Uterine Myomas – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Uterine leiomyomas are well-circumscribed, pseudoencapsulated, benign monoclonal tumors composed mainly of smooth muscle with varying amounts of fibrous connective tissue (1,2).
- 3 major subtypes:
- Subserous: Common; external; may become pedunculated
- Intramural: Common; within myometrium; may cause marked uterine enlargement
- Submucous: ∼5% of all cases; internal, evincing abnormal uterine bleeding and infection; occasionally protruding from cervix
- System(s) affected: Reproductive
- Synonyms: Fibroids; Myoma; Fibromyoma; Myofibroma; Fibroleiomyoma
- Incidence increases with each decade during reproductive years and is highest in perimenopausal age group (range 5.4–77%).
- Not seen in premenarchal females
- Predominant age: 3rd–4th decades
- Predominant sex: Females only
- 3 times more frequent and occurs earlier in African Americans
- 4–11% of all women
- 20% of women 35 years of age
- 40% of women 50 years of age
- Black women have a 2.9-fold increase in relative risk compared with white women (2).
- Early menarche (<10 years)
- Familial predisposition
- Consuming red meat, alcohol; risk decreases with green vegetables
- Approximately 50% of leiomyomas have an abnormal karyotype (1).
- Most common cytogenetic abnormalities are deletions on chromosome 7.
Enlargement of benign smooth muscle tumors that may lead to symptoms affecting the reproductive, GI, or genitourinary system
Complex multifactorial process involving transition from normal myocyte to abnormal cells and then to visibly evident tumor (monoclonal expansion):
- Hormones (2): Increases in estrogen and progesterone are correlated with myoma formation (i.e., rarely seen before menarche).
- Growth factors (2):
- Increased smooth muscle proliferation (transforming growth factor β [TGF-β], basic fibroblast growth factor [bFGF])
- Increase DNA synthesis (epidermal growth factor [EGF], PDGF)
- Stimulate synthesis of extracellular matrix (TGF-β)
- Promote mitogenesis (TGF-β, EGF, IGF, prolactin)
- Promote angiogenesis (bFGF, VEGF)
- Vasoconstrictive hypoxia (2): Proposed, but not confirmed, mechanism of myometrial injury during menstruation
Commonly Associated Conditions
Endometrial carcinoma is also associated with high unopposed estrogen stimulation.
- Usually asymptomatic
- Symptoms include:
- Abnormal uterine bleeding, usually heavy or prolonged menses
- Pain: Infrequent, usually associated with torsion of pedunculated myoma or degeneration
- Pressure on bladder: Suprapubic discomfort, urinary frequency or obstruction
- Pressure on rectosigmoid: May cause low back pain, constipation
- Infertility: Usually from submucous myoma or with distortion of uterine cavity
Rapid growth, particularly in perimenopausal or postmenopausal patients, may indicate sarcoma
- Usually incidental finding on abdominal and pelvic exam
- Firm, smooth nodules or masses arising from uterus
- Masses are mobile without tenderness.
Diagnostic Tests & Interpretation
Initial lab tests
- Pregnancy test
Follow-Up & Special Considerations
Consider CA-125: May be slightly elevated in some cases of uterine myoma but generally more useful in differentiating myomas from various gynecologic adenocarcinomas
- Pelvic ultrasound: Shows characteristic hypoechoic appearance (3)[B]
- Saline-infusion hysterosonography: Helps to distinguish submucosal myomas (3)[B]
- Hysterosalpingogram: Evaluates the contour of the endometrial cavity (3)[B]
- CT scan or MRI: May help to differentiate complex cases or used when uterine artery embolization is planned (3)[B]
Follow-Up & Special Considerations
- Intravenous pyelogram: If suspect ureteral distortion (3)[B]
- Barium enema
- Fractional dilation and curettage: Aids in ruling out cervical or uterine carcinomas when clinically suspicious
- Hysteroscopy: Helps to diagnose submucosal or intracavitary myomas
- Laparoscopy: Useful in complex cases and to rule out other pelvic diseases or disorders
- Myomas are usually multiple and vary in size and location; have been reported up to 100 lb.
