The uterine fibroids (leiomyoma) can progressively increase in size and attain enormous dimensions.

However finding huge leiomyomas occupying the whole of the peritoneal cavity alongwith hydronephrosis and colonic adhesions is uncommon1. http://www.pafmj.org/showdetails.php?id=180&t=c http://www.medicinenet.com/hydronephrosis/article.htm

What is hydronephrosis?
Hydronephrosis describes the situation where the urine collecting system of the kidney is dilated. This may be a normal variant or it may be due to an underlying illness or medical condition. Normally, the kidney filters waste products from blood and disposes of it in the urine. The urine drains into individual calyces (single=calyx) that form the renal pelvis. This empties into the ureter, a tube that connects the kidney to the bladder. The urethra is the tube that empties the bladder.

While obstruction or blockage is the most frequent cause of hydronephrosis, it may be due to problems that occur congenitally in a fetus (prenatal) or may be a physiologic response to pregnancy. Technically, hydronephrosis specifically describes dilation and swelling of the kidney, while the term hydroureter is used to describe swelling of the ureter. Hydronephrosis may be unilateral involving just one kidney or bilateral involving both. A complication of hydronephrosis is decreased kidney function. The increased pressure of extra fluid within the kidney decreases the blood filtration rate and may cause structural damage to kidney cells. This decrease in function is reversible if the underlying condition is corrected but if the hydronephrosis

lasts many weeks, the damage may be permanent.

What causes hydronephrosis?

There are numerous causes of hydronephrosis that are categorized based upon the location of the swelling and whether the cause is intrinsic (located within the urinary collecting system), extrinsic (outside of the collecting system) or if it due to an alteration in function. Examples of intrinsic causes of hydronephrosis Ureter Kidney stone. Likely the most common reason to have unilateral hydronephrosis is a kidney stone that causes obstruction of the ureter. The stone gradually moves from the kidney into the bladder but if it should act like a dam while in the ureter, urine will back up and cause the kidney to swell. This would be classified as an intrinsic obstruction. Blood clot Stricture or scarring Bladder Bladder cancer Bladder stones Cystocele Bladder neck contracture Urethra The inability to empty the bladder (urinary retention) for any reason may cause bilateral hydronephrosis. Urethral stricture Urethral valves Examples of extrinsic causes of hydronephrosis Ureter Tumors or cancers that compress the ureter and prevent urine flow. Examples include lymphoma and sarcoma, especially if they are located in the retroperitoneum, where the kidneys and ureters are located behind the sac that contains the bowel. Retroperitoneal fibrosis Ovarian vein syndrome Cancer of the cervix Cancer of the prostate Pregnancy Uterine prolapse Scarring due to radiation therapy

Urethra Prostate hypertrophy or swelling is a common cause of urinary retention and subsequent hydronephrosis in males. Prostate cancer Examples of functional causes of hydronephrosis Bladder Neurogenic bladder or the inability of the bladder to function properly occurs because of damage to the nerves that supply it. This may occur in brain tumors, spinal cord injuries or tumors, multiple sclerosis, and diabetes among other causes. Vesicoureteral reflux where urine flows backwards from the bladder into the ureter. Prenatal hydronephrosis is an example, though it may occur at any time in life.

Hydronephrosis (cont.)

Take the Kidney Disease Quiz Medical Author: Benjamin Wedro, MD, FACEP, FAAEM Medical Editor: Charles Patrick Davis, MD, PhD In this Article What is hydronephrosis? What causes hydronephrosis? What are the symptoms of hydronephrosis? When should I seek medical care for hydronephrosis? How is hydronephrosis diagnosed? What is the treatment for hydronephrosis? What are the complications of hydronephrosis? Can hydronephrosis be prevented? Hydronephrosis At A Glance Hydronephrosis Glossary Hydronephrosis Index

What are the symptoms of hydronephrosis?

There may or may not be direct symptoms of hydronephrosis depending upon the underlying cause.

Individuals with acute hydronephrosis, for example symptoms from renal colic due to a kidney stone begin with an acute onset of intense flank or back pain radiating to the groin, associated with nausea, vomiting, and sweating. Colicky pain comes and goes and its intensity may cause the person to writhe or roll around or pace in pain. There may be blood seen in the urine. Chronic hydronephrosis develops over time and there may be no specific symptoms. Tumors in the pelvis or bladder obstruction may develop silently and the person may have symptoms of kidney failure. These are very non specific and may include weakness, malaise, nausea and vomiting. If electrolyte abnormalities occur because the kidneys are unable to regulate sodium, potassium, and calcium, there may be heart rhythm disturbances and muscle spasms.

