Gynecology Topic 24. Benign diseases of the uterus

I. Overview

Benign Diseases of the Uterus

• Main exam conditions: endometriosis, adenomyosis, uterine fibroid / leiomyoma.
• This topic mainly tests leiomyoma; endometriosis/adenomyosis are covered more fully elsewhere.
• Other benign uterine/endometrial lesions: endometrial polyp, Asherman syndrome / intrauterine adhesions.

II. Uterine Fibroid / Leiomyoma

Definition and Epidemiology

• Leiomyoma / myoma / fibroid: benign estrogen- and progesterone-responsive smooth muscle tumor of the myometrium.
• Most common benign uterine tumor; about 25% of women develop clinically relevant fibroids.
• Usually multiple, firm, well-circumscribed, white whorled tumors.
• Growth is reproductive-age related; often stabilizes/regresses after menopause.
• Malignant transformation is very rare; leiomyosarcoma usually arises de novo.

Risk Factors

• Nulliparity.
• African ancestry.
• Early menarche.
• Increasing reproductive age.
• Family history / genetic predisposition.
• Obesity.

Classification by Location

1. Submucous: projects into uterine cavity; often bleeding/infertility; may be pedunculated.
2. Intramural: within myometrium; most common type.
3. Subserous: projects outward; often pressure symptoms; may be pedunculated.
4. Parasitic: separates from uterus and gains extrauterine blood supply.
5. Cervical.
6. Intraligamentary: between broad-ligament layers.

III. Clinical Features and Diagnosis

Clinical Features

• Most are asymptomatic.
• AUB: menorrhagia, metrorrhagia, dysmenorrhea → iron deficiency anemia.
• Pelvic heaviness/fullness, pelvic pain.
• Acute pain: degeneration/necrosis, torsion of pedunculated fibroid, infarction.
• Pressure symptoms: urinary frequency/incontinence/retention, constipation, dyspareunia.
• Reproductive effects: infertility and recurrent spontaneous abortion, especially with submucous cavity distortion.
• Pregnancy complications: miscarriage, malpresentation, obstructed labor, cesarean delivery, postpartum hemorrhage.
• Red degeneration in pregnancy: acute localized pain + low-grade fever/leukocytosis → usually analgesia + observation.

Diagnosis

• Bimanual examination: enlarged, mobile, firm, irregular uterus.
• Labs: pregnancy test if relevant; CBC/ferritin for iron deficiency anemia.
• Leukocytosis/fever may occur with degeneration but infection must be excluded.
• Pelvic ultrasound: confirmatory first-line test; well-circumscribed myometrial mass.
• Saline infusion sonography or hysteroscopy: best for submucosal fibroids and cavity distortion.
• MRI: preoperative mapping; differentiates fibroid from adenomyosis or suspected leiomyosarcoma.
• Endometrial biopsy: AUB with age/risk factors for endometrial hyperplasia/cancer.

Differential Diagnosis

• Pregnancy.
• Adenomyosis.
• Endometrial polyp or hyperplasia/cancer.
• Ovarian/adnexal mass.
• Leiomyosarcoma / uterine sarcoma: postmenopausal growth, rapid enlargement, atypical MRI.

IV. Management

Observation

• Asymptomatic or mild symptoms, especially near/post menopause → observation.
• Follow-up: symptoms + pelvic exam/ultrasound, often every 6-12 months.
• Treat if symptoms, growth, infertility/cavity distortion, anemia, pressure effects, or malignancy concern.

Medical Treatment

• Goal: control bleeding/pain or shrink temporarily before surgery; medication usually does not cure fibroids.
• Bleeding control: OCP/progestin therapy, levonorgestrel IUD if cavity not distorted, tranexamic acid.
• Pain: NSAIDs.
• GnRH agonist, e.g. leuprolide: temporary hypoestrogenic shrinkage; useful preoperatively, limited by hot flashes/bone loss/recurrence after stopping.
• Ulipristal acetate / SPRM: can reduce bleeding/size, but use is restricted in many countries because of liver-safety concerns.

Surgical Treatment

• Surgery is contraindicated/avoided in pregnancy unless exceptional emergency because bleeding risk is high.

1. Myomectomy

• Fertility-preserving removal of fibroid(s).
• Hysteroscopic: submucosal fibroids.
• Laparoscopic/laparotomic/robotic: intramural or subserosal fibroids depending on size/location.
• Indication: symptomatic patient with desired fertility or uterine preservation.
• Disadvantages: bleeding, adhesions, recurrence/new fibroids; cesarean may be needed in later pregnancy after deep myometrial incision.

2. Hysterectomy

• Definitive cure for large/symptomatic fibroids when fertility is not desired.
• Routes: vaginal, abdominal, laparoscopic, robotic.
• No recurrence; ovaries are not automatically removed unless indicated/consented.
• Complications: bleeding, infection, bladder/ureter/bowel injury, vaginal vault prolapse, urinary/sexual symptoms.

Uterus-Preserving Procedures

1. Uterine artery embolization (UAE)

• Catheter via femoral/radial artery → embolic particles occlude uterine arteries → fibroid ischemia/shrinkage.
• Usually no general anesthesia; shorter recovery than hysterectomy/myomectomy.
• Risks: post-embolization pain/fever, infection, premature ovarian insufficiency, repeat procedure/hysterectomy.
• Fertility/pregnancy safety is uncertain → not preferred if pregnancy is strongly desired.

2. MRI-guided focused ultrasound / HIFU

• Focused ultrasound thermally ablates fibroid; non-invasive, availability variable, fertility data limited.

Other Benign Uterine Conditions: Brief Positioning

• Adenomyosis: endometrial glands in myometrium → enlarged tender uterus, dysmenorrhea, heavy bleeding.
• Endometriosis: endometrial-like tissue outside uterus → dysmenorrhea, chronic pelvic pain, infertility.
• Endometrial polyps: focal protrusions into uterine cavity → AUB/intermenstrual bleeding; hysteroscopic removal and histology if symptomatic or risk factors.
• Asherman syndrome: intrauterine adhesions after curettage/infection → hypomenorrhea/amenorrhea, infertility; hysteroscopic adhesiolysis.