and controlled dissection from above without a large abdominal incision.

Rapid growth of a uterus caused by leiomyoma (doubling in size in <6 months) may be the result of leiomyosarcoma, and hysterectomy is generally recommended.

3 – Embolization of the uterine arteries supplying the leiomyomas has been found to be effective, at least in the short term, for controlling leiomyoma-induced bleeding and to shrink the myomas.

4 – Endometrial ablation with hysteroscopic resection, laser ablation, or roller ball may be technically difficult if the leiomyomata distort the cavity,

This approach may be appropriate for women who are poor candidates for more extensive surgery

5 – Laser ablation of fibroids:
can be carried out at surgery either using a hysteroscope or a laparoscope depending on the position of the fibroids. Laser can also be used with
MRI or ultrasound guidance.

Alternatively MRI guidance can be used to focus ultrasound and fibroid necrosis occurs without significant adverse outcomes.

MRI-guided focused ultrasound (MRgFUS)
Endometrial polyps

Benign localised overgrowth of endometrial glands and stroma, covered by epithelium, projecting above the adjacent epithelium

The presence of endometrial polyps is being increasingly recognized since the widespread adoption of transvaginal ultrasound and outpatients hysteroscopy.

It is probable that they are present in 25% of women with abnormal vaginal bleeding.

At least 10% of asymptomatic women are also likely to have polyps.
common in women in thier 40s and 50s. They are particularly common in women taking preparations such as tamoxifen

intermenstrual or post-menopausal bleeding
Persistent bleeding following curettage
Risk factors
2-high blood pressure
3-history of cervical polyp
4-taking tamoxifen or hormon replacement therapy

Differential Diagnosis
1-Endometrial hyperplasia
2-polypoid endometrial carcinoma
-stromal cells cytologically atypical and mitotically active
-stromal cells packed tightly around non malignant glands
-leaf like pattern

Diagnosis of endometrial polp
1 – Transvaginal ultrasound ,Intrauterine injection of saline can markedly increase the diagnostic performance of transvaginal ultrasound.

2 – Hysteroscopy ,The best method for diagnosing polyps is hysteroscopy; so it is a possibility that they might then be treated at the sametime.
They can be distinguished from pedunculated fibroids since they have fewer vessels over the surface.

Malignant polyps are more likely to be irregular, vascular or friable. Biopsy should be carried out to confirm the diagnosis since appearance is not sufficient.

Treatment of end. Polyp:
In the symptomatic women, treatment will normally be performed under general anaesthesia.
they can also be treated in the outpatients setting either by removal under direct vision or by treatment with specially developed diathermy instrumentation.

She may note frequency of urination. Urinary retention and hydronephrosis are rare but result from the fact that the bladder and large leiomyomas compete for space within the pelvis.

In addition, pressure pains may occur in the lower abdomen and pelvis if a myomatous uterus becomes incarcerated within the pelvis.

5 – Dyspareunia is also common with incarceration.

By ..sabat tayfur
7-bowel problem
diagnosis of polyp
1 – Transvaginal ultrasound ,Intrauterine injection of saline can markedly increase the diagnostic performance of transvaginal ultrasound.

2 – Hysteroscopy ,The best method for diagnosing polyps is hysteroscopy; so it is a possibility that they might then be treated at the sametime.
They can be distinguished from pedunculated fibroids since they have fewer vessels over the surface.

Degeneration of fibroid
Degeneration Of Fibroid
Hyline:aseptic necrosis with loss of muscle cell structure ,this may lead to calcification.
Cystic:- a sequel to hyaline change with subsequent breakdown & cyst formation giving a honey comb appearance
fatty :- in which partial necrosis result in the development of fatty substance which may subsecquently undergo calcification .
Red :- necrobiosis, particularly encountered in mid-trimesterof pregnancy or early puerperium,this breakdown of blood supply by thrombosislead to necrosis
Risk factors for developing leiomyomas include:
1 – Increasing age during the reproductive years,
2 – Ethnicity (African-American women have at least a 2- to 3-fold increased risk compared to Caucasian women),
3 – Nulliparity,
4 – Family history.
5 – Higher body mass index is associated with a greater risk of leiomyomata.

Oral contraceptive pills and depot medroxyprogesterone acetate (DMPA) injections may be associated with reduced risk
Medical Management :
oxford handbook of O & G
Obstetric and gynaecology (dianahamilton-fairley )
lecture notes of 5th stage
Types of fibroid

** use of inta uterine system containing levonorgestril may reduce incidence of polyp in women using tamoxifen .
Endometrial polyps are usually benign although some may be precancerous or cancerous.About 0.5% of endometrial polyps contain adenocarcinoma cells.
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