Uterine Leiomyomata Case File

Uterine Leiomyomata Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 41

A 40-year-old G5P5 woman complains of heavy vaginal bleeding with clots of 2-year duration. She denies bleeding or spotting between periods. She states that several years ago a doctor had told her that her uterus was enlarged. Her records indicate that 1 year ago she underwent a uterine dilation and curettage, with the tissue showing benign pathology. She denies fatigue, cold intolerance, or galactorrhea. She takes ibuprofen without relief of her vaginal bleeding. On examination, her blood pressure (BP) is 135/80 mm Hg, heart rate (HR) is 80 beats per minute (bpm), weight is 140 lb, and temperature is 98°F (36.6°C). The heart and lung examinations are normal. The abdomen reveals a lower abdominal midline irregular mass. On pelvic examination, the cervix is anteriorly displaced. An irregular midline mass approximately 18 weeks’ size seems to move in conjunction with the cervix. No adnexal masses are palpated. Her pregnancy test is negative. Her hemoglobin level is 9.0 g/dL, leukocyte count is 6,000/mm3, and platelet count is 160,000/mm3.

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ANSWER TO CASE 41:

Uterine Leiomyomata                                           

Summary: A 40-year-old G5P5 woman with a history of an enlarged uterus complains of menorrhagia and anemia despite ibuprofen. A prior uterine dilation and curettage showed benign pathology. Examination reveals an irregular midline mass approximately 18 weeks’ size that is seemingly contiguous with the cervix, and there is an anteriorly displaced cervix.

• Most likely diagnosis: Symptomatic uterine leiomyomata.
• Next step: Offer the patient a hysterectomy.

ANALYSIS

Objectives

1. Understand that the most common reason for hysterectomy in the United States is symptomatic uterine fibroids.
2. Know that hysterectomy is generally reserved for women with symptomatic uterine fibroids that are refractory to an adequate trial of medical therapy.
3. Know that menorrhagia is the most common symptom of uterine leiomyomata.

Considerations

This 40-year-old woman complains of menorrhagia. The physical examination is consistent with uterine fibroids, because of the enlarged midline mass that is irregular and contiguous with the cervix. If the mass were lateral or moved apart from the cervix, another type of pelvic mass, such as ovarian, would be suspected. This patient complains of menorrhagia (excessive bleeding during menses), the most common symptom of uterine fibroids. If she had intermenstrual bleeding, the clinician would have to consider other diseases, such as endometrial hyperplasia, endometrial polyp, or uterine cancer, in addition to the uterine leiomyomata. Irregular cycles (menometrorrhagia) may suggest an anovulatory process. The patient has anemia despite medical therapy, constituting the indication for intervention, such as hysterectomy. If the uterus were smaller, consideration may be given toward another medical agent, such as medroxyprogesterone acetate (Provera). Also, a gonadotropin-releasing hormone (GnRH) agonist can be used to shrink the fibroids temporarily, to correct the anemia, or make the surgery easier. The maximum shrinkage of fibroids is usually seen after 3 months of GnRH agonist therapy. After the GnRH agonist is stopped, the fibroids would regrow.

APPROACH TO:

Suspected Uterine Leiomyomata                                              

DEFINITIONS

LEIOMYOMATA: Benign, smooth muscle tumors, usually of the uterus.

LEIOMYOSARCOMA: Malignant, smooth muscle tumor, with numerous mitoses.

SUBMUCOSAL FIBROID: Leiomyomata that are primarily on the endometrial side of the uterus and protrude into the uterine cavity (Figure 41– 1).

INTRAMURAL FIBROID: Leiomyomata that are primarily in the uterine muscle.

SUBSEROSAL FIBROID: Leiomyomata that are primarily on the outside of the uterus, on the serosal surface. Physical examination may reveal a “knobby” sensation.

PEDUNCULATED FIBROID: Leiomyoma that is on a stalk.

CARNEOUS DEGENERATION: Changes of the leiomyomata due to rapid growth; the center of the fibroid becomes red, causing pain. This is synonymous with red degeneration.

Figure 41–1. Uterine leiomyomata. Various uterine leiomyomata are depicted based on their location in the uterus.

