Leiyomyoma

Leiomyoma, as it is named is a benign tumor arising from uterine smooth muscle.  It is also can be termed as may contain fibrous tissue giving it a firm consistency. It is a common tumor that can cause heavy menstrual bleeding, pelvic pressure symptoms and reproductive disorders.

Histological findings usually show a whorled of smooth muscle cells, enclosed in a pseudocapsule as it compressed the adjacent normal smooth muscle tissues. Grossly, it is a nodule which can be located as described :

·         Adjacent to and bulging into the endometrial cavity (submucous fibroid)

·         Centrally within myometrium (intramural fibroid)

·         Outer border of the myometrium (subserosal fibroid)

·         Attached to uterus by a narrow pedicle containing blood vessels (peduculated fibroid)

It is believed to be an estrogen-dependant mass. Fibroids have higherer concentrations of estrogen receptors if to be compared with normal myometrium. Hence, estrogen plays a major role in setting the pathogenesis of fibroids in motion. This is evidenced by increasing prevalence during reproductive ages particularly more than 30 yrs old and markedly reduce following menopause. It is never present in preadolescent female.

Early menarche and obesity also are associated with risk of developing fibroid due to exposure towards endogenous steroid hormones. Having family history of fibroids and nulliparity do increase the risk as well. Caution is required, however, when linking association to cause.

Fibroid is often asymptomatic,requiring no treatment or may also be found coincidentally. Patients may presented with prolonged history of menorrhagia together with remarkable anemia symptoms made her decided to bring the medical problem to attention of physician. 

Menorrhagia by definition, is an excessive menstrual bleeding diagnosed when monthly menstrual loss exceeds 80ml. It  usually signify that the fibroid is of submucous origin because it increases the endometrial surface area hence distorting the endometrial cavity. There are other possible symptoms which might occur in women with fibroid such as :

• ·         Subfertility as it distorts the endometrial cavity, preventing the implantation of a fertilized ovum. Fallopian tube might be occluded as well.
• ·         Compressive symptoms if it is large enough to compress the adjacent organs such as rectum and urinary bladder, causing tenesmus and increased urinary frequency respectively.
• ·         Pain if there is acute degeneration of the tissue. This is often associated with mild pyrexia and leuckocytosis.
• ·         Pregnancy problem such as abnormal lie and postpartum hemorrhage secondary to inefficient uterine contraction.

There was a patient, I've clerked for my case write up, let say Madam Lola... in her case she denied denied any pressure symptoms like urinary retention or frequency, constipation or tenesmus. She is also fertile and never had problem with her pregnancy except for her miscarriage in second pregnancy. The cause of the miscarriage was unknown, as that happened 19 years ago so the patient couldn't recall why she had the miscarrriage. However, endometrial pathology may cause miscarriage as mentioned before. There was no pain in case of the Madam Lola.

After the fibroid is suspected based on the history (e.g.: heavy menses, lethargy) and general inspection (eg: pallor), evaluation usually started with pelvic examination which includes both speculum examination and bimanual examination. Abdomen should be examined thoroughly to describe the mass, hence helps in narrowing the diagnosis. Full blood count which is routinely done is very important to confirm the anaemia.

Transvaginal ultrasound is often done to confirm the source of a pelvic mass and define the anatomy of pathology which can lead to menorrhagia like what Puan Farida have had. Hysteroscope is best carried out to see the uterine cavity, at which sometimes is helpful in obtaining endometrium sample for histological analysis.

Management and treatment of choice involves counselling of the patient by the specialist beforehand, considering the desire of the patient (and the spouse if married) whether they have desire to keep the patient’s fertility, socio-economical status and cosmetic purpose.

Treatment options are :

a)      Conservative management

·         In asymptomatic and minimal symptom

·         Follow-up for 6-12 monthly to asses the growth rate by abdominal examination and ultrasound

b)      Medical management

·         Gonadotrophin-releasing hormone to shrink (reduce vascularity and size) the fibroids. It can be used to reduce the size prior to surgery if necessary. This is useful in reducing blood loss and transfusion.

c)      Surgical management

·         Myomectomy : preferred if fertility is desired but more risk of threatening bleeding which may be proceeded with emergency hysterectomy.

·         Hysterectomy  :  The definitive of treatment for menorrhagia. There are several types of hysterectomy, distinguished by the method used to approach the organ.

·         Hysteroscopic resection

·         Embolization of uterine artery : latest option peformed by interventional radiologist.

Vaginal hysterectomy was a treatment of choice for Madam Lola and agreed by her husband because they do not have plan to have any more children in the future. She also would prefer to avoid scar left on her abdomen to have a better quality of life after the surgery.

           

Btw, nowadays, it is not really accurate to describe heavy menstruation  as menorrhagia. Most specialists I've   met they prefered to describe the heavy menstruation  in detailed manner and don't  prefer to use the term menorrhagia. Whether it is prolonged, regular, increased number of pads...etc. 

 In obstetric, fibroid may interfere with normal fetal lie as well. And fibroid degeneration ia quite common as well, leading to acute abdominal  pain in pregnancy. Chack that out. 

References

Voorhis, B. V. (2009) A 41-Year-Old woman with menorrhagia, anemia, and fibroids: review of      

          treatment of uterine fibroids, JAMA, 301(1):82-93

Monga, A., Dobbs, S. (2011)  Gynaecology by ten teachers. CPC Press.

 Shaw, H. A. (2013, June 5). Vaginal Hysterectomy  [Article for reference]. Retrieved 2014,   

         September 23 from http://emedicine.medscape.com/article/1839938-overview.