Submucosal Myomas Research Articles

Aberrant HOXA10 Methylation in Patients With Common Gynecologic Disorders: Implications for Reproductive Outcomes.

HomeoboxA10 (HOXA10) is a transcription factor that is crucial for the development and patterning of the uterus during embryogenesis. In the adult endometrium, HOXA10 expression is regulated by steroid hormones and embryonic signals. Expression of sufficient HOXA10 messenger RNA is essential to endometrial receptivity and embryo implantation. Aberrant methylation is believed to alter the expression of HOXA10. Methylation of this gene may be associated with decreased fertility, implantation defects, and/or reproductive wastage seen in certain disease states that affect the female reproductive tract. This study describes the differences in methylation patterns of HOXA10 gene in uterine myomas, endometriosis, uterine septum, Asherman syndrome, or uterine polyps of women undergoing hysteroscopic surgery. In the endometrium of uteri with polyps, submucosal myomas, and intramural myomas, there were CpG sites within the HOXA10 gene that were highly methylated compared to controls. The HOXA10 gene in women with endometriosis was hypomethylated compared to controls. DNA methylation may be a common molecular mechanism that results in reproductive dysfunction seen in gynecologic disease.

Apport d’un simulateur d’hystéroscopie virtuelle dans l’apprentissage de la résection hystéroscopique de fibrome

ObjectivesUterine myomas are a frequent pathology affecting 20% of women of reproductive age. Myomas induce abnormal uterine bleeding, pelvic pain and increase the risk of infertility and obstetrical complications. Symptomatic sub-mucosal myomas are classically treated by hysteroscopic resection. Simulation is a method of education and training. It could improve quality and security of cares. The aim of this study is to assess the interest of a hysteroscopic simulator for the resection of myoma by novice surgeons. MethodsTwenty medical students were recruited, in a prospective study, in august 2014. The virtual-reality simulator VirtaMed HystSim™ (VirtaMed AG, Zurich, Switzerland) was used to perform the hysteroscopic training. All students received a short demonstration of myoma resection. The practice consists of a submucous myoma type 0 resection. The procedure and the evaluation were performed before and after a specific training in hysteroscopic resection of sixty minutes long. The main outcome criteria were time for the resection before and after training. The second criteria were fluid quantity used, number of contact between optic and uterine cavity and uterine perforation. ResultsTwenty students aged from 22 to 24years were included. The time for the procedure was significantly reduced after training (170s versus 335s, P<0.01). There is the same for fluid quantity used (335mL versus 717mL, P<0.01) and the number of contact between optic and uterine cavity (0.2 contact versus 3, P=0.012). No perforation occurred in the simulation. ConclusionThe results suggest that hysteroscopic simulator enhances and facilitates hysteroscopic resection for novice surgeons.

Myoma-associated pain frequency and intensity: a retrospective evaluation of 1548 myoma patients

ObjectiveTo analyze the possible relation between symptoms (especially pain) reported by myoma patients and objective features of their myomas as determined by ultrasound. Specifically: (1) What is the frequency and intensity of myoma-related pain? (2) Does the pain intensity depend on the number, size, or location of the myomas? (3) Is there any correlation between premenstrual pain, menstrual pain, and pain during sexual intercourse? Study designA retrospective analysis of data from a patient questionnaire and ultrasound exams, collected from February 2009 until January 2013 at the myoma clinic of a university hospital in a large European city. The study analyzed data from 1548 myoma patients. Patients completed a 0–10 Likert scale questionnaire about their symptoms. The number, size, and location of myomas were determined from ultrasound exams. ResultsThe three most frequent symptoms reported were hypermenorrhea, dysmenorrhea, and premenstrual pain. There was no statistically significant relationship between premenstrual pain or pain during sexual intercourse on the one hand and the number, size, or location of myomas on the other hand. For women with severe dysmenorrhea (Likert-scale scores of 8–10), submucosal myomas were significantly more frequent than all other myoma locations (p=0.01). Severe dysmenorrhea (Likert-scale scores of 8–10) was reported by a significantly (p<0.001) greater portion of the women whose largest myoma had a largest diameter of <5cm than by the women whose largest myoma had a diameter ≥5cm. The number of myomas did not have a significant influence on the dysmenorrhea intensity. The three types of pain (premenstrual, menstrual, and/or during sexual intercourse) had moderate pairwise correlations (ρ values from 0.304 to 0.542) that were all statistically highly significant (p<0.001). ConclusionMyoma-associated pain is, alongside hypermenorrhea, the most frequent problem reported by the affected patients. Unlike premenstrual pain and pain during sexual intercourse, the intensity of menstrual pain is clearly dependent on the location and size of the largest myoma. Further research is needed to better understand the degree to which the pain reported by the patients is due to features of the myomas versus other possible factors.

