子宫肌瘤
Myoma of uterus
? Benign neoplasm composed primarily of
smooth muscle
? Present in 20-25% of reproductive-age
women
? Usually asymptomatic
? most common benign tumor of female
reproductive system,And the most common
benign tumor in human body
Introduction
? The exact cause is not very
clear,Probably relates to female
hormones,
? Evidence:Not detectable before puberty
and after menopause,estrogen and E-R
are higher in myoma than that in
normal myometrium.P may promote
mitosis of myoma
Etiology
1.According to the location,myoma is
divided into,
Uterine body myoma(92%)
Cervical myoma(8%).
Classification
2.according to the relationship
between myoma and uterine
myometrium,myoma is divided into:
? Submucous myoma(10%~15%), lie just
beneath the endometrium and grow toward
the uterine lumen
? Intramural myoma(60%~70%),lie within the
uterine wall
? Subserous myoma(20%):lie just beneath the
serosal surface of the uterus
Submucous myoma
Submucous myoma by
hysteroscope
Subserous myoma
Intramural myoma
Pathology
? On gross examination
they are white-colored,round,smooth,and usually
firm,Leiomyomas have a pseudocapsule,so they can
be easily and cleanly enucleated from the
surrounding myometrial tissue.
?On microscopic examination
Myoma originates from uterine smooth
muscle cells or from vascular smooth muscle
cells.Under microscope,it is whorled
appearance and its smooth muscle fibers are
arranged in interlacing bundles of varying
size running in different directions.
Pathology
? Degeneration:lose the original typical structure.
? The following types:
1,Hyaline degeneration
2,Cystic degeneration
3,Red degeneration
4,Sarcomatous change
5,Degeneration with calcification
Degeneration
Hyaline degeneration
?Hyaline degeneration
The most common degeneration.its
whorled structure disappears and is
replaced by clear substance,white
color.Under microscope,the cells in the
degeneration area disappear,
?Cystic degeneration
It is a secondary change following hyline
degeneration.There is tissue necrosis and
liquefaction and forms mutiplecysts
Cystic degeneration
?Degeneration with calcification
Majority occur in the myomas with thin
pedecle or after menopause,for the circu-
lation is insufficient,which causes
precipitation of calcium carbonate and
phosphate within the tumor,Often secon-
dary to the fatty degeneration
Degeneration with calcification
Red degeneration
? Venous thrombosis and congestion with interstitial
hemorrhage are responsible for the dark red color
of a leiomyoma undergoing red degeneration.Its
whorled structure disappears and has bad smell.
? Red degeneration is most common During
pregnancy and puerperium.It is a special type
necrosis,the cause is not clear.
? The process is usually accompanied by pain and
fever and rapidly enlarged myoma.
Sarcomatous change
? Sarcomatous change is malignant
transformation of leiomyoma.
? The frequency is 0.4-0.8%,often occurs in
old women.The myoma enlarges rapidly
in short term with irregular vaginal bleed-
ing.
Sarcomatous
change
Symptoms
? Usually no symptoms.
? Once there are symptoms,the
symptoms from leiomysmas depend
on their location,the speed of
growth and degenerations,and not
associate with the size and the
number of myomas.
? 1,menstruation change
? 2,abdominal mass
? 3,leucorrhea
? 4,Abdominal pain
? 5,compress symptom
? 6,infertility
? 7,anemia
Main symptoms
Main symptoms
? Abnormal uterine bleeding
1,It is the most common and most important
clinical manifestation of myoma
2,The most common symptom:large intrmural
myoma,sub-mucous myoma,necrosis or infection
of myoma,subserous or small myoma.
?Mass of lower abdomen
Mass could be found when palpate
the patients,lower abdomen.
?Leukorrhagia:myoma increase the
size of uterine cavity,infection of
submucous myoma
Main symptoms
Main symptoms
? Pain
Pain may result from
1,Red degeneration Infection
2,torsion of a pendunculated subserous
myoma
3,myometrial contractions to expel a
submucous myoma from the uterine
cavity.
