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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: (1) intramural, (2) submucous, (3) subserous, (4) intraligamentous, (5) parasitic (ie, deriving its blood supply from an organ to which it becomes attached), and (6) cervical (see eFigure 18–2). Submucous myomas may become pedunculated and descend through the cervix into the vagina.

CLINICAL FINDINGS

A. Symptoms and Signs

In nonpregnant women, myomas are frequently asymptomatic. The two most common symptoms of uterine leiomyomas for which women seek treatment are AUB and pelvic pain or pressure. 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.

B. Laboratory Findings

Iron deficiency anemia may result from blood loss; in rare cases, polycythemia is present, presumably as a result of the production of erythropoietin by the myomas.

C. Imaging

Ultrasonography will confirm the presence of uterine myomas and can be used sequentially to monitor growth (see eFigure 18–3). When multiple subserous or pedunculated myomas are being followed, ultrasonography is important to exclude ovarian masses. MRI can delineate intramural and submucous myomas accurately and is necessary prior to uterine artery embolization to assess blood flow to the fibroids. Hysterography or hysteroscopy can also confirm cervical or submucous myomas.

DIFFERENTIAL DIAGNOSIS

Irregular myomatous enlargement of the uterus must be differentiated from the similar, but symmetric enlargement that may occur with pregnancy or adenomyosis. Subserous myomas must be distinguished from ovarian tumors. Leiomyosarcoma is an unusual tumor occurring in 0.5% of women operated on for symptomatic myoma. It is very rare under the age of 40 and increases in incidence thereafter.

TREATMENT

A. 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 DMPA, 150 mg intramuscularly every 3 months, or use of a GnRH agonist, such as depot leuprolide, 3.75 mg intramuscularly monthly, or nafarelin, 0.2–0.4 mg intranasally twice daily, will slow or stop bleeding, and medical treatment of anemia can be given prior to surgery. Levonorgestrel-containing IUDs have also been used to decrease the bleeding associated with fibroids; however, IUD placement can be more technically ...

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