When should I seek medical care for hydronephrosis

A person with acute hydronephrosis usually develops significant pain and needs emergent help with pain control. Blood in the urine is never normal and should not be ignored. Most often in women, it is due to a bladder infection, but other causes include kidney stones, tumors, and occasionally is associated with appendicitis. Individuals who have the diagnosis of hydronephrosis who develop a fever need to be seen immediately. If a urinary tract infection occurs and there is decreased urine flow, there is the risk of becoming very ill or septic. Hydronephrosis is a true emergency in patients with only one kidney and should the person believe that the lone kidney is at risk, urgent medical care should be accessed.

How is hydronephrosis diagnosed?

There are numerous conditions that will cause hydronephrosis. Sometimes the diagnosis is relatively easy. For example, when a patient has symptoms and signs of writhing flank pain and blood in the urine, and he or she has a family history of kidney stones, the clinical diagnosis of renal colic from a kidney stone may be considered but still needs to be confirmed. Sometimes the diagnosis is difficult and is found during the evaluation of a patient who complains of weakness and is found to be in kidney failure. The diagnosis begins with taking a history of the signs and symptoms that the patient experiences. The health care practitioner may want to ask questions that will direct whether further tests need to be ordered. Reviewing the patient's past medical history and family history may be helpful. Depending upon the situation and whether there is acute onset of symptoms, physical examination may reveal tenderness in the flank or where the kidneys are located. The bladder may be found to be distended when the abdomen is examined. Usually, in males, a rectal examination is done to assess the size of the prostate. In women a pelvic examination may be performed to evaluate the uterus and ovaries. Laboratory tests The following laboratory tests may be ordered depending upon what potential diagnosis is being considered. Urinalysis to look for blood, infection or abnormal cells Complete blood count (CBC) may reveal anemia or potential infection

 Electrolyte analysis may be helpful in chronic hydronephrosis since the kidneys are responsible for maintaining and balancing their concentrations in the blood stream. BUN (blood urea nitrogen), creatinine and glomerular filtration rate (GFR) are blood tests that help assess kidney function. Imaging Studies CT scan of the abdomen can be performed to evaluate the kidney anatomy and make the diagnosis of hydronephrosis. It also may allow the health care practitioner to look for the underlying cause including kidney stones or structures that are compressing the urinary collecting system. Depending upon the situation and the health care practitioner's concerns, the CT may be done with or without contrast dye injected into a vein, and with or without oral contrast (that the patient drinks) to outline the intestine. Most commonly, for kidney stones, neither oral nor intravenous contrast is needed. Ultrasound is another imaging study that can be done to look for hydronephrosis. The quality of the test depends upon the skill of the ultrasonographer to evaluate the structures in the abdomen and retroperitoneum. Ultrasound is also useful in women who are pregnant where radiation concerns exist. Intravenous pyelography (IVP) has mostly been replaced by CT scanning but does have a role in diagnosing some patients and its use is now limited. KUB X-rays (an X-ray that shows the kidney, ureter, and bladder) are used by some urologists to classify a kidney stone as radiodense or radiolucent and may use KUB X-rays to determine if the stone is able to migrate down the ureter into the bladder.

What is the treatment for hydronephrosis?

The goal of treatment for hydronephrosis is to restart the free flow of urine from the kidney and decrease the swelling and pressure that builds up and decreases kidney function. The initial care for the patient is aimed at minimizing pain and preventing urinary tract infections. Otherwise, surgical intervention may be required. The timing of the procedure depends upon the underlying cause of hydronephrosis and hydroureter and the associated medical conditions that may be present. For example, patients with a kidney stone may be allowed 1-2 weeks to pass the stone with only supportive pain control if urine flow is not completely blocked by the stone. If, however, the patient develops an infection or if they only have one kidney, surgical intervention may be done emergently to remove the stone. Shock wave lithotripsy (SWL or extracorporeal shock wave lithotripsy) is the most common treatment for kidney stones in the U.S.. Shock waves from outside the body are targeted at a kidney stone causing the stone to fragment into tiny pieces that are able to be passed out of the urinary tract in the urine. For patients with urinary retention and an enlarged bladder as a cause of hydronephrosis, bladder catheterization may be all that is needed for initial treatment. For patients with ureteral strictures or stones that are difficult to removal, a urologist may place a stent into the ureter that bypasses the obstruction and allows urine to flow from the kidney. Using a fiberoptic scope inserted through the urethra into the bladder, the urologist can visualize where the ureter enters and can thread the stent through the ureter into the kidney pelvis bypassing any obstruction. When a stent cannot be placed, an alternative is inserting a percutaneous nephrostomy tube. A urologist or interventional radiologist uses fluoroscopy to insert a tube through the flank directly into the kidney to allow urine to drain.