? Pressure effects
1,Large tumors may fill the true pelvis and
compress the ureters,bladder,or rectum.
2,Cervical tumors may cause dyspareunia and
infertility
3,Parasitic tumors may cause intestinal
obstruction if they are largely involved in
bowel.
Main symptoms
Main symptoms
? Infertility and Spontaneous abortion
1,The relationship between myoma and infertility
remains uncertain,Between 25% and 40% of
women with multiple leiomyomas are reported
to be infertile.Cause.
2,The incidence of spontaneous abortion
secondary to leiomyoma is unknown
? Anemia
Signs
The physical signs are associated with the size,loc-
Ation,number and whether there is degeneration.
Large myoma
On gynecological examination:intramural myoma,
subserous myoma,submucous myoma,myoma
located on external cervical OS or in vagina,
myoma infection.
Diagnosis
? Not usually difficult
? Evidence:
1,Typical symptoms and signs
2,Ultrasound
3,Hysteroscopy and Laparoscopy
Differential diagnosis
? Pregnancy
? Ovarian cysts or neoplasia
? Adenomyosis or adenomyoma
? Inflammatory pelvic mass(e.g,tubo-
ovarian inflammatory masses)
? Uterine anomalies
Treatment
? Choice of treatment depends on
1,Patient age
2,Pregnancy status
3,Desire for future pregnancies
4,General health
5,Symptoms
6,The size,location,and state of
leiomyomas
Treatment
? In most instances,myomas do not
require treatment,particularly if there is
no symptom,myoma is small or if the
patient is postmenopausal.
? Following observation:the patient should
initially be examined every 3-6 months
after diagnosis to establish the rate of
growth of the myomas.
Medical therapy--GnRH
? Although no definitive medical therapy is
currently available for leiomyomata,the
gonadotropin-releasing hormone(GnRH)
agonists have proven very useful for
limiting growth or to cause a temporary
decrease in tumor size.
? GnRH agonists treatment fits for small
myoma(<2 month gestation）
Medical therapy--GnRH
? GnRH treatment will achieve the following
results:
1,Maximal shrinkage of the myomatous uterus to
approximately 50% of its volume
2,This shrinkage is achieved within 3 months of
treatment
3,Amenorrhea and hypoestrogen side effects
4,Osteoporosis may occur,especially with
treatment lasting longer than 6 months
Medical therapy--GnRH
? Indication:
1,Control of bleeding from myoma
2,shrinkage may be sufficient to
allow laparoscopically assisted
vaginal hysterectomy,standard
vaginal hysterectomy and in
certain cases for myomectomy.
Surgical measures
? Include
1,Myomectomy
2,Hysterectomy
Myomectomy
? Myomectomy should be planned for the
symptomatic patient who wishes to preserve
fertility or conserve the uterus,<35years old.
? Increasingly myomectomy is being performed
through the hysteroscope in cases of submucous
leiomyomata and through the laparoscope for
subserous leiomyomata.
? Indeed,these less invasive procedures are
liberalizing the surgical indications for
myomectomy.
Hysterectomy
? Indication:
1,Obviously symptomatic patient
2,No wish of preserving fertility or conserving
the uterus
3,Suspects malignant transformation
4,Numerous large tumors
? Types of operation:
Total abdominal hysterectomy
Subtotal abdominal hysterectomy
If <50,and ovary is normal,it should be
preserved.
Myomas during pregnancy
? During labor leiomyomas may produce
uterine inertia,fetal malpresentation,or
obstruction of the birth canal.
? In general,delivery may be accomplished.
Nevertheless,a large cervical or isthmic
myoma may be rather immobile and may
necessitate cesarean delivery.
? Leiomyomas may interfere with effective
uterine contraction immediately after
delivery; therefore,the possibility of
postpartum hemorrhage should be
anticipated.
Degeneration of myomas
during pregnancy
? During the second and third trimesters
of pregnancy,myomas may rapidly
increase in size and undergo vascular
deprivation and subsequent
degenerative changes,Clinically this
most commonly leads to pain fever
nausea and localized tenderness but
may also initiate preterm labor.
