Leiomyoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Synonyms and keywords:

Historical Perspective

• Leiomyoma was first discovered by Hippocrates, a greek physician also called as father of modern medicine in 460-375 B.C and called it “uterine stone”.
• In the second centruary of Christian era, Galen described the lesion as "scleromas".
• In 1860 and 1863, Rokitansky and Klob coined the term fibroid.
• In 1854, Virchow a German pathologist demonstrated that those tumors originated from the uterine smooth muscle. Thus, the term "myoma" became current in clinical use.
• In 1809, the first laparotomy consequent to myoma indication was conducted by Ephraim McDowell to treat Leiomyoma in Danville, USA.
• The first successful myomectomy was performed by Amussat in 1840, after a clinical diagnosis of ovarian tumor because pelvic examination showed a pediculate and large uterine leiomyoma.
• The first scientific report of a uterus conserving myomectomy through the vagina appeared in 1845 in the American Journal of the Medical Science, accomplished by Washington Atlee, in Pennsylvania.
• In 1898, Alexander Adam presented 11 cases of myomectomy through an abdominal route, in Liverpool.
• In 1940, Carlos R. Círio proposed a technique of the myometrium emptying, called myometrectomy.

Classification

• Leiomyoma may be classified according to their location into 3 subtypes:

• Submucosal – lie just beneath the endometrium.
• Intramural – lie within the uterine wall.
• Subserous – lies at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.

Pathophysiology

• The pathogenesis of leiomyoma is characterized by benign smooth muscle neoplasm. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.
• The chromosome aberrations such as t(12;14)(q14-q15;q23–24), del(7)(q22q32), rearrangements involving 6p21, 10q, trisomy 12, and deletions of 1p3q has been associated with the development of leiomyoma.
• On gross pathology, round, well circumscribed (but not encapsulated), solid nodules that are white or tan, and whorled are characteristic findings of leiomyoma .
• On microscopic histopathological analysis, elongated, spindle-shaped cells with a cigar-shaped nucleus are characteristic findings of leiomyoma.

Causes

• Chromosome aberrations such as t(12;14)(q14-q15;q23–24), del(7)(q22q32), rearrangements involving 6p21, 10q, trisomy 12, and deletions of 1p3q has been associated with the development of leiomyoma.

Differentiating Leiomyoma from other Diseases

• Uterine leiomyoma must be differentiated from other diseases that cause uterine mass, such as:

• Uterine adenomyoma
• Pregnancy
• Hematometra
• Uterine sarcoma
• Uterine carcinosarcoma
• Endometrial carcinoma
• Metastasis

Epidemiology and Demographics

Age

• Leiomyoma is more commonly observed among patients aged 40 years and older.

Race

• Leiomyoma usually affects individuals of the Afro-American women.

Risk Factors

• Common risk factors in the development of uterine leiomyoma are Afro-American race, early menarche, prenatal exposure to diethylstilbestrol, having one or more pregnancies extending beyond 20 weeks, obesity, significant consumption of beef and other reds meats, hypertension, family history, and alcohol consumption.

Natural History, Complications and Prognosis

• The majority of patients with uterine leiomyoma remain asymptomatic for 30s or 40s.
• Common complications of uterine leiomyoma include dysmenorrhea, dyspareunia, leiomyoma degeneration or torsion, transcervical prolapse, and miscarriage.

Diagnosis

Symptoms

• Leiomyoma is usually asymptomatic.
• Symptoms of uterine leiomyoma may include the following:

• Abnormal gynecologic hemorrhage
• Heavy or painful periods
• Abdominal discomfort or bloating
• Back ache
• Urinary frequency or retention
• Infertility

Physical Examination

• Physical examination may be remarkable for:

• Enlarged, mobile uterus with an irregular contour on bimanual pelvic examination

Imaging Findings

• On ultrasound imaging, uterine leiomyoma is characterized by the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam.

Other Diagnostic Studies

• Uterine leiomyoma may also be diagnosed using diagnostic hysteroscopy, magnetic resonance imaging, and hysterosalpingography.

Treatment

The presence of fibroids does not mean that they need to be treated; it is expectantly depending on the symptomatology and presence of related conditions. The presence of uterine fibroids can cause problems which can be solved by:

• Surgery: Surgical removal of a uterine fibroid usually takes place via hysterectomy, in which the entire uterus is removed, or myomectomy, in which only the fibroid is removed. It is possible to remove multiple fibroids during a myomectomy. Although a myomectomy cannot prevent the recurrence of fibroids at a later date, such surgery is increasingly recommended, especially in the case of women who have not completed bearing children or who express an explicit desire to retain the uterus. There are three different types of myomectomy:
  • In a hysteroscopic myomectomy, the fibroid is removed by the use of a resectoscope, an endoscopic instrument that can use high-frequency electrical energy to cut tissue. Hysteroscopic myomectomies can be done as an outpatient procedure, with either local or general anesthesia used. Hysteroscopic myomectomy is most often recommended for submucosal fibroids. A French study collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm.
  • A laparoscopic myomectomy requires a small incision near the navel. The physician then inserts a laparoscope into the uterus and uses surgical instruments to remove the fibroids. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm.
  • A laparotomic myomectomy (also known as an open or abdominal myomectomy) is the most invasive surgical procedure to remove fibroids. The physician makes an incision in the abdominal wall and removes the fibroid from the uterus. A particularly extensive laparotomic procedure may necessitate that any future births be conducted by Caesarean section. Recovery time from a laparatomic procedure is generally expected to be four to six weeks.
• Uterine artery embolization (UAE): Using interventional radiology techniques, the Interventional Radiologist occludes both uterine arteries, thus reducing blood supply to the fibroid . A small catheter (1 mm in diameter) is inserted into the femoral artery at the level of the groin under local anesthesia. Under imaging guidance, the interventionnal radiologist will enter selectively into both uterine arteries and inject small (500 µm) particles that will block the blood supply to the fibroids. This results in shrinking of the fibroids and of the uterus, thus alleviating the symptoms in most cases. Uterine Artery Embolization is now recognized as a viable alternative to hysterectomy and most women suffering from fibroid related symptoms can be treated with this technique.

Medical Therapy

• The mainstay of therapy for uterine leiomyoma is oral contraceptive pills, either combination pills or progestin-only, Gonadotropin-releasing hormone analogs

Surgery

• Surgery is the mainstay of therapy for uterine leiomyoma.
• Uterine artery embolization in conjunction with laparotomic myomectomy is the most common approach to the treatment of [disease name].
• Hysteroscopic myomectomy can also be performed for patients with uterine leiomyoma.