Some conditions, for example retroperitoneal fibrosis or tumors, may require steroid therapy, a formal operation or laparoscopy to relieve the hydronephrosis or hydroureter while oral alkalinization therapy may be used to dissolve uric acid kidney stones.

What are the complications of hydronephrosis?

If hydronephrosis remains untreated, the increased pressure within the kidney may decrease the ability of the kidney to filter blood, remove waste products, and make urine as well as regulate the electrolytes in the body. Hydronephrosis can lead to kidney infections (pyelonephrosis), sepsis, and in some cases, complete kidney function loss or death. Kidney function will begin decreasing almost immediately with the onset of hydronephrosis but is reversible if the swelling resolves. Usually kidneys recover well even if there is an obstruction lasting up to 6 weeks. The term acute hydronephrosis may be used when after resolution of the kidney swelling, kidney function returns to normal. Chronic hydronephrosis may be used to describe the situation where kidney function is lost even if the obstruction and swelling have resolved.

Can hydronephrosis be prevented?

Since hydronephrosis is a situation that occurs because of an underlying cause, prevention depends upon avoiding the underlying cause. For example, individuals with kidney stones that cause ureteral obstruction and hydronephrosis may try to decrease the chance of a recurrent stone by keeping well hydrated.
Hydronephrosis At A Glance

Hydronephrosis describes swelling of the kidney with the inability of urine to drain from the kidney into the bladder. Hydroureter describes swelling of the ureter, the tube that connects the kidney to the bladder. The obstruction may occur at any level in the urinary collecting system from the kidney to the ureter to the bladder to the urethra. Depending on the level of the cause, hydronephrosis may be unilateral involving one kidney or bilateral involving both. The increased pressure caused by hydronephrosis potentially can compromise kidney function if it is not relieved in a reasonable period of time. Symptoms of hydronephrosis depend upon whether the swelling occurs acutely or progresses more gradually. If it is an acute obstruction, symptoms may include writhing pain, nausea, and vomiting. Treatment of hydronephrosis and hydroureter is aimed at restoring urine flow from the affected kidney. REFERENCES: eMedicine.com. Hydronephrosis and Hydroureter. <http://emedicine.medscape.com/article/436259-overview Mulhollad MW, et al. Greenfield's Surgery Scientific Principles and Practice. 4th edition 2006

Lippincott Williams and Wilkins. WebMd.com. Kidney Stones - Treatment Overview <http://www.webmd.com/kidney-stones/kidney-stones-treatment-overview> An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus.[1] They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated).[1][2] Pedunculated polyps are more common than sessile ones.[3] They range in size from a few millimeters to several centimeters.[2] If pedunculated, they can protrude through the cervix into the vagina.[1][4] Small blood vessels may be present, particularly in large polyps.[1]

Contents
[hide] 1 Cause and sympto ms 2 Diagno sis 3 Treatm ent 4 Progno sis and complic ations 5 Risk factors and epidemi ology 6 Structur e 7 See also 8 Referen ces

[edit] Cause and symptoms

No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen.[2] They often cause no symptoms.[3] Where they occur, symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy

menstrual bleeding (menorrhagia), and vaginal bleeding after menopause.[2][5] Bleeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood "spotting" between menstrual periods, or after menopause.[6] If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea) may result.[4]

[edit] Diagnosis

Micrograph of an endometrial polyp. H&E stain. Endometrial polyps can be detected by vaginal ultrasound (sonohysterography), hysteroscopy and dilation and curettage.[2] Detection by ultrasonography can be difficult, particularly when there is endometrial hyperplasia (excessive thickening of the endometrium).[1] Larger polyps may be missed by curettage.[7]

