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73 Cards in this Set

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synonyms of myoma
fibroid.
leiomyoma.
fibromyoma.
fibroma.
myoma is benign or malignant?
b9

Myoma is a kind of mesenchymal tumor.
Mesenchyme, or mesenchymal connective tissue, is a type of undifferentiated loose connective tissue
content of myoma.
smooth muscle.
fibrous connective tissue.
epidemiology of myoma.
occur in 20-40% of reproductive-aged women

high incidence in black women.

more common in nulliparous.

prevalence year:35-45 yo

regress incidence in menopouse women.

increases with age, decreases with having a live-born child.

may increase with body mass index, and may decrease with cigarette smoking.

Risk may also increase with diets high in red meat and ham and it may decrease with diets high in intake of green vegetables.
increasing RF factor.
nulliparity
obesity
hyper-estrogenic state
black women
red meat rich diet
definition of nulliparity.
the condition in a woman of never having given birth.
reducing RF factor.
smoking
multiparity
diet rich in green vege
origin of myoma. pathogenesis.
it arise from neoplastic single smooth muscle cell of myometrium.

stimuli of neoplastic transformation:
~chromosomal abnormality

~role of polypeptide growth factor.
Epidermal growth factor (EGF)
Insulin like growth factor-1 (IGF-1)
tranSforming growth factor (TGF)
*this hormones stimulate the growth of myoma either Directly or via Estrogen.

positive family history is often present.
estrogen dependent growth evidence.
increased growth during pregnancy.

do not occur before menarche.

growth is potentially limited during childbearing.

they content more estrogen
receptors compared to adjacent
myometrium.

cessation during menopouse.

frequently associated with anovulation.
definition of childbearing.
parturition. process of giving birth.
myoma and menopouse.
myoma growth is a result of the stimulation of estrogen, which is present until menopause.

Conversely, many myomas begin to shrink as menopause removes the estrogen stimulation and many myoma-related symptoms resolve spontaneously shortly after menopause.
gross appearance of myoma.
greyish
type of myoma.
body (at body of uterus)
~aka corporeal myoma
~submucous, intramural, subserous, pedunculated.

cervical
~upon position: anterior, lateral, posterior, central.
pseudocervical fibroid.
this is SUBMUCOUS fibroid arising from uterine body and burrow downwards into cervix canal.
types of cervical myoma.
anterior myoma.
tumor arise from superficial muscle of the anterior lip of cervix bulge forward and weaken the bladder.

posterior
arise at posterior part of cervix and cause flattening of douglas pouch backwards (compression rectum against sacrum), weakenin of peritoneum in bottom of douglas pouch and obliterate cul-de-sac, lift the serous membrane off the anterior surface of the rectum and sacrum and push down between vagina and rectum, separating waldeyer's fascia.

lateral
myoma burrows into broad ligament and expand it.

central.
either submucous or interstitial(intramural), expanding the cervix in all directions.
where is the location of douglas pouch?
between rectum and back wall of uterus. it is the continuity of peritoneal cavity.
what is wandering or parasitic fibroid?
the pedunculated subserous fibroid in which its stalk is thorn from the uterus and the fibroid gets nourishment from omental or mesenteric adhesion.
most dangerous type of myoma.
submucous.
fate of submucous myoma.
surface necrosis.
polypoid change.
infection.
degeneration including sarcomatous change.
corporeal myoma.
gross appearance.
uterus is enlarged.
distorted shape: can be nodular.
firm.
surface is smooth, whitish color.

cut surfaced: whorled and trabeculation.
(due to intermingling of fibrous tissue with muscle bundles)

false capsule.
it is formed by the compressed adjacent myometrium.
capsule separated from the growth by thin loose areolar tissue (blood supply runs through this plane)

peripheral part is more vascular compared central part n most likely to degenerate.
blood supply of myoma usually comes from which artery?
uterine artery.
secondary changes in fibroid.
degeneration
atrophy
necrosis
infection
vascular changes
sarcomatous changes
types of degeneration in fibroid.
Hyaline degeneration
cystic degeneration
fatty degeneration
calcerous degeneration
red degeneration
most common degeneration type in fibroid.
hyaline degeneration
what happen in fatty degeneration of fibroid?
fat globules deposited (mainly in muscle cells).