Подслизистая миома матки. Социальная значимость и пути решения проблемы

Подслизистая миома матки. Социальная значимость и пути решения проблемы

High-intensity focused ultrasound combined with hysteroscopic resection to treat retained placenta accreta

We present a case of retained placenta accreta treated by high-intensity focused ultrasound (HIFU) ablation followed by hysteroscopic resection. The patient was diagnosed as submucosal myoma based on ultrasonography in local clinic. Pathologic examination of several pieces of tumor mass from the hysteroscopic procedure revealed necrotic chorionic villi with calcification. HIFU was performed using an ultrasound-guided HIFU tumor therapeutic system. The ultrasound machine had been used for real-time monitoring of the HIFU procedure. After HIFU treatment, no additional vaginal bleeding or complications were observed. A hysteroscopic resection was performed to remove ablated placental tissue 7 days later. No abnormal vaginal bleeding or discharge was seen after the procedure. The patient was stable postoperatively. We proposed HIFU and applied additional hysteroscopic resection for a safe and effective method for treating retained placenta accreta to prevent complications from the remaining placental tissue and to improve fertility options.

Infertility and uterine fibroids

Uterine fibroids are the most common tumors in women and their prevalence is higher in patients with infertility. At present, they are classified according to their anatomical location, as no classification system includes additional parameters such as their size or number. There is a general agreement that submucosal fibroids negatively affect fertility, when compared to women without fibroids. Intramural fibroids above a certain size (>4cm), even without cavity distortion, may also negatively influence fertility. However, the presence of subserosal myomas has little or no effect on fertility. Many possible theories have been proposed to explain how fibroids impair fertility: mechanisms involving alteration of local anatomical location, others involving functional changes of the myometrium and endometrium, and finally endocrine and paracrine molecular mechanisms. Nevertheless, any of the above mentioned mechanisms can cause reduced reproductive potential, thereby leading to impaired gamete transport, reduced ability for embryo implantation, and creation of a hostile environment. The published experience defines the best practice strategy, as not many large, well-designed, and properly powered studies are available. Myomectomy appears to have an effect in fertility improvement in certain cases. Excision of submucosal myomas seems to restore fertility with pregnancy rates after surgery similar to normal controls. Removal of intramural myomas affecting pregnancy outcome seems to be associated with higher pregnancy rates when compared to non-operated controls, although evidence is still nοt sufficient. Treatment of subserosal myomas of reasonable size is not necessary for fertility reasons. The results of endoscopic and open myomectomy are similar; thus, endoscopic treatment is the recommended approach due to its advantages in patient's postoperative course.

Childhood Rhabdomyosarcoma With Hysteroscopic Resection of an Unusual Number of Submucosal Myomas

Childhood Rhabdomyosarcoma With Hysteroscopic Resection of an Unusual Number of Submucosal Myomas

Cold loops applied to bipolar resectoscope: A safe "one-step" myomectomy for treatment of submucosal myomas with intramural development.