[edit] Treatment
Polyps can be surgically removed using curettage with or without hysteroscopy.[8] When curettage is performed without hysteroscopy, polyps may be missed. To reduce this risk, the uterus can be first explored using grasping forceps at the beginning of the curettage procedure.[6] Hysteroscopy involves visualising the endometrium (inner lining of the uterus) and polyp with a camera inserted through the cervix. If it is a large polyp, it can be cut into sections before each section is removed.[6] If cancerous cells are discovered, a hysterectomy (surgical removal of the uterus) may be performed.[2] A hysterectomy would usually not be considered if cancer has been ruled out.[6] Whichever method is used, polyps are usually treated under general anesthetic.[7]

[edit] Prognosis and complications

Endometrial polyps are usually benign although some may be precancerous or cancerous.[2] About 0.5% of endometrial polyps contain adenocarcinoma cells.[9] Polyps can increase the risk of miscarriage in women undergoing IVF treatment.[2] If they develop near the fallopian tubes, they may lead to difficulty in becoming pregnant.[2] Although treatments such as hysteroscopy usually cure the polyp concerned, recurrence of endometrial polyps is frequent.[6] Untreated, small polyps may regress on their own.[10]

[edit] Risk factors and epidemiology

Endometrial polyps usually occur in women in their 40s and 50s.[2] Risk factors include obesity, high blood pressure and a history of cervical polyps.[2] Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps.[2][11] The use of an IntraUterine System containing levonorgestrel in women taking Tamoxifen may reduce the incidence of polyps.[12] Endometrial

polyps occur in up to 10% of women.[1] It is estimated that they are present in 25% of women with abnormal vaginal bleeding.[11]

[edit] Structure
Endometrial polyps can be solitary or occur with others.[13] They are round or oval and measure between a few millimeters to several centimeters in diameter.[6][13] They are usually the same red/brown color of the surrounding endometrium although large ones can appear to be a darker red.[6] The polyps consist of dense, fibrous tissue (stroma), blood vessels and glandlike spaces lined with endometrial epithelium.[6] If they are pedunculated, they are attached by a thin stalk (pedicle). If they are sessile, they are connected by a flat base to the uterine wall.[13] Pedunculated polyps are more common than sessile ones.[3] Uterine fibroids remain the most common tumor of women of either benign or malignant derivation (1). Estimates of prevalence of range from 20-50% of adult females in most reports (2). The cell of origin is presumed to be smooth muscle cells of the uterus although other fibro muscular tissues have reportedly developed changes, which are called myomatous. Myomas may cause symptoms ranging from excessive or dysfunctional uterine bleeding, severe pain, or pressure related symptoms from excessive enlargement (1). Conversely, myomas of significant girth and weight have been described in patients with little or no symptoms. Infertility or recurrent pregnancy loss has been associated with myomas that significantly distort the uterine cavity (2).

view larger image

view larger image Fibroid Tumors as seen at Laparoscopy Appearance of uterus after removal of uterine fibroids

Growth/enlargement of uterine myomata appears to be related to the tissues exposure to estrogen (5,6). This sensitivity to estrogen has become a helpful therapeutic association as limitation of growth of these neoplasias can be seen with the use of an anti-estrogenic or pseudo-menopausal therapy prior to or in lieu of surgical therapy (7,8).

The goal of the physician caring for patients with uterine myomas is to accurately diagnose the disease, (ruling out other or more significant pathology), assess the need for medical or surgical therapy, and then choose the most efficient and more healthy alternative for that patient undergoing treatment for this extremely common gynecological disorder.

Diagnosis: Symptoms, which may suggest the presence of uterine myomatas, are: Dysfunctional uterine bleeding Anemia of undetermined origin Pelvic/uterine mass with rapid growth Uterine mass enlarging after menopause Recurrent pregnancy loss Infertility The physical examination should be able to suggest pelvic mass although the presence of sub-clinical submucous uterine myomata may be hard to define in a routine pelvic exam. Transvaginal sonography can provide an excellent method of localization and measurement of uterine disease particularly when paired with hysterosalpingo sonography to assess submucous lesions (9). Magnetic resonance imaging is an excellent tool but is rather expensive and not as readily available to many practicing physicians. CT scan has little or no place in routine evaluation of myomata. Flexible or rigid diagnostic hysteroscopy can target surgery for submucous lesions most accurately and may be performed in office by the physician, thus reducing the economic burden to the patient. In some cases a trial of hormonal therapy can provide information with regard to those myomata, which may be of a more suspicious nature, i.e. unresponsive tumors may suggest a more proliferative possibly malignant process (10).

