('''leiomyomata''', singular '''leiomyoma''') are the most common
Neoplasm in females, and may affect about of 25 % of white and 50% of black women during the reproductive years. Fibroids may be removed simply by means of a
Hysterectomy , but much more favourably by a
Myomectomy or by
Uterine Artery Embolization , which preserve the
Uterus .
Leiomyomas grossly appear as round, well circumscribed (but not encapsulated), solid nodules that are white, or tan whorled. The size varies, from microscopic to lesions of considerable size. Typically lesions the size of a grapefruit or bigger are felt by the patient herself through the abdominal wall.
Microscopically, tumor cells resemble normal cells (elongated, spindle-shaped, with a cigar-shaped nucleus) and form bundles with different directions (whirled). These cells are uniform in size and shape, with scarce mitoses. There are three benign variants: bizarre (atypical); cellular; and mitotically active.
Leiomyomas are estrogen sensitive and have
Estrogen Receptor s. They may enlarge rapidly during pregnancy due to increased estrogen levels. As estrogen levels decline with menopause, fibroids tend to regress after menopause. Hormonal therapy is based on these facts.
More recent studies have revealed a possible role of progesterone and progestins to fibroid growth as well
and applicability of progestin agonists as part of treatment are currently being considered.[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12738519&query_hl=24
Fibroids, particularly when small, may be entirely asymptomatic. Generally, symptoms relate to the location of the lesion and its size. Important symptoms include abnormal
Gynecologic Hemorrhage , pain,
Infertility ,
Dysuria and urinary frequency. During
Pregnancy they may be the cause of
Miscarriage , bleeding,
Premature Labor , or interference with the
Position of the fetus.
Fibroids may be single or multiple. Most fibroids start in an intramural location,- that is the layer of the muscle of the uterus. With further growth, some lesion may develop towards the outside of the uterus (subserosal or pedunculated), some towards the cavity (submucosal or intracavitary). Lesions affecting the cavity tend to bleed more and interfere with pregnancy. Secondary changes that may develop within fibroids are hemorrhage, necrosis, calcification, and cystic changes. Less frequently, leiomyomas may occur at the lower uterine segment,
Cervix , or
Uterine Ligaments .
Diagnosis is usually accomplished by bimanual examination, better yet by
Gynecologic Ultrasonography . Sonography will depict the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam. In cases where a more precise assay of the fibroid burden of the uterus is needed, also magnetic resonance imaging (
MRI ) can be used to generate a depiction of the size and location of the fibroids within the uterus. While no imaging modality can clearly distinguish between the benign uterine leiomyoma and the malignant uterine leiomyosarcoma, the rarity of the latter and the prevalence of the former make it, for practical purposes, a non-issue unless evidence of local invasion is present, though more recent studies have improved diagnostic capabilities using MRI
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The presence of a fibroid does not mean that it needs to be treated; many lesions are followed expectantly.
Treatment of uterine fibroids that cause problems can be accomplished by:
- : , Laparoscopy , or Hysteroscopy .
- (UAE): Using interventional radiology techniques, the Interventional physician occludes both uterine arteries, thus reducing blood supply to the fibroid(s).
- therapy: This involves the use of medication to reduce estrogens in an attempt to create a medical menopause-like situation. Gonadotropin-releasing Hormone Analog s are used for this. Selective Progesterone Receptor Modulator s, such as Progenta , are under investigation as therapeutic agents, as of 2005.
- (High frequency focused ultrasound), also called Magnetic Resonance Guided Focused Ultrasound , is a non-invasive intervention (requiring no incision) that uses high intensity focused ultrasound waves to ablate (destroy) tissue in combination with Magnetic Resonance Imaging (MRI), which guides and monitors the treatment. This technique is relatively new, and is still under trials.
Very few lesions are or become malignant. Signs that a fibroid may be malignant are rapid growth or growth after menopause. Such lesions are typically a
Leiomyosarcoma on histology.