To assess the safety and efficacy of cold loop myomectomy applied to bipolar resectoscope to perform "one-step" myomectomy of submucosal myomas with intramural involvement. Seventy-two patients with at least one symptomatic G1 or G2 myoma (Wamsteker's classification) underwent cold loop myomectomy from January 2011 to January 2013. All surgical procedures were performed using a 26Fr resectoscope and bipolar energy source. At one month after the procedure, all patients underwent an office hysteroscopy check-up. A subgroup of seven infertile patients underwent an office hysteroscopy every two-weeks to evaluate recovery time of the myometrial fovea. Resectoscopic myomectomies were successfully performed in one surgical step in 70 out of 72 patients without any significant complications. Overall, the mean diameter of resected myomas was 32.2 ± 9 mm. Median operative time was 34.2 ± 24.1 min. Median fluid deficit was 761.22 ± 480.34 ml. The fovea was almost completely restored (>80%) six weeks after surgery in six of the seven infertile patients who underwent repeated follow-up office hysteroscopies every two weeks. Data from the present study show that the use of cold loops applied to bipolar resectoscope represent an effective, safe technique for "one-step" myomectomy of G1-G2 myomas, allowing rapid recovery of the myometrial fovea.

Thermal Bowel Injury During Difficult Laparoscopic Myomectomy

A 38-year-old woman underwent a difficult laparoscopic myomectomy for multiple myomas with a uterus size of 24 weeks and complaints of heavy menstrual bleeding and severe dysmenorrhea. She had previously undergone laparoscopic myomectomy for a single large myoma. Intraoperatively, the patient had 9 submucosal myomas, which were resected hysteroscopically, and dense bowel adhesions to the uterus and anterior abdominal wall (Fig. 1a), which were released using scissors and bipolar forceps, and then proceeded with laparoscopic myomectomy. She received 2 units of packed cell transfusion. The postoperative period was eventful, with persistent abdominal distension and low grade fever with reactive basal pleural effusion. On postoperative day 5, we posted her for diagnostic laparoscopy, suspecting a bowel injury. She had localized peritonitis (Fig. 1b) with evidence of small bowel thermal injury and necrosis (Fig. 1c). We performed laparoscopic-assisted wide bowel resection (Fig. 1d) and an end-to-end anastomosis, with intensive care monitoring and electrolyte correction. The patient recovered on postoperative day 10 and was discharged in a healthy condition.

Hysteroscopic Myomectomy After Uterine Embolization in Large Sized Submucosal Myoma

We report seven cases of large sized submucosal myoma treated successfully by hysteroscopic myomectomy after uterine artery embolization(UAE).

Randomized comparative trial of cervical block protocols for pain management during hysteroscopic removal of polyps and myomas.

PurposeTo evaluate the efficacy of two cervical block protocols for pain management during hysteroscopic removal of intrauterine polyps and myomas using the MyoSure® device.Patients and methodsThis was a randomized, comparative treatment trial conducted by five private Obstetrics and Gynecology practices in the USA. Forty premenopausal women aged 18 years and older were randomized to receive either a combination para/intracervical block protocol of 37 cc local anesthetic administered at six injections sites in association with the application of topic 1% lidocaine gel, or an intracervical block protocol of 22 cc local anesthetic administered at three injections sites without topical anesthetic, for pain management during hysteroscopic removal of intrauterine polyps and/or a single type 0 or type 1 submucosal myoma ≤3 cm. The main outcomes were a composite measure of procedure-related pain and pain during the postoperative recovery period, assessed by the Wong-Baker Faces Rating Scale (0= no pain to 10= maximum pain). The lesion characteristics, procedure time, and adverse events were summarized.ResultsA total of 17 polyps and eight myomas were removed in the para/intracervical block group, with diameters of 1.3±0.5 cm and 1.8±0.8 cm, respectively. In the intracervical block group, 25 polyps with a mean diameter of 1.2±0.7 cm and 7 myomas with a mean diameter of 1.9±0.9 cm were removed. The mean tissue resection time was 1.2±2.0 minutes and 1.2±1.4 minutes for the para/intracervical and intracervical block groups, respectively. The mean composite procedure-related pain score was low for both cervical block protocols, 1.3±1.4 in the para/intracervical block group vs 2.1±1.5 in the intracervical block group. During the postoperative recovery period, the mean pain scores were 0.3±0.7 vs 1.2±1.7 for the para/intracervical and intracervical block groups, respectively. There were no serious adverse events.ConclusionThe MyoSure procedure for removal of polyps and myomas was well tolerated, with low pain scores reported for both the para/intracervical and intracervical block protocols.