Myoma of uterus
? Benign neoplasm composed primarily of
smooth muscle
? Present in 20-25% of reproductive-age
women
? Usually asymptomatic
? most common benign tumor of female
reproductive system,And the most common
benign tumor in human body
Introduction
? The exact cause is not very
clear,Probably relates to female
hormones,
? Evidence:Not detectable before puberty
and after menopause,estrogen and E-R
are higher in myoma than that in
normal myometrium.P may promote
mitosis of myoma
Etiology
1.According to the location,myoma is
divided into,
Uterine body myoma(92%)
Cervical myoma(8%).
Classification
2.according to the relationship
between myoma and uterine
myometrium,myoma is divided into:
? Submucous myoma(10%~15%), lie just
beneath the endometrium and grow toward
the uterine lumen
? Intramural myoma(60%~70%),lie within the
uterine wall
? Subserous myoma(20%):lie just beneath the
serosal surface of the uterus
Submucous myoma
Submucous myoma by
hysteroscope
Subserous myoma
Intramural myoma
Pathology
? On gross examination
they are white-colored,round,smooth,and usually
firm,Leiomyomas have a pseudocapsule,so they can
be easily and cleanly enucleated from the
surrounding myometrial tissue.
?On microscopic examination
Myoma originates from uterine smooth
muscle cells or from vascular smooth muscle
cells.Under microscope,it is whorled
appearance and its smooth muscle fibers are
arranged in interlacing bundles of varying
size running in different directions.
Pathology
? Degeneration:lose the original typical structure.
? The following types:
1,Hyaline degeneration
2,Cystic degeneration
3,Red degeneration
4,Sarcomatous change
5,Degeneration with calcification
Degeneration
Hyaline degeneration
?Hyaline degeneration
The most common degeneration.its
whorled structure disappears and is
replaced by clear substance,white
color.Under microscope,the cells in the
degeneration area disappear,
?Cystic degeneration
It is a secondary change following hyline
degeneration.There is tissue necrosis and
liquefaction and forms mutiplecysts
Cystic degeneration
?Degeneration with calcification
Majority occur in the myomas with thin
pedecle or after menopause,for the circu-
lation is insufficient,which causes
precipitation of calcium carbonate and
phosphate within the tumor,Often secon-
dary to the fatty degeneration
Degeneration with calcification
Red degeneration
? Venous thrombosis and congestion with interstitial
hemorrhage are responsible for the dark red color
of a leiomyoma undergoing red degeneration.Its
whorled structure disappears and has bad smell.
? Red degeneration is most common During
pregnancy and puerperium.It is a special type
necrosis,the cause is not clear.
? The process is usually accompanied by pain and
fever and rapidly enlarged myoma.
Sarcomatous change
? Sarcomatous change is malignant
transformation of leiomyoma.
? The frequency is 0.4-0.8%,often occurs in
old women.The myoma enlarges rapidly
in short term with irregular vaginal bleed-
ing.
Sarcomatous
change
Symptoms
? Usually no symptoms.
? Once there are symptoms,the
symptoms from leiomysmas depend
on their location,the speed of
growth and degenerations,and not
associate with the size and the
number of myomas.
? 1,menstruation change
? 2,abdominal mass
? 3,leucorrhea
? 4,Abdominal pain
? 5,compress symptom
? 6,infertility
? 7,anemia
Main symptoms
Main symptoms
? Abnormal uterine bleeding
1,It is the most common and most important
clinical manifestation of myoma
2,The most common symptom:large intrmural
myoma,sub-mucous myoma,necrosis or infection
of myoma,subserous or small myoma.
?Mass of lower abdomen
Mass could be found when palpate
the patients,lower abdomen.
?Leukorrhagia:myoma increase the
size of uterine cavity,infection of
submucous myoma
Main symptoms
Main symptoms
? Pain
Pain may result from
1,Red degeneration Infection
2,torsion of a pendunculated subserous
myoma
3,myometrial contractions to expel a
submucous myoma from the uterine
cavity.
