Abnormal uterine bleeding (AUB) is the major complaint in approximately one-third of gynecological visits in premenopausal women, and in >70% of appointments of perimenopausal and postmenopausal women. Uterine myoma is one of the main causes of AUB during menacme, especially when it is submucosal. The association of myoma and AUB may be related to several factors, from local alterations of angiogenic and vasoactive substances to changes in uterine contractility. The objective of this paper is to show the different associations of myoma and AUB.
Highlights
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Of the uterine myomas, the submucous type is more often related to abnormal uterine bleeding (AUB).
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There is a correlation between the degree of penetration of the submucosal myoma and the intensity of the AUB.
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The size of the submucosal myoma is a secondary parameter in correlating the degree of bleeding.
Abnormal uterine bleeding (AUB) is defined as bleeding from the uterine corpus, which is abnormal in duration, volume, and/or frequency, and mostly lasts for 6 months. Moreover, it is responsible for approximately one-third of the gynecological appointments in premenopausal women, and >70% of the visits of perimenopausal and postmenopausal women . Menstrual disorders are common, with an annual prevalence of 53.0 per 1000 women in the United States of America .
The etiopathogenesis varies according to age groups and the origin of the condition may be in the lower genital tract, hypothalamus–hypophysis–ovary axis, and may be related to systemic and hormone alterations, such as coagulation and thyroid disorders. In order to manage this condition, it is crucial to identify or rule out the cause in order to provide adequate treatment. If all the causes are ruled out, the diagnosis of dysfunctional uterine bleeding is made.
During menacme, structural uterine alterations, uterine polyps, and myomas are the main causes of AUB. In younger women, dysfunctional bleeding is more common. In 2011, based on an international consensus, the International Federation of Gynecology and Obstetrics (FIGO) established a system for the evaluation of AUB in patients during menacme and nonpregnancy, which was named PALM–COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) . It summarizes the most frequent causes of AUB.
During postmenopause, in the presence of hypoestrogenism, the most probable cause of AUB is endometrial atrophy, but some cases may be associated with polyps, myomas, or adenomyosis. In this age group, the presence of vaginal bleeding requires evaluation of the uterine cavity to rule out the presence of hyperplasia or neoplasia, because during this phase of life the most frequent complaint of patients with endometrial cancer is AUB, especially if associated with thickening of the endometrium .
Uterine fibroids are the most common tumors in women during childbearing age. They are benign nodules, of unicellular origin, and are asymptomatic in >50% of affected women. When symptomatic, they are associated with AUB, pelvic pain, infertility, and premature birth. AUB is the most frequent symptom of fibroids .
The bleeding caused by the uterine myoma occurs during the menstrual period, with heavier flow or prolonged period. Intermenstrual and postmenopausal bleeding are related to other types of uterine diseases, and adequate investigation should be made .
In 1956, Jacobson and Enzer described the correlation between the submucosal myoma and AUB, demonstrating that 57% of cases of AUB were found in submucosal myomas .
Even when the submucosal myoma is associated with AUB, its number and size, as well as its location, may interfere in symptoms. It is possible to associate the AUB of the uterine myoma with some factors:
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Increased endometrial surface.
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Increased uterine vascularization.
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Changes in uterine contractility pattern.
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Exposure and ulceration of the submucosal myoma surface.
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Degeneration of the myomatous nodule.
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Uterine venous ectasia by compression of the venous plexus by the nodules.
The presence of myomas inside the uterus would lead to increased endometrial surface, greater shedding area, and bleeding ( Fig. 1 ).
The myoma is poorly irrigated, with peripheral vascularization, which could lead to bleeding by rupture of a surface vessel, in some cases ( Fig. 2 ).
There is a correlation between AUB and the degree of fibroid penetration in the uterine cavity. Submucous myomas (FIGO 0, 1, 2, and 3) are most frequently related to significant menorrhagia . Some intramural fibroids can also be responsible for AUB. The mechanisms are unclear, but may include both microscopic and macroscopic abnormalities of the uterine vasculature, impaired endometrial hemostasis, or molecular deregulation of angiogenic factors, which are likely to be more frequent in myomas near the cavity .
Yang et al . compared the hemoglobin levels of patients with single submucosal myomas, in the absence of other pathologies associated with menorrhagia, and concluded that the size of the myoma is the major factor associated with anemia. In addition, the degree of protrusion of the nodule into the uterine cavity also showed an association with hemoglobin levels. Patients with myomas measuring < 2 cm had similar hematimetric levels, regardless of the degree of protrusion of the myoma into the cavity. Myomas measuring 2–3.9 cm had an inverse association of the hemoglobin levels with the degree of protrusion. Myomas with <50% protrusion into the cavity had similar hemoglobin levels, regardless of the size of the nodule. In cases of myomas with a degree of protrusion of 50–79% and ≥ 80%, the hemoglobin levels were lower, as the nodule diameter increased.
The size of the myoma is related to AUB, provided it is in the uterine cavity or is distorting the cavity (FIGO 0, 1, 2, and 3). According to Wegienka et al ., nonsubmucosal leiomyomata were associated with essentially the same increase in heavy bleeding as submucosal leiomyomata of similar size ( Table 1 ).
| Penetration/distortion | Degree of penetration (FIGO) | Size | Bleeding | Intensity |
|---|---|---|---|---|
| Yes | 0, 1, 2, 3 | < 2 cm | Yes | 0 = 1 = 2 = 3 |
| Yes | 0, 1, 2, 3 | 2–3.9 cm | Yes | 0 > 1 > 2 > 3 |
| Yes | 0, 1, 2, 3 | ≥ 4 cm | Yes | 0 = 1 = 2 = 3 |
| No | No | Any | No | No |
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