Fertilité après résection hystéroscopique de myomes sous-muqueux chez des patientes infertiles

Myoma is the most frequent benign uterine tumor and might have a negative impact on fertility. In 5 to 10% of cases, infertility is associated with myoma and in 1 to 3% myoma is the only infertility factor. Even if effect of myomectomy on fertility is controversial, benefit of hysteroscopic myomectomy for submucosal myoma on fertility has already been shown. The aim of this study is to evaluate fertility of infertile women less than 46years old after hysteroscopic resection of submucosal myoma. This retrospective unicentric study took place in the gynecologic unit of a teaching hospital. All infertile women with a hysteroscopic myomectomy for submucosal myoma between March 2009 and May 2013 were included. A phone questionnaire was conducted to evaluate pregnancy rate, eventual medical assistance, time between submucisal resection and pregnancy and issue of pregnancies. Seventy-one infertile women with a hysteroscopic resection of submucosal myoma were included. Pregnancy rate was 33.8% with 50% of live births, 41.6% of miscarriages and 8.4% of late fetal losses with a mean follow-up of 28.7months. Mean time between hysteroscopic resection and pregnancy was 9.9months. A medical assistance was necessary for 6 women (25% of pregnancy). This study reports hysteroscopic resection of submucosal myoma for infertile women. The rate of pregnancy after treatment is 33.8%.

Uterine artery embolization for symptomatic fibroids in postmenopausal women

PurposeThe aim of the current study was to evaluate the efficacy of uterine artery embolization (UAE) for symptomatic fibroids in postmenopausal women. Materials and methodsAmong 900 cases who underwent UAE between 2007 and 2013, a total of 9 postmenopausal women with symptomatic fibroids (n=6) and fibroid with adenomyosis (n=3) were included in this retrospective study. Ages ranged from 49 to 55years (median of 52). The embolic agent was nonspherical polyvinyl alcohol particles. We evaluated 18 uterine arteries in nine patients and compared the size of the uterine artery relative to inferior mesenteric artery (IMA) in preprocedural magnetic resonance (MR) angiography. Magnetic resonance imaging (MRI) was performed before and 3months after UAE. Predominant fibroid and uterine volumes were calculated from MR images. ResultsUrinary frequency was the most common symptom, observed in seven patients (77.8%). Of two patients (22.2%) with vaginal bleeding from submucosal myomas, one patient had been on hormone replacement therapy (HRT). One patient underwent UAE due to growing leiomyoma after HRT. All of the 18 uterine arteries were bigger than the corresponding IMAs in MR angiography. Contrast-enhanced MRI revealed complete necrosis of the predominant fibroid in all patients. Eight (88.9%) of the nine participants demonstrated resolution of symptoms. The mean predominant fibroid and uterine volume reduction rates were 39.7% and 36.9%, respectively. ConclusionsIn postmenopausal women, UAE was effective to treat symptomatic fibroids, and it could be considered as an alternative treatment to hysterectomy.

