BENIGN TUMORS OF THE UTERUS

JOMBWE DESIRE NORAH

 INTRODUCTION
DEFINITION
• Benign uterine tumors are non-cancerous, abnormal growths that
develop in the uterus. They typically arise from the various tissue
types found within or around the uterus, including smooth muscle,
endometrial tissue, or connective tissue.
• These tumors are one of the most common gynecological issues
encountered in women of reproductive age and can lead to
symptoms ranging from mild to severe. Understanding these
tumors is essential, as they can impact quality of life, fertility, and,
in rare cases, become a surgical emergency.
 EPIDEMIOLOGY

PREVALENCE
• The incidence of benign uterine tumors increases with
age, with leiomyomas (fibroids) being the most common.
By the age of 50, around 70-80% of women have some
form of fibroid, though not all experience symptoms.
 TYPES OF BENIGN UTERINE TUMORS

We will focus on the three main types of benign uterine

tumors:
1. Leiomyomas (commonly known as fibroids);
• The most frequently occurring benign tumors of the uterus.
• Composed of smooth muscle cells, they are usually well-
circumscribed, round, and firm in texture.
• Although they are hormone-dependent, especially sensitive
to estrogen and progesterone, the exact cause is not
completely understood.
 CONT.
2. Adenomyomas
• Consist of both glandular endometrial tissue and surrounding
stromal tissue that has infiltrated the myometrium.
• This condition is often related to adenomyosis, where endometrial
tissue grows within the uterine muscle wall
3. Endometrial polyps
• Localized overgrowths of the endometrial lining tissue.
• They are usually small and may be pedunculated or sessile.
• Polyps are most commonly found in the endometrial cavity but
can sometimes protrude into the cervix.
 LEIOMYOMAS(FIBROIDS)

Etiology and Risk Factors:

• The exact cause of leiomyomas remains unclear, but
hormonal factors, particularly the presence of estrogen
and progesterone, play a crucial role in their growth.
• They usually take 3-5 years to grow sufficiently to be felt
per abdomen
• Risk factors include age (common between 30 and 50
years), African-American ethnicity, obesity, nulliparity
(having no children), and a family history of fibroids.
TYPES OF LEIOMYOMAS
 TYPES
• Submucosal Leiomyomas: Located just under the endometrial lining
and may protrude into the uterine cavity. These are often associated with
heavy menstrual bleeding and fertility issues.
• Intramural Leiomyomas: Found within the muscular wall of the uterus,
intramural fibroids are the most common type and can lead to an
enlarged uterus, pelvic pain, and pressure symptoms.
• Subserosal Leiomyomas: Positioned on the outer surface of the
uterus, subserosal fibroids often project outward and may press against
adjacent organs, leading to urinary or gastrointestinal symptoms.
• Cervical Leiomyomas: A rare type that originates in the cervix. Cervical
fibroids may cause problems with labor and delivery or lead to urinary
retention if large enough.
 Clinical Presentation of Leiomyomas

Symptoms Based on Size and Location:

• Menorrhagia (Heavy Menstrual Bleeding): Particularly
common with submucosal fibroids, which may disrupt the
endometrial lining and blood flow during menstruation.
• Dysmenorrhea (Painful Menstruation): The increased size
of the uterus and pressure against surrounding organs may
cause painful periods.
• Pelvic Pain and Pressure: Larger fibroids can cause a
sensation of heaviness or pressure within the pelvis,
sometimes radiating to the lower back or legs.
 CONT.
• Urinary and Bowel Symptoms: If the fibroids press on the bladder,
women may experience urinary frequency or difficulty emptying the
bladder completely. If they press on the rectum, constipation may occur.
• Infertility or Pregnancy Loss: Submucosal and large fibroids can alter
the shape of the uterine cavity, potentially impacting embryo
implantation or pregnancy.
Physical Examination Findings:
• PALLOR
• The uterus may feel enlarged and irregular upon palpation. On
bimanual examination, it might feel “lumpy” or “knobby” due to the
presence of multiple fibroids.
 SECONDARY CHANGES IN FIBROIDS

• Degenerations
• Atrophy
• Necrosis
• Infection
• Vascular changes
DANIVaS
• Sarcomatous changes
 CONT.
• Degenerations:
– Hyaline degeneration
– Cystic degeneration
– Fatty degeneration
– Calcific degeneration
– Red degeneration

– Atrophy: due to loss of support from estrogen

– following menopause
– Following pregnancy enlargement
 CONT.
• Necrosis: due to circulatory inadequacy (central necrosis
of the tumor )
– Pedunculated subserous fibroid
• Infection: access through the thinned and sloughed surface
epithelium of the submucous fibroid.
– Following delivery or abortion
– Intramural fibroid may also be infected following delivery.
–Vascular changes: Telangiectasis (dilatation of the vessels) or
lymphangiectasis (dilatation of the lymphatic channels) inside the
myoma may occur. Cause is not known.
 CONT.
–Sarcomatous changes: may occur in <0.1% cases. The usual
type is leiomyosarcoma.
OTHER COMPLICATIONS
• Hemorrhage
– Intracapsular
– Ruptured surface vein of subserous fibroid  intraperitoneal
• Polycythemia
– Erythropoietic function by the tumor
– Altered erythropoietic function of the kidney through ureteric
pressure
 CONT.
• Torsion of subserous pedunculated fibroid
• Inversion of uterus
• Endometrial carcinoma associated with fibromyoma
• Endometrial and myohyperplasia
• Accompanying adenomyosis
• Parasitic fibroid
 DIFFERENTIAL DIAGNOSIS
• pregnancy
• full bladder
• ectopic pregnancy
• benignor malignant ovarian tumor
• bicornuate uterus
• adenomyosis
• chronic PID
 INVESTIGATIONS
• Haemoglobin, blood grouping
• Ultrasound abdomen & pelvis
• Hysterosalphingography (to identify submucous myoma)
• Hysteroscopy
• D&C (to rule out endometrial cancer)
• Laparoscopy
• MRI (to identify adenomyosis and myoma)

