Leiomyoma of the Uterus (Fibroid Tumor)

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 leiomyomas are the most common benign neoplasm of the female genital tract

• They are discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue

• More common in African American women

• The most convenient classification is by anatomic location

  • Intramural

  • Submucous

  • Subserous

  • 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

• Cervical myomas larger than 3–4 cm in diameter or pedunculated myomas that protrude through the cervix can cause

  • Bleeding

  • Infection

  • Degeneration

  • Pain

  • Urinary retention

• Myomas that significantly distort the uterine cavity may affect fertility by

  • Interfering with implantation

  • Rapidly distending in early pregnancy

  • Impairing uterine contractility

Differential Diagnosis

• Pregnancy

• Adenomyosis

• Ovarian tumors

• Leiomyosarcoma

Diagnosis

Laboratory Findings

• Iron deficiency anemia may result from blood loss

Imaging

• Ultrasonography

  • Confirms presence of uterine myomas

  • Can be used sequentially to monitor growth

  • Can be used to exclude ovarian masses when multiple subserous or pedunculated myomas are being monitored

• MRI

  • Can delineate intramural and submucous myomas accurately

  • Typically used prior to uterine artery embolization to determine fibroid size and location in relation to uterine blood supply

Diagnostic Procedures

• Hysterography or hysteroscopy can also confirm cervical or submucous myomas

Treatment

Nonsurgical Measures

• Nonhormonal therapies (such as NSAIDs and tranexamic acid) have been shown to decrease menstrual blood loss

• Women with heavy bleeding related to fibroids often respond to estrogen-progestin oral contraceptives or the levonorgestrel IUD, although an IUD cannot be used with a distorted cavity

• Hormonal therapies, such as GnRH agonists, and selective progesterone receptor modulators (SPRMs), such as low-dose mifepristone and ulipristal acetate, have been shown to reduce

  • Myoma volume

  • Uterine size

  • Menstrual blood loss

• SPRMs are not approved for fibroid treatment in the United States, however

• GnRH analogs such as depot leuprolide, 3.75 mg intramuscularly monthly, or nafarelin, 0.2–0.4 mg intranasally twice a day, can be used preoperatively for 3- to 4-month periods to

  • Induce reversible hypogonadism

  • Temporarily reduce the size of myomas

  • Reduce surrounding vascularity

Surgical Measures

• Surgical intervention is based on the patient's symptoms and desire for future fertility

• Uterine size alone ...