Therapy Medical therapy can be mounted in those patients who wish to conserve the uterus and/or those who have questionable indications for surgery. Therapies can include progesterone therapy (11), oral contraceptive therapy (12), Danocrine (13), gnRH agonist (14), antiprogesterone agents (RU 486) or anti-prostaglandins (15). The length of therapy with these drugs is considered variable but two dictums seem to be true: 1. Maximum reduction in uterine volume occurs at approximately 12 weeks of treatment and

2. Cessation of therapy will usually result in reoccurrence of myoma size (7). On our service, pre-operative therapy usually involves gnRH agonist (Depo Leuprolide 3.75 mg) for three monthly injections with scheduling of surgery following the third injection. This schedule allows for maximum reduction in myoma size, reduction in active blood supply to the uterus and adequate time and stimulus for hematopoeisis allowing the patient to "auto transfuse" thereby increasing red blood cell count in the pre-operative period. Surgical therapy may be considered conservative or more radical. If the patient has completed child bearing, she may want to consider removal of the uterus. Multiple fibroids imply a recurrence rate as much as 50%, whereas, solitary myoma return in only 10-20% of reported studies (10). However, a number of women do not wish to have the uterus removed, and therefore, should have the option of myomectomy. In that patient who wishes to continue fertility, myomectomy can be considered either via hysteroscopy or via an abdominal approach depending upon the location of the myomata. Any patient undergoing myomectomy must be counseled regarding the risk of hysterectomy, and the risk of potential pregnancy related complications if that patient does conceive (17) these complications can be related to disorders of placentation or weakness in the uterine wall predisposing uterine rupture. Patients who have had a myomectomy who become pregnant may need to consider cesarean delivery at the fetal maturity if a significant defect is encountered.

Technique Submucous myomas of 3-5 cm diameter may be removed by resectoscope or Nd:YAG laser resection via hysteroscopy. Myolysis can be considered hysteroscopically if appropriate. Simultaneous laparoscopy is recommended for safety and further diagnosis during these hysteroscopic procedures. Controversy surrounds the methods of abdominal myomectomy. The major criticism leveled at laparoscopic methods of myomectomy concerns the ability to obtain adequate closure of the defect after myoma removal from the uterine wall (18). With current curved needle suturing techniques which have made retropubic suspension and posterior floor defect repair possible, most if not all of these myoma defects may be closed via laparoscopy. Most would agree that if these closures can be accomplished, the documentably lower morbidity associated with laparoscopy would make this the procedure of choice. Clinical results including lower adhesion scores (or scarring) and increased or similar pregnancy rates achieved with laparoscopic approaches to ectopic pregnancy and endometriosis would support this position (19,20). Currently pedunculated fibroids and small subserosal myomas are readily removed via minimally invasive techniques (21). It is reasonable to assume that with good clinical closure larger intramural myoma can be included in this group. The current author's experience is consistent with this assumption (Figure 1).

Conclusion

Uterine myomas are a frequently seen gynecological malady. Only a fraction of those patients with myomas are candidates for surgical therapy. However, for those individuals with indications for surgery, all options should be explored including minimally invasive techniques. Clinical outcome data must be gathered and reported in order to evaluate these techniques and the relative morbidity. This authors experience is favorable and other clinicians have reported excellent clinical outcomes (27, 28). However, further study is required. It should be noted that there is no currently available long term or short term data comparing conventional procedures and endoscopic approaches assessing pregnancy success, uterine integrity, recurrence rates etc. In existing literature data exists only as isolated case reports and much of the data obtained is aged significantly. Currently, it seems that the only barrier preventing most patients from accessing these less morbid procedures is the endoscopic skill of their surgeon. It is, therefore, incumbent for those surgeons who care for women to develop those abilities, which can provide for our patients all choices of the most effective and least morbid surgical experience. http://www.thomasllyons.com/myomectomy.htm

What are Fibroids?

