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A Symptoms and Signs
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In nonpregnant women, myomas are frequently asymptomatic However, they can cause urinary frequency, dysmenorrhea, heavy bleeding (often with anemia), or other complications due to the presence of an abdominal mass Occasionally, degeneration occurs, causing intense pain Infertility may be due to a myoma that significantly distorts the uterine cavity
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B Laboratory Findings
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Hemoglobin levels may be decreased as a result of blood loss, but in rare cases polycythemia is present, presumably as a result of the production of erythropoietin by the myomas
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Surgical measures available for the treatment of myoma are laparoscopic or abdominal myomectomy and total or subtotal abdominal, vaginal, or laparoscopy-assisted vaginal hysterectomy Myomectomy is the treatment of choice during the childbearing years Recent developments include transcatheter bilateral uterine artery embolization, myolysis with MRI-guided high frequency focused ultrasound, or laser cauterization While these approaches are promising and potentially cost-effective alternatives, randomized clinical trials to compare long-term outcomes of these new methods with conventional therapy are needed
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C Imaging
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Ultrasonography will confirm the presence of uterine myomas and can be used sequentially to monitor growth When multiple subserous or pedunculated myomas are being followed, ultrasonography is important to exclude ovarian masses MRI can delineate intramural and submucous myomas accurately Hysterography or hysteroscopy can also confirm cervical or submucous myomas
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Prognosis
Surgical therapy is curative Future pregnancies are not endangered by myomectomy, although cesarean delivery may be necessary after wide dissection with entry into the uterine cavity
Prevention
Prompt endometrial sampling for patients who report abnormal menstrual bleeding or postmenopausal uterine bleeding will reveal many incipient as well as clinical cases of endometrial cancer Younger women with chronic anovulation are at risk for endometrial hyperplasia and subsequent endometrial cancer They can reduce the risk of hyperplasia almost completely with the use of oral contraceptives or cyclic progestin therapy
When to Refer
Refer to a gynecologist for treatment of symptomatic leiomyomata
When to Admit
For acute abdomen associated with an infarcted leiomyoma
Spies JB et al Recent advances in uterine fibroid embolization Curr Opin Obstet Gynecol 2005 Dec;17(6):562 7 [PMID: 16258335] Walker CL et al Uterine fibroids: the elephant in the room Science 2005 Jun 10;308(5728):1589 92 [PMID: 15947177]
Staging
Examination under anesthesia, endometrial and endocervical sampling, chest radiography, intravenous urography, cystoscopy, sigmoidoscopy, TVS, and MRI will help determine the extent of the disease and its appropriate treatment The staging is based on the surgical and pathologic evaluation
Treatment CARCINOMA OF THE ENDOMETRIUM
Treatment consists of total hysterectomy and bilateral salpingo-oophorectomy Peritoneal material for cytologic examination is routinely taken and lymph node sampling may be done If invasion deep into the myometrium has occurred or if sampled lymph nodes are positive for tumor, postoperative irradiation is indicated The role of adjuvant chemotherapy alone or with irradiation is currently under investigation Palliation of advanced or metastatic endometrial adenocarcinoma may be accomplished with large doses of progestins, eg, medroxyprogesterone, 400 mg intramuscularly weekly, or megestrol acetate, 80 160 mg daily orally
ESSENTIALS OF DIAGNOSIS
Abnormal bleeding is the presenting sign in 80% of cases Pap smear is frequently negative After a negative pregnancy test, endometrial tissue is required to confirm the diagnosis
General Considerations
Adenocarcinoma of the endometrium is the second most common cancer of the female genital tract It occurs most often in women 50 70 years of age Some patients will have taken unopposed estrogen in the past; their increased risk appears to persist for 10 or more years after stopping the drug Obesity, nulliparity, diabetes, and polycystic ovaries with prolonged anovulation and the extended use of tamoxifen for the treatment of breast cancer are also risk factors Abnormal bleeding is the presenting sign in 80% of cases Endometrial carcinoma may cause obstruction of the cervix with collection of pus (pyometra) or blood (hematometra) causing lower abdominal pain However, pain generally occurs late in the disease, with metastases or infection Papanicolaou smears of the cervix occasionally show atypical endometrial cells but are an insensitive diagnostic tool Endocervical and endometrial sampling is the only reliable means of diagnosis Adequate specimens of each can usually be obtained during an office procedure performed following local anesthesia (paracervical block) Simultaneous hysteroscopy can be a valuable addition in order to localize polyps or other lesions within the uterine cavity Vaginal ultrasonography may be used to determine the thickness of the endometrium as an indication of hypertrophy and possible neoplastic change Pathologic assessment is important in differentiating hyperplasias, which often can be treated with cyclic oral progestins
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