Introduction
Uterine leiomyomata are benign muscle tumors, and the most common female pelvic tumors. Prevalence estimates range from 30% to 70% of women, with higher rates in African Americans and women over the age of 40. The pathogenesis of leiomyomata is multifactorial, with genetics, sex hormones, and growth factors linked to their development. The majority of patients with myomata are asymptomatic. They may be diagnosed on routine physical exam, incidentally found on pelvic imaging or discovered when associated symptoms are investigated. Their clinical importance is usually limited to the reproductive years. They tend to enlarge during pregnancy and shrink after menopause.
Leiomyomas range in size from microscopic lesions to huge tumor masses filling the entire abdomen. They can be single or multiple, and are classified according to their location as submucous, intramural or subserous. Occasionally, they can be found between the leaves of the broad ligament, in the cervix or associated with the round ligaments. They are surrounded by a pseudocapsule of areolar tissue from which they derive their blood supply. The tumors themselves consist of tightly compacted muscle and fibrous tissue arranged in a whorled pattern that is relatively avascular. On rare occasions, a leiomyoma can undergo sarcomatous change. As there are no laboratory or imaging studies to screen or predict malignant change, sudden growth of the tumor may be the only clue. Generally, subserous myomata are asymptomatic, but may be confused with an adnexal mass; intramural tumors may also be asymptomatic, but can cause pressure and pain as they enlarge; and the submucous ones often stimulate heavy bleeding with menses. Other symptoms associated with leiomyomatous uteri include urinary frequency and increased abdominal girth secondary to external bladder pressure and increased tumor growth.
History
If the patient is symptomatic, it must be determined how and to what degree these symptoms affect her life. Any co-existing medical problems must be elucidated to determine if they are contributing to her symptoms, and to what extent they might influence treatment choices. Pelvic pain and pressure are very common complaints, so it must be determined whether the leiomyomata are the cause of these symptoms or just coincidental to other pathology. Timing of the pain, especially in relation to menses, the effectiveness of any prior therapy for this pain, any previous pelvic surgeries, rapid growth of the tumors or any associated gastrointestinal or urinary symptoms might point towards or away from the leiomyomata being the source of the symptomatology.
Abnormal vaginal bleeding, usually menorrhagia, is another common symptom of the leiomyomatous uterus, especially if submucous myomata are present, and its evaluation should include a detailed menstrual history with any documentation of prior anemia or blood transfusions. In multiple studies, patient self-evaluation of actual menstrual blood loss has been found to be inaccurate. However, changes noted in the menstrual pattern are generally reliable.
Obstetric history, including future fertility desires, as well as any history of recurrent spontaneous abortion strongly influence treatment decisions.
Physical exam
As any co-existing condition may influence symptoms or treatment, a complete physical exam should be performed on any patient presenting for evaluation of leiomyomata. A speculum exam will reveal any vulvar, vaginal or cervical lesions, as well as any pelvic prolapse. The bimanual examination should evaluate uterine size, position, and mobility, and the location and size of any palpable leiomyomata. Other causes of uterine enlargement and asymmetry, such as pregnancy, adenomyosis, and congenital anomalies, must be considered. Additionally, other pelvic masses, such as solid or cystic ovarian tumors, hydrosalpinges, and endometriosis, can be confused with myomata.
Laboratory findings
Laboratory abnormalities associated with leiomyomata depend on the symptoms. Each patient should have a complete blood count and metabolic panel to assess any anemia, as well as any other conditions which might influence treatment. Additionally, women who are over the age of 35 with any type of abnormal bleeding should have an endometrial biopsy to determine the presence of hyperplasia or cancer. Women under 35 years with an irregular menstrual pattern should also be considered for an endometrial lining biopsy.
Imaging
Transvaginal ultrasound is the best imaging procedure for evaluating uterine anatomy. On occasion, transabdominal ultrasound may be needed to visualize uteri which have grown out of the pelvis. Broad ligament leiomyomata may be difficult to differentiate from adnexal masses, and a CT or MRI may be beneficial. With a central, globularly enlarged uterus, especially if myomectomy is planned, an MRI can differentiate myomata, a surgically resectable condition, from adenomyosis, a nonsurgically resectable lesion.
Evaluation of the uterine cavity may be achieved with office hydrosonography and/or with hysteroscopy. Both permit visualization of intracavitary polyps and leiomyomata, and indicate the potential for hysteroscopic resection. Further characterization of the uterine cavity can be gained by performing hysterosalpingography, which has the added benefit of evaluating fallopian tube patency. These three modalities have their greatest value when uterine preservation is being considered.
Due to the low risk of malignancy with leiomyomata, treatment decisions are based on symptoms, leiomyoma location, the fertility wishes of the patient, and any co-existing medical problems. Treatment options currently available are no treatment, medical treatment, surgical treatment, and uterine artery embolization.
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