Transcript UTERINE MYOMAS An Overview of Development, Clinical Features, and Management 부산백병원 산부인과 R2 손영실 1/30

UTERINE MYOMAS
An Overview of Development, Clinical
Features, and Management
부산백병원 산부인과
R2 손영실
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INDEX
◎ Clinical Manifestations
◎ Growth Patterns
◎ Therapy
1.
2.
3.
4.
5.
6.
Hysterectomy
Abdominal Myomectomy
Hysteroscopic Myomectomy
Laparoscopic Myomectomy
Uterine Artery Embolization
Hormone Therapy
- Progestins
- GnRHa
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CHARACTERISTICS
◎ The most common solid pelvic tumors in women
- occurring in 20~40% of women during their
reproductive years
◎ Benign tumors that originate from smooth muscle cells
of the uterus
◎ Consists of uterine smooth muscle tissue as well as
fibrous tissues
◎ Size : seedlings ~ large tumors
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CHARACTERISTICS
◎ Types
1) intramural
- found within the myometrium
2) subserous
- externally extending to the serosa
3) submucous
- internally impinging on the uterine cavity
4) pedunculated
5) extend through the internal os of the cervix
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CHARACTERISTICS
◎ Estrogen-dependent tumors
- associated with exposure to circulating estrogen
- decrease in size during menopause
- maximum growth
: when estrogen secretion is maximal, spurt in
growth in the decade before menopause
(anovulatory cycles with unopposed circulation
estrogen)
- occasionally grow during pregnancy
(caused by estrogen)
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CLINICAL MANIFESTATION
1. Most patients with uterine myomas are “symptom-free”
2. Excessive menstrual bleeding
- the only symptom produced by myomas
- obstructive effect on uterine vasculature
⇒ proximal congestion in the myometrium
and endometrium
⇒ excessive bleeding
- uterine cavity size & endometrial surfaces are ↑
⇒ increasing the quantity of menstrual flow
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CLINICAL MANIFESTATION
3. Pain
- relatively infrequent
① torsion of the pedicle of a pedunculated myoma
② cervical dilatation by a submucous myoma
protruding through the lower uterine segment
③ carneous degeneration associate with pregnancy
⇒ pain is acute and requires immediate attention
4. Pressure and increased abdominal girth
- develop insidiously, often less apparent symptom
- urinary tract Sx : frequency, outflow obstruction,
compression of the ureter
- G-I Sx : constipation or tenesmus
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CLINICAL MANIFESTATION
5. Infertility
- rarely caused by myomas
- associated with a submucous myoma
: interferes with normal implantation or with sperm
transport
- implicated in recurrent pregnancy loss
- improvement in reproductive outcome after surgery
6. Malignant transformation
- extremely rare
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GROWTH PATTERNS
◎ Because malignancy in association with myomas is
rare, careful consideration must be given to specific
indications for performing surgery
◎ A history of rapid growth, especially postmenopausal
growth
⇒ should prompt resection of tumor, even in absence
of symptoms
◎ Small asymptomatic myomas require only serial flow-up
- initially at 3-month intervals to establish a growth pattern
- if growth pattern is stationary, pelvic exam can be
repeated in 4~6 month intervals
◎ USG, CT, MRI hysterosalpingography
⇒ assists in documenting growth of myomas
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GROWTH PATTERNS
◎ Indications for Surgical Management of Uterine Myomas
• Abnormal uterine bleeding not responding to conservative
treatments
• High level of suspicion of pelvic malignancy
• Growth after menopause
• Infertility when there is distortion of the endometrial cavity
or tubal obstruction
• Recurrent pregnancy loss (with distortion of the endometrial
cavity)
• Pain or pressure symptoms (that interfere with quality of life)
• Urinary tract symptoms (frequency and/or obstruction)
• Iron deficiency anemia secondary to chronic blood loss
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THERAPY
◎ Medical management
- GnRH analogues, progestational compounds,
antiprogestins
◎ Surgical management
- myomectomy or hysterectomy
◎ Uterine artery embolization
◎ Others
- high frequency ultrasonography, laser Tx, cryotherapy,
thermoablation
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THERAPY
◎ The choice should be predicated upon careful
consideration of many factors
- medical and social : age, parity, childbearing aspirations,
extent and severity of symptoms, size, number and
location of myoma, associated medical condition,
possibility of malignancy, proximity to menopause,
desire for uterine preservation
◎ For example,
① multiple myoma & completed childbearing
⇒ benefit from hysterectomy
② nulliparous woman ⇒ myomectomy
③ submucosal myoma ⇒ hysteroscopic resection
④ subserosal pedunculated myoma ⇒ laparoscopic resection
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THERAPY
1. Hysterectomy
- second most frequent major surgical procedure
performed in women in the US
- indication for hysterectomy
① uterine myoma (33.5%)
② endometriosis (18.2%)
③ uterine prolapse (16.2%)
④ cancer (11.2%)
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THERAPY
- Why do a hysterectomy? Why remove the entire uterus?
