Leiomyoma of the Uterus (Fibroid Tumor)

Key Features

Essentials of Diagnosis

• Irregular enlargement of the uterus (may be asymptomatic)

• Heavy or irregular uterine bleeding

• Pelvic pain, dysmenorrhea, 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 cannot be used with a distorted cavity

• 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), ...