Outpatient transcervical microwave myolysis assisted by transabdominal ultrasonic guidance for menorrhagia caused by submucosal myomas

Purpose: The aim of this paper was to evaluate the effectiveness in day clinics of microwave endometrial ablation (MEA) on transcervical microwave myolysis for patients with menorrhagia caused by submucosal myomas. Materials and methods: Thirty-five outpatients (average age 44.8 ± 5.2 years (mean ± SD), range 34–58) with a single submucosal myoma that was 4–7 cm (5.5 ± 2.1 cm) in size underwent MEA with transcervical microwave myolysis using a specifically developed transabdominal ultrasound probe attachment for transcervical puncture. Primary outcomes were the changes in the blood haemoglobin level and the volume of myoma before and after the treatment. Secondary outcomes were the improvement in menorrhagia and satisfaction after the operation, assessed by visual analogue scale (VAS). Results: The mean operation time was 27.9 ± 13.6 min. The myomas had shrunk by 56.2% at 3 months and 73.8% at ≥6 months after the operation. Blood haemoglobin levels had increased significantly at 3 months (10.2 ± 2.0 vs. 12.7 ± 1.2, p < 0.001). The average VAS assessment of menstrual bleeding had decreased to 1.7 ± 1.7 at 3 months after the operation (preoperative VAS = 10). The average VAS score for feelings of satisfaction 3 months after the operation was 9.8 ± 0.5 (full score = 10). Conclusions: MEA with transcervical microwave myolysis is a feasible and effective procedure in a day surgery clinic for menorrhagia caused by submucosal myomas. The procedure may be an alternative to hysterectomy for menorrhagia caused by submucosal myomas in women during the perimenopausal period.

Ultrasound-guided manipulation of fetal entrapment by a large uterine fibroid

FIGURE 2 Dolichocephalic fetus preprocedure Case notes A 34-year-old G2P0010 presents for nuchal translucency at 12 weeks’ gestation. Ultrasound revealed a dolichocephalic fetus (cephalic index of 49) (Figure 1). This was attributed to fetal “entrapment” secondary to compartmentalization of the fetus superiorly due to an anterior, submucosal myoma (8.8 9.4 8.0 cm) separating it inferiorly from the placenta and amniotic fluid (Figure 2). Nuchal translucency could not be measured

Uterine anomalies in women with recurrent pregnancy loss

One percent of couples trying to have children are affected by recurrent miscarriage. These pregnancy losses have different pathogenetic (genetic, endocrine, anatomic, immunologic, microbiologic, haematologic and andrologic) backgrounds, but recurrent miscarriage remains unexplained in more than half of the affected couples. To explore risk factors for recurrent pregnancy loss the authors studied the incidence of anatomic disorders of the uterine cavity occur in Hungarian women with recurrent miscarriage. Medical records of 152 patients with recurrent miscarriage were analyzed retrospectively. In order to explore disorders of the uterine cavity hysteroscopy or 3-dimensional sonography in 132 women, hysterosalpingography in 16 and hysterosalpingo-sonography in 4 patients were used. Incidence of anomalies in the uterine cavity was found in women with recurrent miscarriage to be 15.8%. A variety of the uterine anomalies was found including uterine septum in 6.5%, endometrial polyp in 2.6%, arcuate and bicornuate uteri both in 2% and 2%, submucosal myoma in 1.3 %, and intrauterine synechiae in 1.3%. These findings suggest that morphologic disorder of the uterine cavity is frequent in Hungarian women with recurrent miscarriage. Therefore, assessment of the uterine anatomy is recommended in such patients.

Three-month treatment with triptorelin, letrozole and ulipristal acetate before hysteroscopic resection of uterine myomas: prospective comparative pilot study