- Gross pathology: Firm tumors with characteristic whorl-like trabeculated appearance; a thin pseudocapsular layer is present.
- Microscopic: Bundles of smooth muscle mixed with varying amounts of connective tissue elements running in different directions
- Cellular variant has a preponderance of muscle cells. Mitoses are rare.
- May undergo various types of degeneration:
- Hyaline degeneration: Very common
- Calcification: Late result of circulatory impairment to myomas
- Infection and suppuration: Most common with submucosal myomas
- Necrosis: Most common with pedunculated myomas secondary to torsion
- Sarcomatous changes: Incidence 0.1–1.0% of clinically apparent myomas
- Intrauterine pregnancy
- Ovarian or uterine cancer
- Cecal or sigmoid tumor
- Appendiceal abscess
- Pelvic kidney
- Urachal cyst
- Treatment must be individualized.
- Initially, medication therapy may be of benefit.
- 60% of patients may elect surgery by 2 years (4).
- Patients with minimal symptoms may be managed with iron preparations and analgesics.
- Conservative management of asymptomatic myomas:
- Pelvic exams and ultrasound at 3- to 6-month intervals as long as size remains stable
- Regression usually occurs after menopause.
- Progestins may reduce overall uterine size (3)[B]:
- Norethindrone 10 mg/d
- Medroxyprogesterone (Depo-Provera) 200 mg IM monthly
- Combination oral contraceptives: Help prevent development of new fibroids:
- Contraindications: History of thromboembolic events: See manufacturer’s profile.
- Adverse reactions and significant interactions: See manufacturer’s profile.
- Luteinizing hormone–releasing hormone:
- Nafarelin (Synarel Nasal Spray), goserelin (Zoladex Depot), and leuprolide (Lupron Depot)
- Induces abrupt artificial menopause; may reduce myoma symptoms dramatically; induces atrophy of myomas by up to 40% in 2–3 months (3)[B]
- May be valuable as preoperative adjunct to myomectomy or hysterectomy by allowing recovery of anemia, donation of autologous blood, and possibly converting abdominal to vaginal hysterectomy, thereby decreasing postoperative pain, hospitalization, and morbidity (3)[B]
- Not recommended for use >6 months because of osteoporosis risk
- Following discontinuation, myomas return within 60 days to pretherapy size.
- Shown to have similar reduction in myoma size as gonadotropin-releasing hormone agonists (5)[B]
Patients not desiring pharmacologic therapy or surgery may consider:
- Uterine artery embolization: Averages 30–45% shrinkage of myomas (3)[A]; painful and may cause ovarian failure, amenorrhea or other complications; shorter hospital stay and quicker recovery but no difference in satisfaction compared with hysterectomy (6)[A]
- Magnetic resonance imaging-guided focused ultrasound: Noninvasive, ultrasound transducer passes through abdominal wall and causes coagulative necrosis of fibroid. Efficacy may be comparable with other hysterectomy-sparing procedures (5)[B].
Issues for Referral
- Medical therapy may be initiated by a primary care physician or gynecologist. Adequate pelvic examination must be performed initially.
- Surgical considerations may be pursued with gynecologic consultation.
- Uterine embolization may be discussed with an interventional radiologist.
- Surgical management is indicated in the following situations (3)[B]:
- Excessive uterine size or excessive rate of growth (except during pregnancy)
- Submucosal myomas when associated with hypermenorrhea
- Pedunculated myomas that are painful or undergo torsion, necrosis, and hemorrhage
- If a myoma causes symptoms from pressure on bladder or rectum
- If differentiation from ovarian mass is not possible
- If associated pelvic disease is present (endometriosis, pelvic inflammatory disease)
- If infertility or habitual abortion is likely due to the anatomic location of the myoma
- Surgical procedures:
- Preliminary pelvic examination, Pap smear, and endometrial biopsy should be performed to rule out malignant or premalignant conditions.