revise composition of fibroid.

fatty degeneration usually occur at or after menopouse.
what happen in calcerous degeneration?
precipitation of calcium carbonate or phosphate whithin the tumor.

usually involve subserous fibroid.
usually preceded by fatty degeneration.

if the whole of tumor is calcified, it is called 'womb-stone'
what happen in hyaline degeneration?
microscopic examination shows hyaline changes of both muscle and fibrous tissues.

in cut surface: irregular homogenous area with loss of whorl-like appearance.

hyaline degeneration commonly takes place at:
at all size tumore except tiny one.
tumor having more connective tissue.
where is the common site of hyaline degeneration?
central part of tumor where least vascular.

*tumor become elastic (no longer firm)
what happen in cyctic degeneration?
liquefaction of tumor with hyaline changes.

cystic space are lined by irregular ragged walls.

common in interstitial fibroids.

can be minstaken with ovarian cyst or pregnancy
what happen in red degeneration?
naked eye appearance: dark area (due to presence of haemolysed rbc and hemoglobin)

cut section: raw-beef appearance often containing cystic spaces.

odor often fishy due to fatty acid.

microscopic: evidence of necrosis
vessels are thrombosed
red degeneration aka?
carneous degeneration.
when usually carneus degeneration takes place?
during second trimester and puerperium.

usually occur in large fibroid.
what is common sarcomatous change in fibroid case?
leiomyosarcoma.
what vascular changes may occur in myoma?
telangiectasia,

lymphangiectasia.
what cause atrophy changes in fibroid?
decrease estrogen level.

thats y atrophy changes usually occur after menopouse.
in what case necrosis of myoma takes place?
inadequacy of circulatory.
which part of fibroid most like to undergo necrosis first? and why
central part, due to lack of vascularity
infection of fibroid occur in which type of myoma mostly? how.
submucous.

infection rise from thin/sloughed off epithelium surface

usually occur following delivery and abortion or any medical manipulation.
complication of fibroid.
degeneration
necrosis
infection
sarcomatous changes
torsion of pedunculated fibroid
hemorrhage
polycythemia
symptoms of myoma mostly related to?
size.
anatomic type.
what is myomatous-erythrocytosis syndrome?
triad of myomatous uterus, erythrocytosis, and restoration and maintenance of normal hematologic values after hysterectomy.
what are the main presentation of myoma?
pain
pressure symptoms
swelling/lumps
menstrual abnormalities
infertility
dysmenorrhea,dyspareunia
pregnancy related problem

NB! 75% are Asymptomatic
describe characters of pain in myoma.
fibroids are mostly painless.
maybe due to its slow growth hence the mass effect is tolerable by patient.

Acute pain may occur in such case:
degeneration(infarct) of the tumor.
torsion of the fibroid.
extrusion of polyp.

asscociated pathology which can cause painful event:
PID
endometriosis
how myoma may cause infertility?
uterine:
distortion/elongation of uterine cavity-> difficult sperm ascend

impairment of rythmical uterine contraction due to fibroid during intercourse->impaired sperms transport.

congestion and dilatation of endometrial venous plexus->defective nidation.

atrophy and ulceration of the endometrium over the submucous fibroid->defective nidation.

Tubal:
cornual block due to position of the fibroid.
associated salpingitis with tubal block.

Ovarian.
anovulation

peritoneal
endometriosis
how can myoma affect pregnancy?
PROBLEM:
abortion.
preterm labor.
intrauterine growth restriction.

REASON:
defective implantation of placenta
poorly developed endometrium
reduce space of growing
enumerate life-threatening complications of fibroid.
persistent menorrhagia, metrorrhagia or continued vaginal bleeding -> severe anemia

sarcoma

severe infection leading to peritonitis or septicemia

severe intraperitoneal haemorrhage due to rupture of veins over subserous fibroid.
what are the symptoms in cervical myoma?
anterior:
bladder symptom like frequency, retention of urine