CLINICAL APPROACH

Evaluation

Uterine leiomyomata are the most common tumors of the pelvis and the leading indication for hysterectomy in the United States. They occur in up to 25% of women, and have a variety of clinical presentations. The most common clinical manifestation is menorrhagia, or excessive bleeding during menses. The exact mechanism is unclear and may be due to an increased endometrial surface area or the disruption of hemostatic mechanisms during menses by the fibroids. Another speculated explanation is ulceration of the submucosal fibroid surfaces.

Many uterine fibroids are asymptomatic and only need to be monitored. Very rarely, uterine leiomyomata degenerate into leiomyosarcoma. Some signs of this process include rapid growth, such as an increase of more than 6 weeks’ gestational size in 1 year. A history of radiation to the pelvis is a risk factor.

If the uterine leiomyomata are sufficiently large, patients may also complain of pressure to the pelvis, bladder, or rectum. Rarely, the uterine fibroid on a pedicle may twist, leading to necrosis and pain. Also, a submucous leiomyomata can prolapse through the cervix, leading to labor-like uterine contraction pain.

The physical examination typical of uterine leiomyomata is an irregular, midline, firm, nontender mass that moves contiguously with the cervix. This presentation is approximately 95% accurate. Most of the time, ultrasound examination is performed to confirm the diagnosis. Lateral, fixed, or fluctuant masses are not typical for fibroids. The differential diagnosis includes ovarian masses, tubo-ovarian masses, pelvic kidney, and endometrioma. Significant menorrhagia often leads to anemia.

Treatment

The initial treatment of uterine fibroids is pharmacological, such as with nonsteroidal anti-inflammatory agents or progestin therapy. Gonadotropin-releasing hormone agonists lead to a decrease in uterine fibroid size, reaching its maximal effect in 3 months. After the discontinuation of this agent, the leiomyomata usually regrow to the pretreatment size. Thus, GnRH agonist therapy is reserved for tumor shrinkage or correction of anemia prior to operative treatment. Other treatments include the levonorgestrel intrauterine device (IUD), selective progesterone receptor antagonists, or oral contraceptives. Notably, the levonorgestrel IUD can be used for women with uterine fibroids without marked distortion of the uterine cavity. With intracavitary (submucosal) uterine fibroids, hysteroscopic resection is the best conservative treatment option.

Hysterectomy is considered the proven treatment for symptomatic uterine fibroids when future pregnancy is undesired. The indication for surgery is persistent symptoms despite medical therapy. Myomectomy is still considered the procedure of choice for women with symptomatic uterine leiomyomata who desire pregnancy. One in four women who undergo myomectomy will require a hysterectomy in the following 20 years. Myomectomy can be accomplished through several approaches including hysteroscopic, open abdominal, laparoscopic and robotically. Advantages to robotic-assisted laparoscopic myomectomy include decreased intraoperative blood loss, shorter hospital stays; however, the technique incurs higher cost and greater intraoperative time. Myomectomy is not indicated in women who have uterine fibroids unless there have been pregnancy complications due to uterine fibroids in the past.

Uterine artery embolization is a technique performed by cannulizing the femoral artery and catheterizing both uterine arteries directly, and infusing embolization particles that preferentially float to the fibroid vessels. Fibroid infarction and subsequent hyalinization and fibrosis result. Short-term results appear promising; initial studies with follow-up over 5 years show symptom relief for approximately 75% of patients. This intervention should not be used in women who want to get pregnant in the future since there is an increased risk of placentation abnormalities. Very large uteri (> 20 weeks size) or very large fibroids may not respond as well; also, submucosal fibroids may cause bleeding, pain, cramping, and expulsion which can be unpleasant for the patient. Pregnancy, a suspected gynecologic malignancy, history of PID, or renal failure are contraindications to the procedure.

Recent Advances

In 2014, the FDA issued a warning on the use of laparoscopic power morcellation during hysterectomy or myomectomy for women with suspected uterine fibroids due to the concerns of undiagnosed uterine leiomyosarcoma. This was due to concerns raised by the case of an unsuspected Boston anesthesiologist who underwent laparoscopic power morcellation for suspected fibroids. The risk calculated by the FDA was 1:350 cases, and that the power morcellation would spread the malignant cells in the peritoneal cavity and worsen the prognosis. Various hospitals and physicians have taken different approaches to this FDA warning; however, the use of laparoscopic power morcellation has been dramatically reduced.