- Hysterectomy: May be performed vaginally, laparoscopically, robotically or by laparotomy:
- Effective in relieving symptoms and improving quality of life (5)[B]
- Abdominal, laparoscopic, or robotic myomectomy may be performed in younger women who want to maintain fertility (3)[B].
- Hysteroscopic or laparoscopic cautery or laser myoma resection can be performed in selected patients.
- Endometrial ablation: For small submucosal myomas
- Usually outpatient
- Inpatient for some surgical procedures
- Pelvic examination and ultrasound: Every 2–3 months for newly diagnosed symptomatic or excessively large myomas
- Hemoglobin and hematocrit: If uterine bleeding is excessive
- Once uterine size and symptoms stable, monitor every 6–12 months.
- Medline Plus: http://www.nlm.nih.gov/medlineplus/uterinefibroids.html
- JAMA Patient Page: http://jama.ama-assn.org/cgi/reprint/301/1/122.pdf
- Society of Interventional Radiology: http://sirweb.org/patients/uterine-fibroids/
- US Department of Health and Human Services: http://womenshealth.gov/faq/uterine-fibroids.cfm
- American Congress of Obstetricians and Gynecologists (ACOG): http://www.acog.org
- Resection of submucosal fibroids has been associated with increased fertility (5)[B].
- Laparoscopic myomectomy does not have any difference in clinical pregnancy rate and live birth rate than laparotomy (7)[C].
- At least 10% of myomas recur after myomectomy; however, most women will not require further treatment (5)[B].
- May mask other gynecologic malignancies (e.g., uterine sarcoma, ovarian cancer)
- Degenerating fibroids may cause pain.
- May rarely prolapse through the cervix
- Rapid growth of fibroids is common.
- Pregnant women may need additional fetal testing if placenta is located over or near fibroid.
- Complications during pregnancy: Abortion, premature labor, 2nd-trimester rapid growth leading to degeneration and pain, and 3rd-trimester fetal malpresentation and dystocia during labor and delivery
- Previous myomectomy patients may develop uterine rupture during labor. Cesarean section is recommended if the endometrial cavity has been entered during myomectomy.
In postmenopausal patients with newly diagnosed uterine myoma or enlarging uterine myomas, have a high suspicion of uterine sarcoma or other gynecologic malignancy.
1. Okolo S. Incidence, aetiology and epidemiology of uterine fibroids. Best Pract Res Clin Obstet Gynaecol.2008.
2. Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril. 2007;87:725–36.
3. Wallace EE, et al. Uterine Myomas: An overview of development, clinical features and management.Obstetrics Gynecol. 2004;104(2):393–406.
4. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding.Cochrane Database Syst Rev. 2006:CD003855.
5. Parker WH. Uterine myomas: management. Fertil Steril. 2007;88:255–71.
6. Gupta JK, Sinha AS, Lumsden MA, et al. Uterine artery embolization for symptomatic uterine fibroids.Cochrane Database Syst Rev. 2006:CD005073.
7. Griffiths A, et al. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2007:3.
Cheng MH, Chao HT, Wang PH. Medical treatment for uterine myomas. Taiwan J Obstet Gynecol. 2008;47:18–23.
Istre O. Management of symptomatic fibroids: conservative surgical treatment modalities other than hysterectomy and abdominal or laparoscopic myomectomy. Best Pract Res Clin Obstet Gynaecol. 2008.
- 218.0 Submucous leiomyoma of uterus
- 218.1 Intramural leiomyoma of uterus
- 218.2 Subserous leiomyoma of uterus
- 218.9 Leiomyoma of uterus, unspecified
- 95315005 uterine leiomyoma (disorder)
- 95279007 submucous leiomyoma of uterus (disorder)
- 95280005 subserous leiomyoma of uterus (disorder)
- 93616000 intramural leiomyoma of uterus (disorder)
- Uterine myomas are benign smooth muscle tumors composed mainly of fibrous connective tissue.
- Usually incidental finding on pelvic exam or ultrasound, but may cause pelvic pain and pressure, abnormal uterine bleeding, and/or infertility
- Management ranges from conservative to medical to surgical.