子宫肌瘤子宫肌瘤Myoma of uterus Myoma of uterus

王世宣 （ Shixuan Wang ）

Department of OB/GYN

Tongji Hospital

Tongji Medical College of HUST

Topics today

发病相关高危因素 High risk factors 分类 Classification 病理 Pathology 肌瘤变性 Degeneration of uterine myoma 临床表现 Clinical manifestation 诊断及鉴别诊断 Diagnosis and differential

diagnosis 治疗 Management

Female Internal genitalia

Myoma of uterus

Most common Most common benign tumor benign tumor in female in female genitalia!genitalia!

MYOMA OF THE UTRUS--

in various region of uterus

General consideration

Terms: Myoma, leiomyoma, fibroid, fibroid tumor

Consists of: smooth muscle tissue + connective tissue

The most common benign tumor in female genital organs

20% of women over 30; 25% of women over 40

Commonly seen in women of age: 30-50; 40- 50 yrs old with peak incidence

Rare in girls under 20; shrink after menopause

High risk factors (1)

Cytogenetic factors Female Hormones Growth Factors Molecular factors

The exact causes remain unclear

High risk factors (2)

Cytogenetic factors:

20%- 50%, cytogenetic abnormalities

(chromosome) family history

Female Hormones:

Estrogens ↑, ER ↑

Hypersensitivity to estrogen

Progestin ?

High risk factors (3) Growth Factors:

Epidermal growth factor (EGF)

Insulin-like growth factor (IGF)-I

Basic fibroblast growth factor (BFGF)

Cellular and Molecular factors:

Hypothesis:Hypothesis: stem cells

monoclonal → single myoma

polyclonal → multiple myomas

Pathogenesis of uterine myomaPathogenesis of uterine myoma

Cytogenetic background

Growth factors

EstrogenHigh ER

hypersensitivity

Myoma of uterus

Smooth muscle cells Stem cell(s) of myoma

Classification of myoma of uterus

Originate in the myometrium of uterus

按肌瘤生长部位 Classified by

anatomic location

按肌瘤与肌层关系 Classified by

relationship with myometrium

Anatomy of uterus

Classification- by the location:

宫体肌瘤 Corporeal

myoma: 90%

宫颈肌瘤 Cervical

myoma: 10%

Classification- by the relationship with myometrium

肌壁间 Intramural myoma: 60 % -70 %

浆膜下 Subserous myoma : 20%

粘膜下 Submucous myoma : 10 % -15%

Classification-

by the relationship with myometrium

Subserous

Submucous ( / intracavitary)

Subserous

Submucous + intramural

Submucous + Intramural + Subserous

Pathology

Gross view (Naked eye appearance)

Microscopic features

Pathology – gross view

Mass: Spherical, solid, hard; grey-white; pseudocapsule; often multiple

Section: paler, harder and more fibrous than the normal uterine myometrium (wall)

Pathology － Microscopic features

Smooth muscle cells arising from mostly Smooth muscle cells arising from mostly

myometrium, or endometrium of blood myometrium, or endometrium of blood

vesselsvessels

Composed of unstriped, interlaced bundles of Composed of unstriped, interlaced bundles of

smooth muscle and fibrous tissuesmooth muscle and fibrous tissue

Condensed nuclei, mitotic activity Condensed nuclei, mitotic activity

Fig. 1 100× left ： normal ；right ： myoma with interlaced bundles of smooth muscle tissue

fig. 2 100× Uterine myoma

fig. 3 200×Uterine myoma

Atrophic

hyaline degeneration

cystic degeneration

red degeneration

malignant transformation: mainly

sarcomatous change

Others: myxomatous (fatty), septic,

calcific (calcareous)

肌瘤变性 Degeneration of myoma

Hyaline degeneration

•The commonest change

seen in myoma.

•caused by a gradual

inadequacy of the blood

supply.

Cystic degeneration

not uncommon,

especially after the

menopause

due to liquefaction of the

areas of hyaline change.

Red degeneration

The affected area resembles

raw meat and is stained red.

most freguently seen during

the pregnancy and in

postpartum.

Malignant change

0.1%- 1% of cases

Most likely to be seen in large tumors.

More typical in older patients, especially postmenopausal patients

Presented with rapidly enlarging uterine mass and postmenopausal bleeding.

Metastasis occurs rapidly

症状 Symptoms

Abnormal vaginal bleedingAbnormal vaginal bleeding:: the most common presenting

symptom; hypermenorrhea（经量过多及经期延长）

Lower abdominal mass:Lower abdominal mass: usually asymptomatic

Vaginal discharge ↑Vaginal discharge ↑

Pressure effects:Pressure effects:

Others:Others: abdominal pain, infertility, secondary anemia

Symptoms – Abnormal vaginal bleeding (1)

Submucous myoma:

almost 100%, quite small tumors can lead to severe anemia.

Intramural tumors:

increasing of blood loss; prolonged period

Subserous growths:

do not affect the menstrual loss.

