Uterine Masses

Uterine leiomyomas, most of which are asymptomatic, are by

far the most common benign uterine tumors (195). Other benign
uterine growths, such as uterine vascular tumors, are rare. Uterine
leiomyomas may be diagnosed on physical examination or with pelvic
imaging. They may be subserosal, intramucosal, or submucosal in
location within the uterus or located in the cervix, in the broad
ligament, or on a pedicle (Fig. 14.18). They are estimated to be
present in a high percentage of all women of reproductive age and
may be discovered incidentally during routine annual examination.
Asymptomatic fibroids may be present in 40% to 50% of
women older than 35 years of age (155). Using ultrasonography
screening, other authors have estimated a cumulative
incidence by age 50 of greater than 80% in African-American
women and nearly 70% in white women (153). Leiomyomas may
occur singly but often are multiple. They may cause a range of
symptoms, from abnormal bleeding to pelvic pressure; however, fewer
than one half of uterine leiomyomas are estimated to produce
symptoms (196).
The cause of uterine leiomyomas is unknown. Several studies have
suggested that each leiomyoma arises from a single neoplastic cell
within the smooth muscle of the myometrium (197). There appears to
be an increased familial incidence, and they may be more common in
women who are obese (155). Hormonal responsiveness and binding
has been demonstrated in vitro. Fibroids have the potential to enlarge
during pregnancy as well as to regress after menopause.

Figure 14.18 Uterine leiomyomas in various anatomic locations. (From Hac

Essentials of obstetrics and gynecology. 3rd ed. Philadelphia, PA: WB Saunders, 19
permission.)
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Grossly, fibroids are discrete nodular tumors that vary in size and
number (Fig. 14.18). They may be microscopic or huge (a uterine
weight of 74 lb has been reported). They may cause symmetric uterine

enlargement or they may distort the uterine contour significantly. The

consistency of an individual leiomyoma varies from hard and stony (as
with a calcified leiomyoma) to soft (as with cystic degeneration),
although the usual consistency is described as firm or rubbery.
Although they do not have a true capsule, the margins of the tumor
are blunt, noninfiltrating, and pushing, and are usually separated from
the myometrium by a pseudocapsule of connective tissue, which allows
easy enucleation at the time of surgery. There is usually one major
blood vessel supplying each tumor. The cut surface is characteristically
whorled.
Degenerative changes are reported in approximately two thirds of all
surgical specimens (198). Leiomyomas with an increased number of
mitotic figures may occur in various forms: in women who are
pregnant or taking progestational agents, with necrosis, and as a
smooth muscle tumor of uncertain malignant potential (defined
as having 5 to 9 mitoses per 10 high-power fields [hpf] that do
not demonstrate nuclear atypia or giant cells, or with a lower
mitotic count [24 mitoses/10 hpf] that does demonstrate
atypical nuclear features or giant cells). Studies suggest that
malignant degeneration of a preexisting leiomyoma is extremely
uncommon (199).
Leiomyosarcoma is a rare malignant neoplasm composed of cells that
have smooth muscle differentiation (see Chapter 33); cytogenetic
studies suggest that they arrive de novo via distinct pathogenetic
pathways (200). The typical patient with leiomyosarcoma is in her
mid-50s and seeks treatment for abnormal bleeding. In most cases,
diagnoses are determined (postoperatively) after microscopic
examination of a uterus removed because of suspected leiomyomas.
Sarcomas that have a malignant behavior have 10 mitoses/hpf
or greater.
Uterine leiomyomas are frequently diagnosed on the basis of clinical
findings of an enlarged, irregular uterus on pelvic examination. They
are also frequently noted on ultrasonography obtained for a variety of
indications and may be an incidental finding. However, any pelvic
tumor potentially can be confused with an enlarged uterus.
The most common initial symptom associated with fibroids, and the
one that most frequently leads to surgical intervention, is
menorrhagia. Chronic pelvic pain may also be present. Pain may be
characterized as dysmenorrhea, dyspareunia, or pelvic pressure (see
Chapter 15). Acute pain may result from torsion of a pedunculated
leiomyoma or infarction and degeneration. The following urinary

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symptoms may be present:

Frequency may result from extrinsic pressure on the bladder.
Partial ureteral obstruction may be caused by pressure from large
tumors at the pelvic brim. Reports suggest some degree of ureteral
obstruction in 30% to 70% of tumors above the pelvic brim. Ureteral
compression is three to four times more common on the right, because
the left ureter is protected by the sigmoid colon.
Rarely, complete urethral obstruction results from elevation of the base
of the bladder by the cervical or lower uterine leiomyoma with
impingement on the region of the internal sphincter.
Leiomyomas are an infrequent primary cause of infertility and
have been reported as a sole cause in only a small percentage
of infertile patients (201,202). Pregnancy loss or complications such
as preterm labor, intrauterine growth restriction, and malpresentation
can occur in women with leiomyomas, although most patients have
uncomplicated pregnancies and deliveries (201). One study calculated
a 10% rate of pregnancy complications in women with fibroids (203).
Although growth of leiomyomas may occur with pregnancy, no
demonstrable change in size (based on serial ultrasonographic
examination)
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has been noted in 70% to 80% of patients (204,205). The risk of
pregnancy complications is influenced by both myoma location and
size (206).
The following symptoms may infrequently be associated with
leiomyomas:
Rectosigmoid compression, with constipation or intestinal obstruction
Prolapse of a pedunculated submucous tumor through the cervix, with
associated symptoms of severe cramping and subsequent ulceration
and infection (uterine inversion also can occur)
Venous stasis of the lower extremities and possible thrombophlebitis
secondary to pelvic compression
Polycythemia
Ascites