ObjectiveTo compare the usefulness of preoperative treatment with triptorelin, letrozole or ulipristal acetate or no treatment before hysteroscopic removal of uterine submucosal myomas. Study designSingle center prospective non-randomized comparative pilot study. The study included consecutive premenopausal patients undergoing hysteroscopic resection of myomas graded as type 0, type 1 or type 2 according to the FIGO classification with diameter between 20 and 35mm. Exclusion criteria were: associated polyps, associated non-hysteroscopic surgical procedures, >2 myomas requiring hysteroscopic resection. This study enrolled patients who underwent either direct surgery (group S; n=23) or 3-month preoperative treatment with triptorelin (3.75mg every 28 days; group T; n=20), letrozole (2.5mg/day; group L; n=11) or ulipristal acetate (5mg/day; group U; n=7). Patients underwent hysteroscopic resection of the myomas. ResultsAll medical treatments caused a significant decrease in the volume of myomas (group T, p<.001; group L, p<.001; group U, p=.006); however, the percentage decrease in myoma volume was lower in group U than in group T (p=.001) and in group L (p=.010). The hysteroscopy time was higher in group S than in group T (p<.001) and in group L (p=.001); there was no significant difference in the hysteroscopy time between group S and group U (p=.206). Fluid absorption was lower in group T than in group S (p=.002) and in group L than in group S (p=.048); fluid absorption was similar in group S and group U (p=.110). Intra- and postoperative complications, postoperative pain, and patient satisfaction were similar in the four study groups. Surgeon's evaluation of operative difficulty was better in group T than in group S (p<.005). ConclusionsPreoperative treatment with triptorelin and letrozole decreases the hysteroscopy time and the volume of fluid absorbed during hysteroscopic resection of uterine submucosal myomas.

Preoperative dienogest to improve the surgical field of view in resectoscopic surgery

Abstract Introduction Resectoscopic surgery requires high technological skill to perform the procedure in a limited field of vision. With the preoperative administration of dienogest, a good surgical field of vision can be secured. The lesion and the normal endometrium are easily distinguished, and therefore the removal of normal endometrium can be minimized. Methods Preoperative dienogest was administered to 28 patients with submucosal myomas, 18 patients with endometrial polyps, and one patient with Asherman's syndrome. The patients began taking oral dienogest (2 mg/d) on Day 5 of preoperative menstruation until the day before surgery. Use of dienogest before resectoscopic surgery was approved by the Institutional Review Board of Toho Medical Center Oomori Hospital (Tokyo, Japan; approval number 24-185). Results The duration of oral dienogest treatment was 14–72 days in patients with submucosal myoma and 18–85 days in patients with endometrial polyps. Slight thickening of the endometrium occurred in patients who were administered dienogest for 14 days. However, a thin endometrium occurred in patients who took the drug for 28 days or longer. Submucosal myomas and endometrial polyps were easily distinguished from the normal myometrium. A sufficient intrauterine surgical field was secured to minimize endometrial damage in all patients. Conclusion We found that preoperative dienogest effectively minimized endometrial damage in resectoscopic surgery by thinning the endometrium and clearing the surgical field of vision.

Correlation of Hysterosalpingogram With Diagnostic Hysteroscopy for Uterine Cavity Defects in a Community Hospital Setting [110

INTRODUCTION: The utility and accuracy of hysterosalpingogram in a community hospital setting were evaluated for accuracy in predicting uterine cavity pathology. METHODS: A retrospective chart review was performed for all hysteroscopic procedures that had a hysterosalpingogram performed between August 1, 2012, and August 25, 2014, at a single community hospital in an inner-city setting. Hysterosalpingogram reports by a radiologist were reviewed, and hysteroscopy operative reports were reviewed that were performed by a reproductive endocrinologist. RESULTS: A total of 60 patients were identified. Average age was 31.3 years (median 34 years). Findings correlated for tubal diagnosis in 88.4% of patients. However, for uterine cavity defects, the accuracy was lowest for the finding of uterine septum on hysteroscopy; hysterosalpingogram reported normal findings on all six patients encountered in this series. High sensitivity and correlation were found for findings of intrauterine adhesions (95%), submucosal myomas, and endometrial polyps (90%). The findings for submucosal myomas and endometrial polyps were confirmed with final pathology. CONCLUSION: Hysterosalpingogram has a low sensitivity for finding of uterine septum in this setting. Further studies are needed for correlation with clinical impression by a reproductive endocrinologist.

Conservative management by hysteroscopy in submucosal myomas

Conservative management by hysteroscopy in submucosal myomas