General Considerations:

1. Incidence: around 30% of all reproductive females

2. Synonym: fibroid tumor, leimyoma.

3. Origin: smooth muscle of uterus.

4. Estrogen dependent.

5. Incidence of malignant transformation: 0.4%.

 Clinical Features:

1. Abnormal uterine bleeding, excessive or prolonged menses

2. Pain: when there are degeneration change, myoma delivery, compression, torsion of pedunculated myoma.

3. Palpable mass

4. Asympomatic

5. Infertility, repeated abortion 

Types of myoma:

1. Submucosal myoma

2. Pedunculated myoma (subsersal & submucosal)

3. Intramural myoma

4. Cervical myoma

5. Broad ligament myoma 

Diagnosis:

1. Pelvic examination: size was described as gestation week

2. Gyn. sonography: transabdominal or transvaginal sonography

3. Computed tomography (CT scan)

4. MRI

5. Hysteroscopy: for submucosal myoma 

Secondary Changes:

1. Hyaline degeneration

2. Cystic degeneration

3. Red degeneration

4. Fatty degeneration

5. Calcification degeneration

6. Necrotic degeneration

7. Septic degeneration

8. Malignant change: leiomyosarcoma 

Pathology:

1. Leiomyoma

2. Degeneration changes

 Treatments:

1. Expectant Tx:

a. Myoma < 6 cm often regress after menopause

2. Medical Tx:

a. Progestine and Antiprostaglandin : controll MC amount

b. GnRH-a, LHRH-a: reduce myoma size

c. Danazol: uncertain effect

3. Surgical Tx:

a. Myomectomy: recurrent rate of myoma is high (40%). used in p’t  not completing family or who don’t want to receive hysterctomy.

b. Hysterectomy: ATH, LAVH.

  4. Alternate Tx:

a.  Uterine artery embolization (UAE) , after UAE uterine fibroidshrink at least 50% in volume on average and symptoms of refractory vaginal bleeding and chronic pelvic pain are controlled in approximately 85% of patients. (Reference)

b. Uterine artery ligation (electrocautization or clip ligation)

 Indication of surgery:

1. Severe menorrhagia

2. Obvious symptom and sign of pain, compression

3. Rapid growing tumor

4. Possibility of malignant change 

Pre-OP evaluation:

1. Pathology of Fr D&C + Cx Bx is required

2. Other evaluations are same as general Gyn. Pre-OP  

Post-OP care:

1. Post-OP evaluation in the night of operation

2. C.D., Flatus passage stimulation, CBC/DC et, al. are same as general Gyn  laparotomy

3. Pathology report on the third day postoperatively 

Special Conditions of Uterine Myoma:

1. Leiomyomatosis: polypoid extension of benign smooth muscle tumor into the pelvic vein

2. Leiomyomatosis peritonealis disseminata: multiple myoma in the subperitoneal surface

3. Benign metastasizing fibromyomas: a variant of low-grade leiomyosarcoma

 * 所有的myoma在手術中specimen切下來之後，一定要把所有myoma切開看看，若有necrosis部份必須送frozen section以免漏掉leiomyosarcoma。

* 若uterine myoma同時合併vaginal bleeding必須survey看有沒有凝血機能異常。

* 本院開ATH前一定要有半年內的Fr D&C + Cx Bx報告。

* Myomectomy後子宮縫合傷口最好用Interceed覆蓋以防腸粘黏。