COMPREHENSION QUESTIONS

41.1 A 29-year-old woman is noted to have three consecutive first-trimester spontaneous abortions. After an evaluation for the recurrent abortions including karyotype of the parents, hysterosalpingogram, vaginal sonogram, and testing for antiphospholipid syndrome, the obstetrician concludes the uterine fibroids are the etiology. Which of the following types of uterine fibroids would most likely lead to recurrent abortion?

A. Submucosal

B. Intramural

C. Subserosal

D. Parasitic

E. Pedunculated

41.2 A 39-year-old woman is diagnosed as having probable uterine fibroids based on a pelvic examination revealing an enlarged irregular uterus. She is currently asymptomatic and expressed surprise that she had “growths” of the uterus. If she were to develop symptoms, which of the following would be the most common manifestation?

A. Infertility

B. Menorrhagia

C. Ureteral obstruction

D. Pelvic pain

E. Recurrent abortion

41.3 A 29-year-old G2P1 woman at 39 weeks’ gestation had a myomectomy for infertility previously. While pushing during the second stage of labor, she is noted to have fetal bradycardia associated with some vaginal bleeding. The fetal head, which was previously at + 2 station, is now noted to be at – 3 station. Which of the following is the most likely diagnosis?

A. Submucosal myomata

B. Umbilical cord prolapse

C. Uterine rupture

D. Placental abruption

E. Fetal congenital heart block

41.4 A 65-year-old woman is noted to have suspected uterine fibroids on physical examination. Over the course of 1 year, she is noted to have enlargement of her uterus from approximately 12 weeks’ size to 20 weeks’ size. Which of the following is the best management?

A. Continued careful observation

B. Monitoring with ultrasound examinations

C. Exploratory laparotomy with hysterectomy

D. Gonadotropin-releasing hormone agonist

E. Progestin therapy

41.5 A 38-year-old woman is diagnosed with uterine fibroids of approximately 18 weeks’ size and irregular in contour. She has significant menorrhagia with symptomatic anemia. The patient has finished her childbearing, but adamantly refuses surgical management for her fibroids. Which of the following is the best management for this patient?

A. Endometrial ablation procedure

B. Intramuscular GnRH agonist therapy

C. Levonorgestrel IUD

D. Oral contraceptive therapy

E. Uterine artery embolization

41.6. A 45-year-old G2P2 woman has significant heavy menstrual bleeding due to uterine fibroids. The pelvic ultrasound shows two large uterine fibroids— one in the anterior corpus and one in the uterine fundal region. The patient is considering uterine artery embolization. Which of the following is the best way to ensure that the uterine fibroids are not leiomyosarcoma?

A. Endometrial biopsy

B. Uterine dilatation and curettage

C. Percutaneous biopsy of the fibroid

D. Magnetic resonance imaging

E. Serum markers for CA125 and CEA

ANSWERS

41.1 A. Submucousal fibroids are the fibroids most likely to be associated with recurrent abortion because of their effect on the uterine cavity. The contours of the endometrium are altered and therefore, less favorable for implantation. There may be insufficient vasculature to provide adequate blood supply to the growing embryo if it were to implant along the side of the endometrium containing a submucosal fibroid. In the second trimester of pregnancy, the other answer choices are not associated with an increased risk of recurrent abortion because they do not alter the integrity of the endometrium.

41.2 B. Menorrhagia is the most common symptom of uterine fibroids, and severe menorrhagia often leads to anemia. Infertility and recurrent abortion may occur with submucosal fibroids due to the effects on the uterine cavity, whereas impingement on the ureters is most likely to occur with subserosal fibroids, but these are much less common than menorrhagia. Pelvic pain is not very common, and many uterine fibroids are asymptomatic and only require monitoring. If the uterine leiomyomata are large enough, patients may complain of pressure to the pelvis, bladder, or rectum. Though rare, a uterine fibroid on a pedicle may twist, leading to necrosis and severe pain.