? Pressure effects
1,Large tumors may fill the true pelvis and
compress the ureters,bladder,or rectum.
2,Cervical tumors may cause dyspareunia and
infertility
3,Parasitic tumors may cause intestinal
obstruction if they are largely involved in
bowel.
Main symptoms
Main symptoms
? Infertility and Spontaneous abortion
1,The relationship between myoma and infertility
remains uncertain,Between 25% and 40% of
women with multiple leiomyomas are reported
to be infertile.Cause.
2,The incidence of spontaneous abortion
secondary to leiomyoma is unknown
? Anemia
Signs
The physical signs are associated with the size,loc-
Ation,number and whether there is degeneration.
Large myoma
On gynecological examination:intramural myoma,
subserous myoma,submucous myoma,myoma
located on external cervical OS or in vagina,
myoma infection.
Diagnosis
? Not usually difficult
? Evidence:
1,Typical symptoms and signs
2,Ultrasound
3,Hysteroscopy and Laparoscopy
Differential diagnosis
? Pregnancy
? Ovarian cysts or neoplasia
? Adenomyosis or adenomyoma
? Inflammatory pelvic mass(e.g,tubo-
ovarian inflammatory masses)
? Uterine anomalies
Treatment
? Choice of treatment depends on
1,Patient age
2,Pregnancy status
3,Desire for future pregnancies
4,General health
5,Symptoms
6,The size,location,and state of
leiomyomas
Treatment
? In most instances,myomas do not
require treatment,particularly if there is
no symptom,myoma is small or if the
patient is postmenopausal.
? Following observation:the patient should
initially be examined every 3-6 months
after diagnosis to establish the rate of
growth of the myomas.
Medical therapy--GnRH
? Although no definitive medical therapy is
currently available for leiomyomata,the
gonadotropin-releasing hormone(GnRH)
agonists have proven very useful for
limiting growth or to cause a temporary
decrease in tumor size.
? GnRH agonists treatment fits for small
myoma(<2 month gestation）
Medical therapy--GnRH
? GnRH treatment will achieve the following
results:
1,Maximal shrinkage of the myomatous uterus to
approximately 50% of its volume
2,This shrinkage is achieved within 3 months of
treatment
3,Amenorrhea and hypoestrogen side effects
4,Osteoporosis may occur,especially with
treatment lasting longer than 6 months
Medical therapy--GnRH
? Indication:
1,Control of bleeding from myoma
2,shrinkage may be sufficient to
allow laparoscopically assisted
vaginal hysterectomy,standard
vaginal hysterectomy and in
certain cases for myomectomy.
Surgical measures
? Include
1,Myomectomy
2,Hysterectomy
Myomectomy
? Myomectomy should be planned for the
symptomatic patient who wishes to preserve
fertility or conserve the uterus,<35years old.
? Increasingly myomectomy is being performed
through the hysteroscope in cases of submucous
leiomyomata and through the laparoscope for
subserous leiomyomata.
? Indeed,these less invasive procedures are
liberalizing the surgical indications for
myomectomy.
Hysterectomy
? Indication:
1,Obviously symptomatic patient
2,No wish of preserving fertility or conserving
the uterus
3,Suspects malignant transformation
4,Numerous large tumors
? Types of operation:
Total abdominal hysterectomy
Subtotal abdominal hysterectomy
If <50,and ovary is normal,it should be
preserved.
Myomas during pregnancy
? During labor leiomyomas may produce
uterine inertia,fetal malpresentation,or
obstruction of the birth canal.
? In general,delivery may be accomplished.
Nevertheless,a large cervical or isthmic
myoma may be rather immobile and may
necessitate cesarean delivery.
? Leiomyomas may interfere with effective
uterine contraction immediately after
delivery; therefore,the possibility of
postpartum hemorrhage should be
anticipated.
Degeneration of myomas
during pregnancy
? During the second and third trimesters
of pregnancy,myomas may rapidly
increase in size and undergo vascular
deprivation and subsequent
degenerative changes,Clinically this
most commonly leads to pain fever
nausea and localized tenderness but
may also initiate preterm labor.