Symptoms – Abnormal vaginal bleeding (2)

Mechanisms for increased bleeding:

Alteration of normal myometrial contractile function

Inability of the overlying endometrium to respond to the normal E/P menstrual phases.

Pressure necrosis of the overlying endometrial bed.

Symptoms – abdominal mass

Sometimes the first thing that the patient notices.

Asymptomatic: not tender and rarely gives rise to pain.

Symptoms – Pelvic pressure

Against bladder (frequency and retention of urine)

Against rectum （ constipation ）

Against parauterine tissues: pain or discomfort

Symptoms – abnormal Vaginal discharge

42%

↑Area of uterine cavity

Pelvic congestion

Complications of submucous myoma

Symptoms – pelvic Pain

not a common symptom, when it occurs:

Some complication of myoma such as, degeneration or torsion

Endometriosis

Pelvic inflammatory disease

Symptoms – others

Infertility:Infertility: 3030 ％％ patients with myomapatients with myoma

Spontaneous abortion:Spontaneous abortion: 4 4 ：： 11

Secondary Anemia:Secondary Anemia:

体征 Signs

Vary with the size ， site (region/ location),

number, and complication of myomas.

abdominal examination

pelvic examination

Signs - Abdominal mass

﹤3 months gestational age ： not palpable

＞ 3 months gestational age ： In the middle

of the lower abdomen, irregular, hard, nodular

Signs - Pelvic mass

Intramural ： enlargement of uterus; irregular,

single or multiple nodules on the surface

Subserous ： spherical, nodular masses

Submucous ： symmetrical enlargement of the

uterus ， extrusion of myoma into cervical

canal even vagina

诊断 Diagnosis

History: reproductive age Symtoms: Signs: Ancillary tests:

Ultrasonography

Hysteroscopy

Laparoscopy

Dilation and curettage

HSG

Essentials for diagnosis

Bleeding: hypermenorrhea, metrorrhagia,

dysmenorrhea

Mass: irregular enlargement of the uterus (usually

asymptomatic); solid, spherical, and nodular

Pain: from torsion or degeneration

Pressue symptoms: from neighboring organs (large

tumors)

Diagnosis- ancillary test

Pelvic ultrasound

the most commonly used for confirmation of uterine myomas

Subserous myoma

Submucous myoma

Ancillary test － Laparoscopy

Ancillary test － Hysteroscopy

Differential diagnosis (1)

Other conditions which give rise to a mass in the pelvis （盆腔包块）

Adenomyoma

Ovarian tumors

Inflammatory mass in the pelvis

Pregnancy

Abnormality of uterus

Differential diagnosis (2)

Other conditions which cause metrorrhagia（子宫出血）

Adenomyoma

Endometrial polyp of uterus

Carcinoma of the uterus: endometrial, cervical

Dysfunctional uterine bleeding

Endometrial polyp

Adenomyosis

Adenocarcinoma of the endometrium

Abnormality of uterus

治疗 Management

Follow up Drug therapy Surgical management:

hysterectomy;myomectomy Others: Embolisation of myoma ;

myolysis

Treatment - Follow up

The majority of patients with uterine myomas do not require surgical treatment.

Age: Patients in the late reproductive or perimenopausal years.

Small and asymptomatic

Management: repeat pelvic examinations and assisted by serial pelvic ultrasound measurements

Every 3 - 6 months.

Management - Drug therapy

Indications: Perimenopausal women small myoma ( 2 months﹤ ) Asymptomatic, or with mild symptoms Couldn’t tolerate surgery

Management - Drug therapy

Mechanisms:

Pharmacologic inhibition of effects of estrogen

Inhibit the function of H-P-O axis

Commonly used for 3 to 6 months.

Management - Drug therapy

Drugs: Androgen GnRH-a: down regulation Mifepristone Gestrinone: nemestran Chinese herb medicines

Management - surgery

Surgical treatment is indicated in cases with:

1. Heavy or prolonged bleeding

2. Tumors of large size over 2.5 gestation months, （ 10 weeks ） even if these are not causing symptoms.

3. Possible malignant change, such as a tumor which grows after the menopause

4. Pressure symptoms ( against bladder, bowel, and pelvic floor)

5. Tumors which have undergone torsion or degeneration

Management - surgery

肌瘤切除术 Myomectomy:

Occasionally warranted in younger patients whose

fertility is compromised by the presence of myomas.

子宫切除术 Hysterectomy:

Should be considered as definitive treatment only in

symptomatic women who have completed childbearing.

Laparoscopic Myomectomy

Laparoscopic myomectomy

Management - Uterine myoma Embolization  (Uterine Artery Embolization)

Uterine myoma Embolization  (Uterine Artery Embolization)

Women at age of 30 ～ 50

Abnormal vaginal bleeding

Enlargement of uterus with smooth, spherical, s

olid mass

Pelvic ultrasonography generally assists in esta

blishing diagnosis

Medical and surgical treatment

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