⇒ several factors should influence the gynecologist’s
judgement, including the age and her childbearing
aspirations
- for many women, hysterectomy conjures up the specter
of loss of sexuality and feminity
⇒ counseling with other women who have undergone
hysterectomy can be very constructive before surgery
- several recent report
⇒
improvement in life quality for most women who have
had hysterectomy
hysterectomy dose not adversely influence sexuality
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THERAPY
- surgery to relieve bleeding, pain, pelvic pressure, and
urinary tract symptoms may lead to improvement in
sexual satisfaction and quality of life
- complication
① risk of damage to adjacent structure
urinary tract : uriteral injury, vesicovaginal fistula,
stress incontinence
bowel
② vaginal vault prolapse
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THERAPY
- supracervical hysterectomy
: associated with a decreased risk of urinary tract injury,
less operating time, less vault prolapse
(by preservation of uterosacral and cardinal ligament)
: recent studies, there was no difference in pelvic
relaxation symptoms after 2 years follow-up
⇒ Hysterectomy is an acceptable choice for symptomatic
myomas in patients who have significant bleeding,
pain, pressure or anemia for whom fertility is not an
issue
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THERAPY
2. Abdominal Myomectomy
- preferred treatment whenever preservation of uterus
is desired
- choice for a solitary pedunculated myoma
- interference with fertility or predisposition to repeated
pregnancy loss due to nature or location of myomas
⇒ indication for myomectomy
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THERAPY
- To perform myomectomy, the surgeon must carry out
a thorough preoperative appraisal
① Hypermenorrhea and abnormal bleeding
⇒ required endometrial evaluation in a patient aged more
than 35 years
② Hematologic status
normal Hb ⇒ should have 1 or 2 units of her own blood,
obtained 2 weeks before myomectomy
anemic patient
⇒ pretreatment with GnRH analogues or progestational agent
⇒ produce and amenorrheic state during which iron stores
can be replenished and anemia corrected
to reduce intraoperative blood loss
⇒ pharmacologic vasoconstricting agent and mechanical
vascular occlusion was used
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THERAPY
- multiple myomectomy is frequently a more difficult and
time-consuming procedure than hysterectomy
- morbidity between the 2 procedures (Iverson et al)
① hysterectomy group
: experienced ureteral, bladder, and bowel injuries
② myomectomy group
: no intraoperative visceral injuries
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THERAPY
3. Hysteroscopic Myomectomy
- Resection of submucosal myomas
- Indication
: abnormal bleeding Hx of pregnancy loss, infertility,
and pain
- Contraindication
: endometrial ca. lower reproductive tract infection,
inability to distend the uterine cavity, extension of the
tumor deep into the myometrium
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THERAPY
4. Laparoscopic Myomectomy
- performed when myomas are easily accessible, as in
superficial subserous or pedunculated myomas
- these can be morcellated and removed through the
laparoscopic cannula or placed in the cul-de-sac
and removed via a colpotomy incision
- laparoscopic coagulation of a myoma, or myolysis
① conservative alternative to myomectomy in women
wishing to preserve fertility
② Nd:YAG laser via degeneration of protein and
destruction of vascularity
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THERAPY
- laparoscopic assisted myomectomy involves laparoscopic
dissection of the myomas from the uterine wall and their
extraction through a minilaparotomy incision, thus sparing
a large abdominal incision
- these procedures have not been standarized, so, the
surgeon who undertakes them should be skilled in
operative endoscopy
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THERAPY
5. Uterine Artery Embolization
- this approach had been used for many years to control
pelvic hemorrhage, for treatment of myomas was first
described in 1995
- principle : limiting blood supply to the myomas
(infarction)
⇒ their volume may be reduced
- performed under conscious sedation by an interventional
radiologist
- minimally invasive procedure ⇒ shortened hospital stay
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THERAPY
- recommended for patients with large myomas who are
symptomatic, women who do not want extirpative therapy
- In a series of 80 patients with myoma related
hypermenorrhea, 90% reported complete cessation of
symptoms after embolization
- complication
① pain : persist and last for more than 2 weeks
② postembolization fever, postembolization syndrome,
pyometra, failure of satisfactory regression of
myomas,
sepsis, hysterectomy, and death
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THERAPY
6. Hormone Therapy
◎ Progestins
- Norethindrone, medrogestone, medroxyprogesterone
acetate
- produce a hypoestrogenic effect by inhibiting
gonadotropin secretion and suppressing ovarian
function
- exert a direct antiestrogenic effect
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THERAPY
◎ Gonadotropin-Releasing Hormone Analogues
- used to achieve hypoestrogenism in various
estrogen-dependent conditions
( ex. Endometriosis, precocious puberty, and uterine
myomas)
- transient effect
- within several cycles after discontinuing administration,
myomas tend to return to their pretherapy size
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THERAPY
- adjuvantive therapy with 3~4 month course of GnRHa
should reduce myoma size and render surgery easier,
accompanied by less blood loss
- use of GnRHa has been associated with significant
short- and long-term side effect, such as
postmenopausal symptoms and osteoporosis
- severe pelvic pain occasionally will accompany shrinkage
of myomas during GnRHa treatment
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CONCLUSION
• a thorough understanding of the pathogenesis of uterine
myomas, clinical presentation, and diagnostic tools are
the keys to selecting which course to follow in treating
patient with myomas
• surgery for myomas is not always necessary and should be
performed only for appropriate indications
① the use of GnRHa is the achievement of amenorrhea to
facilitate correction of IDA before surgery
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CONCLUSION
② uterine artery embolization is most effective for patients
with large symptomatic myomas who are poor surgical
candidates and reluctant to undergo a major surgical
procedure
③ gynecologists determine surgical approach, endoscopic
or by laparotomy, based on size, number, extent and
location of myomas
④ all therapeutic measures, and especially invasive
techniques, should be reserved for patients with
symptomatic myomas
- for asymptomatic women, serial follow-up for growth
and development of symptoms is generally safe
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감사합니다.
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