41.3 C. Extensive myomectomies sometimes necessitate cesarean delivery because of the risk of uterine rupture. Most practitioners use the rule of thumb that if the endometrial cavity is entered during myomectomy, a cesarean delivery should be performed with pregnancy. As with uterine rupture, fetal bradycardia may also occur if the umbilical cord becomes prolapsed, but cord prolapse is not a risk factor from having a myomectomy. A submucosalmyomata is related to problems with fertility and implantation of the embryo, not problems during labor such as uterine rupture. Placental abruption is not associated with fetal bradycardia or as a risk after myomectomy. Myomectomies do not cause congenital anomalies or disease processes to occur in a developing fetus.

41.4 C. The rapid growth of the uterus suggests leiomyosarcoma; the diagnosis and treatment are surgical, especially in a woman of nonchildbearing age. Also, substantial growth of uterine fibroids in postmenopausal women is unusual due to the lower estrogen levels. In other words, uterine fibroids typically grow in response to estrogen. Once a fibroid degenerates into cancer, progestin therapy and gonadotropin-releasing hormone agonists have no more effect on the tumor and are no longer treatment options for shrinking the mass.

41.5 E. For a relatively large uterus due to fibroids, uterine artery embolization is the best alternative therapy to surgery. The majority of patients treated with this modality will have improvement. The IUD would likely not stay in place with an irregular uterine cavity; endometrial ablation is technically difficult if not impossible with a large irregular uterine cavity. GnRH agonist is useful in the short term (3-6 months) and is effective in shrinking the fibroids and slowing the bleeding; but its use is limited to 6 months due to the risk of osteoporosis.

41.6 C. Although rare, leiomyosarcoma does occur and can be very difficult if not impossible to distinguish from a uterine fibroid. MR imaging usually reveals a large heterogenous mass in the uterus with areas of both hyper- and hypoenhancement; however, there is considerable overlap between leiomyosarcoma and benign leiomyomata. Thus, percutaneous biopsy or even better surgical resection and pathological examination are the best ways to assess for leiomyosarcoma. Endometrial biopsy and uterine D&C are usually not helpful to evaluate for leiomyosarcoma.

    CLINICAL PEARLS    

» The most common reason for hysterectomy is symptomatic uterine fibroids. » The most common symptom of uterine fibroids is menorrhagia, heavy bleeding during menses. » The physical examination consistent with uterine leiomyomata is an irregular pelvic mass that is mobile, midline, and moves contiguously with the cervix. » Leiomyosarcoma rarely arises from leiomyoma; rapid growth or a history of prior pelvic irradiation should raise the index of suspicion. » Significant growth in suspected uterine fibroids in a postmenopausal woman is unusual and generally requires surgical evaluation. » Asymptomatic uterine fibroids require surgical intervention in the presence of unexplained rapid growth, ureteral obstruction, or the inability to differentiate the fibroid from other types of pelvic masses.

REFERENCES

American College of Obstetricians and Gynecologists. Alternatives to hysterectomy in the management of leiomyomata. ACOG Practice Bulletin 96. Washington, DC; 2008. (Reaffirmed 2014.) 

Barakat EE, Bedaiwy MA, Z imberg S, Nutter B, Nosseir M, Flacone T. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol. 2011;117: 256-266. 

FDA Safety Communication. FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids. http:/ /www.fda.gov/ NewsEvents/Newsroom/ PressAnnouncements/ ucm393689.htm; Accessed 20.09.2015. 

Katz VL. Benign gynecologic lesions. In: Lentz GM, Lobo RA, Gersenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. St. Louis, MO: Mosby-Year Book; 2012:419-470. 

Nelson AL, Gambone JC. Congenital anomalies and benign conditions of the uterine corpus and cervix. In: H acker NF, Gambone JC, H obel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:240-247. 

Spies JB, Bruno J, Czeyda-Pommersheim F, Magee ST, Ascher SA, Jha RC. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol. 2005;106:933. 

Steward EA. Uterine fibroids. New Engl J Med. 2015;372:1646-1655.

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