子宫肌瘤

Myoma of uterus,靳 镭 （Jin Lei） Department of OB/GYNTongji HospitalTongji Medical College of HUST,Topics today,General considerationHigh risk factorsClassificationPathologyDegeneration of myomaClinical manifestationDiagnosis and differential diagnosisManagement,General consideration,Terms: Myoma, leiomyoma, fibroid, fibroid tumorConsists of: smooth muscle tissue + connective tissue The most common benign tumor in female genital organs 20% of women over 30; 25% of women over 40Commonly seen in women of age: 30-50; 40- 50 yrs old with peak incidence Rare in girls under 20; shrink after menopause,Female Internal genitalia,Myoma of uterus,Most common benign tumor in female genitalia!,MYOMA OF THE UTRUS-in various region of uterus,High risk factors (1),Cytogenetic factorsFemale HormonesGrowth Factors Molecular factors,The exact causes remain unclear,High risk factors (2),Cytogenetic factors: 20%- 50%, cytogenetic abnormalities family history Female Hormones: Estrogens , ER Hypersensitivity to estrogen,High risk factors (3),Growth Factors: Epidermal growth factor (EGF) Insulin-like growth factor (IGF)-I Basic fibroblast growth factor (BFGF) Cellular and Molecular factors: Hypothesis: stem cells monoclonal single myoma polyclonal multiple myomas,Pathogenesis of uterine myoma,Cytogenetic background,Growth factors,Estrogen,High ER,Myoma of uterus,Smooth muscle cells,Classification of myoma of uterus,Originate in the myometrium of uterusClassified by anatomic locationClassified by relationship with myometrium,Anatomy of uterus,Classification- by the location:,Corporeal myoma: 90%Cervical myoma: 10%,Classification- by the relationship with myometrium,Intramural: 60 % -70 %Subserous: 20%Submucous: 10 % -15%,Classification- by the relationship with myometrium,Subserous,Submucous ( / intracavitary),Subserous,Submucous + intramural,Submucous + Intramural + Subserous,Pathology,Gross view (Naked eye appearance)Microscopic features,Pathology gross view,Mass: Spherical, solid, hard; grey-white; pseudocapsule; often multiple Section: paler, harder and more fibrous than the normal uterine myometrium (wall),Pathology Microscopic features,Smooth muscle cells arising from mostly myometrium, or endometrium of blood vesselsComposed of unstriped, interlaced bundles of smooth muscle and fibrous tissueCondensed nuclei, mitotic activity,Fig. 1 100 left：normal；right：myoma with interlaced bundles of smooth muscle tissue,fig. 2 100 Uterine myoma,fig. 3 200Uterine myoma,hyaline degenerationcystic degenerationred degenerationmalignant transformation: mainly sarcomatous changeOthers: myxomatous (fatty), atrophic,septic, calcific (calcareous),Degeneration of myoma,Hyaline degenerationThe commonest change seen in myoma.caused by a gradual inadequacy of the blood supply.,Cystic degenerationnot uncommon, especially after the menopausedue to liquefaction of the areas of hyaline change.,Red degeneration The affected area resembles raw meat and is stained red. most freguently seen during the pregnancy and in postpartum.,Malignant change 0.1%- 1% of casesMost likely to be seen in large tumors. More typical in older patients, especially postmenopausal patients Presented with rapidly enlarging uterine mass and postmenopausal bleeding.Metastasis occurs rapidly,Symptoms,Abnormal vaginal bleeding: the most common presenting symptom; hypermenorrheaAbdominal mass: usually asymptomaticPressure effects:Others: abnormal vaginal discharge, abdominal pain, infertility, secondary anemia,Symptoms Abnormal vaginal bleeding (1),Submucous myoma: almost 100%, quite small tumors can lead to severe anemia.Intramural tumors: increasing of blood loss; prolonged periodSubserous growths: do not affect the menstrual bleeding.,Symptoms Abnormal vaginal bleeding (2),Mechanisms for increased bleeding:Alteration of normal myometrial contractile functionInability of the overlying endometrium to respond to the normal E/P menstrual phases.Pressure necrosis of the overlying endometrial bed.,Symptoms abdominal mass,Sometimes the first thing that the patient notices.Asymptomatic: not tender and rarely gives rise to pain.,Symptoms Pelvic pressure,Against bladder (frequency and retention of urine) Against rectum（constipation） Against parauterine tissues: pain or discomfort,Symptoms abnormal Vaginal discharge,42%Area of uterine cavityPelvic congestionComplications of submucous myoma,Symptoms Pain,not a common symptom, when it occurs:Some complication of myoma such as, degeneration or torsionEndometriosis Pelvic inflammatory disease,Symptoms others,Infertility: 30patients with myomaSpontaneous abortion: 4 ：1Anemia:,Signs,Vary with the size，site (region/ location), number, and complication of myomas.abdominal examinationpelvic examination,Signs - Abdominal mass,3 months gestational age：not palpable 3 months gestational age： In the middle of the lower abdomen, irregular, hard, nodular,Signs - Pelvic mass,Intramural：enlargement of uterus; irregular, single or multiple nodules on the surfaceSubserous：spherical, nodular massesSubmucous： symmetrical enlargement of the uterus ，extrusion of myoma into cervical canal even vagina,Diagnosis,History: reproductive ageSymtoms:Signs: Ancillary tests: Ultrasonography Hysteroscopy Laparoscopy Dilation and curettage HSG,Essentials for diagnosis,Bleeding: hypermenorrhea, metrorrhagia, dysmenorrheaMass: irregular enlargement of the uterus (usually asymptomatic); solid, spherical, hard and nodularPain: from torsion or degenerationPressue symptoms: from neighboring organs (large tumors),Diagnosis- ancillary test,Pelvic ultrasound the most commonly used for confirmation of uterine myomas,Subserous myoma,Submucous myoma,Ancillary test Laparoscopy,Ancillary test Hysteroscopy,Differential diagnosis (1),Other conditions which give rise to a mass in the pelvis Adenomyoma Ovarian tumors Inflammatory mass in the pelvis Pregnancy Abnormality of uterus,Differential diagnosis (2),Other conditions which cause metrorrhagia Adenomyoma Endometrial polyp of uterus Carcinoma of the uterus: endometrial, cervical Dysfunctional uterine bleeding,Endometrial polyp,Adenomyosis,Adenocarcinoma of the endometrium,Abnormality of uterus,Management,Follow up Medicin therapy Surgical management: hysterectomy;myomectomyOthers: Embolisation of myoma ; myolysis,Treatment - Follow up,The majority of patients with uterine myomas do not require surgical treatment. Age: Patients in the late reproductive or perimenopausal years.Small and asymptomaticManagement: repeat pelvic examinations and assisted by serial pelvic ultrasound measurements Every 3 - 6 months.,Management Medicine therapy,Indications:Perimenopausal womensmall myoma (2 months)Asymptomatic, or with mild symptomsCouldnt tolerate surgery,Management - medicine therapy,Mechanisms:Pharmacologic inhibition of effects of estrogenInhibit the function of H-P-O axisCommonly used for 3 to 6 months.,Management - Medicine therapy,Medicine:Androgen GnRH-a: down regulationMifepristone Gestrinone: nemestranChinese herb medicines,Management - surgery,Surgical treatment is indicated in cases with:Heavy or prolonged bleedingTumors of large size over 2.5 gestation months, even if these are not causing symptoms.Possible malignant change, such as a tumor which grows after the menopausePressure symptoms ( against bladder, bowel, and pelvic floor)Tumors which have undergone torsion or degene