Symptomatic Leiomyomas Research Articles

Hysterectomy: Patient oriented perspectives

Hysterectomy is the second most common surgical procedure performed on women, the most common being cesarean section. Women often undergo hysterectomies to improve their quality of life. Under these circumstances, the gain from the procedure must justify the potential risks. Indications for surgery include symptomatic leiomyomas, chronic pelvic pain, endometriosis, dysfunctional uterine bleeding, genital prolapse, infection, obstetrical indications, and cancer. Techniques involve the abdominal, vaginal, or combined laparoscopic approaches, with the latter two being more desirable because recovery time is considerably shorter. Medical complications include urinary, gastrointestinal, infectious, hemorrhagic, and those concerning anesthesia. Postoperative deep venous thrombosis and complications from preexisting conditions are also concerns. Psychosexual complications involve sexual dysfunction and depression. Preoperative counseling and postoperative estrogen replacement therapy may be helpful. Additional concerns include the issues of ovarian conservation and hormone replacement therapy relating to cardiovascular and osteoporotic risk, as well as to overall psychosexual function.

Abdominal Hysterectomy or Abdominal Myomectomy for Symptomatic Leiomyoma: A Comparison of Preoperative Demography and Postoperative Morbidity

This retrospective study directly compared the morbidities associated with abdominal hysterectomy and abdominal myomectomy for the treatment of symptomatic leiomyomas in premenopausal women. Medical records of consecutive inpatients with a discharge diagnosis of leiomyoma who underwent operative therapy from July 1990 through June 1991 were reviewed. A total of 313 patients met inclusion criteria and were available for analysis. Women undergoing hysterectomy (n = 204) were older (42.8 ± 0.3 vs 35.8 ± 0.5 years, mean ± SEM, p < 0.0001) and had greater mean gravidity (1.9 ± 0.1 vs 0.7 ± 0.1, p < 0.0001) and parity (1.4 ± 0.1 vs 0.3 ± 0.1, p < 0.0001) than women undergoing myomectomy (n = 109). Preoperative indications, symptoms, and preoperative uterine size were comparable between groups. There was no difference between the groups in the mean length of the procedure, the proportion of patients receiving blood transfusions, or the mean length of hospital stay. Women undergoing hysterectomy had a greater mean estimated blood loss than women undergoing myomectomy (438 ± 24 vs 315 ± 25 mL, p < 0.01). Estimated blood loss was correlated positively with uterine size for women undergoing either hysterectomy (r = 0.14, p < 0.01) or myomectomy (r = 0.27, p < 0.01), the number of myomas resected for patients undergoing myomectomy (r = 0.28, p < 0.005), and length of procedure for patients undergoing hysterectomy (r = 0.64, p < 0.0001) or myomectomy (r = 0.47, p < 0.0001). Febrile morbidity was more common in women undergoing myomectomy than in those having hysterectomy (45% vs 25.%, p < 0.0001), despite an equal proportion of patients receiving preoperative antibiotics, but myomectomy patients were no more likely to have an identified source of infection or longer hospital stay. (J GYNECOL SURG 11:11, 1995)

Symptomatic leiomyoma of the adrenal

Although small leiomyomas of the adrenal are a common incidental finding at autopsy, larger examples are extremely rare and have been asymptomatic, discovered as an incidental finding during computed abdominal scanning. We report the first, to our knowledge, instance of a large, symptomatic adrenal leiomyoma, and discuss the pathological and radiological features of the lesion.

Rapid Regression of Uterine Leiomyomas in Response to Daily Administration of Gonadotropin-Releasing Hormone Antagonist

Objective The efficacy of acute and sustained pituitary gonadotropin down-regulation by the Nal-Glu GnRH antagonist (Nal-Glu) was evaluated in the treatment of uterine leiomyomas. Design Prospective, open clinical trial. Patients Seven normally cycling women with symptomatic leiomyomas. Interventions Nal-Glu (50 μ g/kg per day) was administered subcutaneously for 3 months. Main Outcome Measures Baseline ultrasound examinations were obtained and repeated monthly throughout treatment. Each leiomyoma was mapped and measured in three dimensions. Blood samples were drawn daily for 7 days, weekly for 4 weeks, and monthly for the remaining 2 months. Results Mean leiomyoma size decreased 52.8 ± 7.3% (means ± SD) after 1 month of therapy and remained unchanged for the remainder of the study. Serum levels of E 2 (35.9 ± 11.8 to 9.3 ± 0.8 pg/mL, 131.7 ± 43.3 to 34.0 ± 1.4 pmol/L), estrone (37.3 ± 7.5 to 13.0 ± 2.5 pg/mL, 138.1 ± 27.7 to 48.1 ±9.1 pmol/L), and P (1.6 ± 1.1 to 0.3 ± 0.01 ng/mL, 5.0 ± 3.6 to 0.9 ± 0.04 nmol/L) declined rapidly (within 48 hours) and remained suppressed throughout treatment. Serum LH, FSH, andro-stenedione, T, and DHEA levels did not change significantly. In two subjects who did not have surgical removal, leiomyomas grew to original size within the 1st month off drug. Six patients remained amenorrheic and the other subject spotted during the last 2 months of therapy. Conclusions Continuous treatment with Nal-Glu induces immediate and sustained pituitary-gonadal down-regulation that results in regression in leiomyoma size. By circumventing GnRH agonist-induced pituitary-ovarian up-regulation, GnRH antagonists may prove to be superior tools in the medical management of leiomyomas.