In majority cases, the clinical features are clear cut. Elaborate

investigations are not required.
 MANAGEMENT PROTOCOL
OF UTERINE FIBROIDS

CERVI
BODY
X

ASYMPTOMATI SUPRAVAGINA
SYMPTOMATIC VAGINAL
C L
REGULAR
SUPERVISIO
HYSTERECTO POLYPECTO
MEDICAL SURGERY N (6 SURGERY MYOMECTOMY MYOMECTOMY
MY MY
MONTHS
INTERVAL)
IF SIZE
INCREASE IF SIZE &gt;12
MYOMECTOMY,
&amp; WEEKS, DX
HYSTERECTOM
SYMPTOMS UNCERTAIN,
Y,MYOLYSIS,
APPEAR UNEXPLAINED
EMBOLOTHERA
SURGERY ABORTION/INF
PY
ERTILITY,
PEDUNCULAT
ED
 MEDICAL MANAGEMENT
• Antiprogesterones
– Mifepristone (daily dose of 25-30mg for 3months)
• Danazol
– 200-400mg divided dose for 3months
• GnRH analogs
– Agonists (luporelin, goserelin, buserelin, nafarelin)
– Antagonists (cetrorelix, ganirelix)
• PG synthetase inhibitor - to relieve pain
• Levonogestrel-releasing intrauterine system (LNG-IUS)
– Reduce the size and vascularity of the fibroid
 ADENOMYOMAS

Definition and Pathogenesis:

• Adenomyomas are focal forms of adenomyosis, where
endometrial glands and stromal tissue are found within
the myometrium. This condition is often associated with
uterine enlargement.
Risk Factors:
• More commonly diagnosed in women aged 35-50,
adenomyomas are associated with increased parity and a
history of uterine surgeries such as cesarean sections or
D&C procedures.
 SYMPTOMS
• Symptoms of Adenomyomas:
• Menorrhagia: Heavy, prolonged menstrual bleeding is
common, as adenomyomas disrupt the normal function of
the myometrium.
• Dysmenorrhea: Women may experience progressively
worsening menstrual pain due to inflammation and
increased uterine contractility.
• Chronic Pelvic Pain: Adenomyomas often cause
persistent pain even outside of menstruation due to
chronic inflammation within the uterine muscle.
 CLINICAL EXAM FINDINGS
• Symmetrical enlargement of the uterus (if adenomyosis is
diffused)
• Tender uterus
• Uterine enlargement – rarely exceeds that of 3 months’
pregnancy
GRADES OF ADENOMYOSIS
 INVESTIGATIONS
• Pelvic ultrasound
• MRI
 MEDICAL MANAGEMENT
• Non-steroidal anti-inflammatory drugs (NSAIDs)
Hormonal therapy
• Danazol
• GnRH
• Mirena IUCD
 SURGICAL MANAGEMENT
• Diagnostic hysteroscopy + D&C
– Initial step in the management of adenomyosis because of menorrhagia

• Total hysterectomy (elderly women who passed the age of childbearing)

• Localized excision
– Younger women with localized adenomyosis
– Anxious to have a child

• Transcervical resection of endometrium (TCRE)

– Effective for about 2 years
 ENDOMETRIAL POLYPS

Pathology and Etiology:

• Endometrial polyps are benign overgrowths of the
endometrial lining that may be pedunculated or sessile.
They contain a core of connective tissue and blood
vessels covered by endometrial columnar epithelium.
Risk Factors and Associations:
• Risk factors include obesity, tamoxifen use (a drug used
in breast cancer treatment), and estrogen-rich conditions,
such as those seen in polycystic ovary syndrome
(PCOS).
 CLINCAL FEATURES
• Abnormal Uterine Bleeding (AUB): Polyps often cause
unpredictable bleeding patterns, including heavy
menstrual bleeding and intermenstrual spotting.
• Postmenopausal Bleeding: In postmenopausal women,
polyps can be a common cause of bleeding and may
require evaluation to rule out malignancy.
• Infertility: Polyps may interfere with embryo implantation
or create a hostile environment in the endometrium,
affecting fertility.
 Placental polyp
• Formed from retained placental tissue
• May cause:
– Secondary postpartum hemorrhage
– Intermittent vaginal bleeding following an abortion or normal
term delivery
 DIAGNOSIS
• Clinically, uterine polyp may not be evident and uterus
may or may not be enlarged
• It is easy to diagnose when the polypus protrudes through
the cervical canal

• Ulrasound can detect the uterine polyp

• Saline sonosalphingogram/hysterosalphingogram
 MANAGEMENT
• D&C can scrape the polyp
• Hysteroscopic removal of multiple polyps may be
desirable to ensure their complete removal.
 REFERENCES
• DUTTAS TEXTBOOKS OF GYNAECOLOGY
• TEN TEACHERS TEXTBOOK OF GYNAECOLOGY
THANK YOU