Posterior:
rectal symptom in the form of constipation

lateral:
vascular obstruction may lead to hemmorhoid and leg edema

central
bladder symptom.
cervix expanded at all side, lantern on the dome of st paul condition.
list the examination method in myoma.
abdominal examination
pelvic examination

instrumental examination:
U/S and Color Doppler
MRI
Laparascopy
Hysteroscopy
Uterine curettage
result of abdominal palpation in case of myoma?
firm
margin is well defined
nodular surface
restrictive mobility from above downward, but can move side to side.
what are u/s and color doppler finding in myoma?
~ uterine contour is enlarged and distorted

~fibroids appear as different echogenicity-hypoechoic or hyperechoic (depending on amount of connective tissue or smooth muscle proliferation)

~vascularization at periphery site

~central vascularization indicate degenerative changes.
hysteroscopy method is best to check which type of fibroid?
submucous
what can u see in hysterosalpingography in presence of fibroid?
filling defect.
what are differential diagnosis of fibroid?
~pregnancy
~ full bladder
~ adenomyosis
~ myohyperplasia
~ovarian tumor
~ endometriosis
~ inflammatory mass
what are w anatomical parts of cervix?
vaginal part and supra-vaginal part
what are 2 ways of performing u/s in myoma evaluation?
trans-abdominal.
trans-vaginal.
what complications may arise during pregnancy with myoma?
preterm labor

red degeneration occur more frequently

difficulty in vaginal birth

inteference with pregnancy and its maintenance

clinical contracted pelvis.
drugs used in medical treatment for fibroma are?
NSAID (ibuprofen)
to relieve pelvic pain.

GnRH agonist
~ gosereline, luporelin, burseveline, nafaseline.
~MOA: supress anterior pituitary from producing estrogen.
~often used in pre-surgical therapy to shrink the tumor.

Danazol
~gonadotropin inhibitor. and has androgenic effect
~minimize blood loss and can be used in range 3-6 months
which drugs used to minimize the bleeding?
progestogene.

antifibrinolytic.

anti progesterone.

danazol.

prostaglandin synthethase inhibtor.

GnRH analogue(agonist,antagonist)
benefits of GnRH analogue therapy.
improvement of menorrhagia and may produce amenorrhea

improvement of anaemia

relief pressure symptoms

reduction in size 50% when used for a period of 6 months

reduction of vascularity
of tumor

reduction of blood loss during myomectomy

may facilitate laparscopic or hyteroscopic surgery
pressure symptoms.
~bladder: frequent urination.
obstructed urination.

~rectum: defecation, constipation.
surgical treatment for fibroma.
myomectomy.

endoscopic surgery.

hysterectomy.

aa embolization.
what is myomectomy?
enucleation of myomata
from uterus.
indication of myomectomy.
patient is in reproductive period desiring of having baby.

in case of recurrent miscarriage.
contraindication of myomectomy.
infected fibroid.

big broad ligament fibroid.

too many fibroid.
vaginal myomectomy.
usually it is pedunculated submucous myoma.

if the myoma is big: Morcellation. removal of tumor by metal piece.

if myoma is of moderate size: twisting it.
hysterocopy-endoscopic surgery.
fibroid of 3-4 cm is resected with hysteroscope.

pedicle base of fibroid is coagulated using electrocautery.
complication of hyteroscopic surgery.
uterine penetration.

fluid overload.

hemorrhage.
indication of emergency in fibroid.
torsion of subserous pedunculated fibroid.

massive intra peritoneal haemorrhage following rupture of veins over sub serous fibroid.

uncontrolledinfected fibroid.

uncontrolled bleeding fibroid.
hw is asymptomatic fibroma dealt?
observation.

surgery.
how is observation management done?
patient has to be observed for at least 6 months, frequent visit to doctor to measure growth of the fibroma.

if the symptoms appear or fibroma has increase in size rapidly, surgical management is considered.
indication of surgery in asymptomatic fibroid.
size > 12 weeks of pregnancy

growth of fibroid during observation period.

subserous pedunculated fibroma

unexplained infertility with distorsion of uterine cavity

unexplained recurrent abortion

when the fibroma located at lower part of uterus and likely to complicate delivery.
what u should do if in case of observation of asymtomatic patient, the tumor doesnt grow in size and remain symptomless?
follow up
what are the difference between polyp and myoma? #######
polyp usually appear smaller.

polyp may regress.