Indomethacin for the Treatment of Symptomatic Leiomyoma Uteri During Pregnancy

Pain secondary to carneous degeneration is the most common complication of leiomyoma uteri during pregnancy. Conventional therapy utilizing bed rest and parenteral narcotic analgesics may often be ineffective. We retrospectively reviewed seven cases of degenerating fibroids complicating pregnancy where the prostaglandin synthetase inhibitor, indomethacin (25 mg orally every 6 hours), was used to treat symptoms of pain. In all cases, relief of symptoms was achieved within 48 hours of initiation of therapy. Two patients required a second course of therapy, and one patient required a third course. Mean duration of therapy was 12 days. One fetus developed transient constriction of the ductus arteriosus and transient oligohydramnios. Two pregnancies aborted, one at 22.9 and one at 22.3 weeks; however, no perinatal complications were directly attributable to indomethacin. The five term deliveries were of healthy normal infants. These retrospective data suggest that indomethacin may be effective in the treatment of pain associated with degenerating uterine leiomyomas in pregnancy.

Diffuse Laminar Endocervical Glandular Hyperplasia

We report seven examples of a hitherto undescribed pseudoneoplastic glandular lesion of the uterine cervix that we have designated "diffuse laminar endocervical glandular hyperplasia." The patients ranged in age from 22 to 48 (mean 37) years. Only one of them had a history of hormone intake. All the lesions were incidental findings in hysterectomy specimens performed for dysfunctional uterine bleeding (five cases) or symptomatic leiomyomas (two cases). Microscopic examination revealed a proliferation of moderate-sized, evenly spaced, differentiated endocervical glands within the inner one-third of the cervical wall, sharply demarcated from the underlying cervical stroma. Reactive atypia was seen in some cases but significant cytologic atypia was absent. A marked inflammatory response was present in five of the seven cases. The main consideration in differential diagnosis was adenoma malignum (minimal deviation adenocarcinoma). Major features that helped in this distinction were a lack of irregular stromal infiltration and a desmoplastic stromal response, and an absence of focal malignant cytologic features. Follow-up for an average of 6.5 years in five of the seven cases was uneventful.

Efficacy and safety considerations in women with uterine leiomyomas treated with gonadotropin-releasing hormone agonists: The estrogen threshold hypothesis

Gonadotropin-releasing hormone agonists induce a reversible hypogonadotropic hypogonadal environment. Leiomyomas are common, estrogen-sensitive, benign neoplasms that decrease in size by 40% to 50% during gonadotropin-releasing hormone agonist treatment. During gonadotropin-releasing hormone agonist therapy most women are amenorrheic. After discontinuation of gonadotropin-releasing hormone agonist treatment, uterine and myoma size increase and a return to pretreatment menstrual patterns often occurs. Concerns about the safety of long-term hypoestrogenism have made long-term gonadotropin-releasing hormone agonist administration an undesirable treatment strategy. This article focuses on the use of gonadotropin-releasing hormone agonists as preoperative therapy in selected women undergoing hysterectomy or myomectomy and the combination of a gonadotropin-releasing hormone agonist with estrogen-progestin "add-back" treatment as a potential long-term medical therapy for women with symptomatic leiomyomas. Finally, an estrogen threshold hypothesis to assess the effects of circulating estrogen concentrations on different tissues, is presented.

Hysteroscopic removal of submucous leiomyomas.

Uterine leiomyomas are benign neoplasms that, when symptomatic, may require surgical treatment. The most symptomatic leiomyomas are of the submucous variety, causing persistent or recurrent uterine bleeding. Fifty-nine women experiencing abnormal uterine bleeding, dysmenorrhea, and/or infertility were diagnosed to have submucous leiomyomas, and of these, 52 were treated by hysteroscopic removal. In all women treated, the symptoms disappeared or markedly decreased. Of 16 patients with associated infertility, 10 conceived and 8 of these delivered a viable infant vaginally. Two women had a spontaneous abortion at 6 weeks and 11 weeks gestation, respectively. Although hysteroscopic removal of submucous leiomyomas is feasible in some patients, specific criteria for patient selection are needed that will allow the hysteroscopist to avoid failures and prevent complications. Hysteroscopy offers the best diagnostic method to detect or confirm submucous leiomyomas and, in selected cases, provides a good surgical alternative for treatment.

D-Trp-6-luteinizing hormone-releasing hormone microcapsules in the treatment of uterine leiomyomas

Long acting D-Trp-6-luteinizing hormone-releasing hormone (LH-RH) microcapsules, 3.2 mg were given monthly, intramuscularly for a period of 6 months to 26 menstruating patients with symptomatic leiomyomas. The patients ages were 22 to 52 years. Five patients (20%) were infertile. Patient evaluation before initiation of treatment included endometrial biopsy, ultrasonic measurements of uterine and tumor volumes, and bone-mineral density. The patients were periodically followed hormonally and ultrasonographically. A statistically significant reduction in uterine and tumor volumes (maximal after 4 months of treatment) was observed in all the patients except one. Two patients discontinued the treatment after 2 months, preferring surgery. A nonsignificant decrease in the mean bone-mineral density was noted after completion of therapy. Minor side effects such as hot flushes, vaginal dryness, backache, vaginal spotting, and nervousness, were encountered frequently, disappearing within 6 weeks after the last injection. A significant increase in uterine and myoma volume was noted in all the patients at 3 months after treatment.

Leiomyoma of the Kidney

This is the report of a 27-year old woman with a symptomatic leiomyoma of the left kidney. Symptoms consisted of a mild discomfort at the left flank and a walking difficulty. A left radical nephrectomy was performed. The tumor measured 15 cm in its largest diameter and was composed of elongated cells which demonstrated positive reactivity with anti-desmin and anti-actin antisera and negative reactivity for S-100 protein and cytokeratins. Histologic differential diagnosis is with other spindle cell renal tumors such as leiomyosarcoma, mesoblastic nephroma, angiomyolipoma, fibroma, schwannoma and sarcomatoid renal cell carcinoma.