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Key Features

Essentials of Diagnosis

  • Irregular enlargement of the uterus (may be asymptomatic)

  • Heavy or irregular vaginal bleeding, dysmenorrhea

  • Pelvic pain and pressure

General Considerations

  • Uterine leiomyoma is the most common benign neoplasm of the female genital tract

  • It is a discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue

  • The most convenient classification is by anatomic location

    • Intramural

    • Submucous

    • Subserous

    • Intraligamentous

    • Parasitic (ie, deriving its blood supply from an organ to which it becomes attached)

    • Cervical

  • Submucous myomas may become pedunculated and descend through the cervix into the vagina

Clinical Findings

Symptoms and Signs

  • Frequently asymptomatic in nonpregnant women

  • Abnormal uterine bleeding and pelvic pain or pressure most common symptoms

  • Occasionally, degeneration occurs, causing intense pain

  • The risk of miscarriage is increased if the myoma significantly distorts the uterine cavity and interferes with implantation

  • Fibroids rarely cause infertility by leading to bilateral tubal blockage; they more commonly cause miscarriage and pregnancy complications, such as preterm labor, preterm delivery, and malpresentation

Differential Diagnosis

  • Pregnancy

  • Adenomyosis

  • Ovarian tumors

  • Leiomyosarcoma

Diagnosis

Laboratory Findings

  • Iron deficiency anemia may result from blood loss

  • Polycythemia is rare but may result from product of erythropoietin

Imaging

  • Ultrasonography

    • Confirms presence of uterine myomas

    • Can be used sequentially to monitor growth

  • MRI

    • Can delineate intramural and submucous myomas accurately

    • Necessary prior to uterine artery embolization to assess blood flow to the fibroids

Diagnostic Procedures

  • Hysterography or hysteroscopy can also confirm cervical or submucous myomas

Treatment

Emergency measures

  • Emergency surgery may be required for acute torsion of a pedunculated myoma

  • If the patient is markedly anemic as a result of long, heavy menstrual periods, preoperative treatment with following medications will slow or stop bleeding

    • DMPA, 150 mg intramuscularly every 3 months

    • Depot leuprolide, 3.75 mg intramuscularly monthly

    • Nafarelin, 0.2–0.4 mg intranasally twice daily

  • Then, anemia can be treated before surgery

  • Levonorgestrel-containing IUDs have also been used to decrease the bleeding associated with fibroids; however, IUD placement can be more technically challenging in patients with fibroids

  • The only emergency indication for myomectomy during pregnancy is torsion of a pedunculated fibroid

Specific Measures

  • Women who have small asymptomatic myomas can be managed expectantly and evaluated annually

  • In patients wishing to defer surgical management, nonhormonal therapies (such as NSAIDs and tranexamic acid) have been shown to decrease menstrual blood loss

  • Hormonal therapies such as GnRH agonists and selective progesterone receptor modulators (SPRMs), such as low-dose mifepristone (5–10 mg/day) have been shown to reduce myoma volume, uterine size, and menstrual blood loss

Surgical Measures

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