Images on this page may not be used without permission. Contact James B. Spies, M.D., Georgetown Interventional Radiology or David Klemm, Dept. of Educational Media. Fibroids are benign tumors of smooth muscle, which is the type of muscle that makes up the uterus. They are also called leiomyomas or myomas. Fibroids may arise in different parts of the uterus, as shown in the figure. Fibroids are named according to their position within the uterus; submucosal, intramural, and subserosal. A submucosal fibroid lies just under the inner lining of the uterus, which is called the endometrium. Some of these fibroids grow on a stalk. These are referred to as "pedunculated". An intramural fibroid that lies completely within the muscular wall of the uterus ("intra" means within and "mural" means wall). A serosal or subserosal fibroid lies on the outer part of the uterus, just under the covering of the outside of the uterus, which is called the serosa. Subserosal fibroids may also grow on a stalk and be called pedunculated. Abnormal bleeding is usually caused by submucosal or intramural fibroids. Intramural and subserosal fibroids are the usual cause of pelvic pain, back pain, and the generalized pressure that many patients experience. Who gets fibroids? All women are at risk of getting fibroids. Uterine fibroids are the most common tumors of the female genital tract. They occur in 20 to 25 % of women of childbearing age. The presence of fibroids is the most common reason for a woman to have a hysterectomy in this country, totaling approximately 200,000 each year. In addition, many patients suffer symptoms from fibroids but never undergo a hysterectomy.

African-Americans are as much as 3.2 times as likely to develop fibroids as Caucasians. There is some variation among other racial groups. The reason for this increased risk is not known, although genetic variability is presumed to be a significant factor. While fibroids may appear in patients in their twenties, most patients do not have any symptoms until their late thirties or forties. What causes fibroids? The cause for fibroid development is not known. Leiomyomas arise after menarche (beginning of menstruation in adolescence) and regress after menopause, which suggests that the development of fibroids is dependent on the presence of hormones (primarily estrogen). But the triggering event for the development of the fibroid is not known and the interaction of the various hormones and growth factors likely to be involved is not well understood. Once fibroids appear, their growth rate is also dependent on estrogen, progesterone and possibly other hormones. Growth rates vary greatly among women and the exact cause for this variability is not known, making the prediction of the behavior of fibroids very difficult. Symptoms Most leiomyomas do not cause symptoms. While 25% of women develop fibroids during their lives, only 10 to 20% of these women have symptoms. Therefore, only a minority of women ever require treatment. Heavy Menstrual Bleeding The most common symptom associated with fibroids is abnormal bleeding, which typically presents as heavy menstrual bleeding, often with clot formation. Anemia (low blood count) is a common side effect. The medical term for heavy menstrual bleeding is menorrhagia (pronounced men-o-ray-ja). As the bleeding severity increases, clot passage with the menstrual period commonly occurs. The clots form because the blood stays in the uterus long enough to clot prior to being expelled into the vagina. As these clots pass, they may cause severe menstrual cramping. How fibroids cause abnormal bleeding is not known. Fibroids are believed to alter muscular contraction of the uterus, which may prevent the uterus from controlling the degree of bleeding during a patient's period. In addition, it has been shown that fibroids compress veins in the wall of the uterus. This results in dilation of the veins of the uterine lining. As the pressure in these veins increases, the the lining of the uterus becomes engorged. This may result in heavy bleeding during a menstrual period. It may also contribute to abnormal bleeding. Heavy menstrual bleeding is usually caused by fibroids deep within the wall of the uterus (intramural) or those just under the inner lining of the uterus (submucosal). Very small fibroids in the wall of the uterus or fibroids in the outer part of the uterus (subserosal) usually do not cause abnormal bleeding. There are many other potential causes of heavy menstrual bleeding and so a careful gynecologic history and physical examination is an important part of the evaluation of a patient with heavy bleeding. Just because a patient has fibroids, it does not mean that the fibroids are the cause of abnormal bleeding. Other causes include endometrial hyperplasia (an abnormal thickening of the uterine lining), endometrial polyps, adenomyosis, and even uterine cancer. The likelihood of these causes can often be determined based on a gynecologic history and physical examination, but on occasion additional tests may be needed. Pelvic Pain and Pressure Another symptom is pelvic pain. On rare occasions, a fibroid may suddenly degenerate (spontaneously shrink and scar due to decrease in blood supply). This is a painful process that may last several days or weeks. This type of severe pain is unusual. Severe or burning pain during a menstrual cycle is perhaps more commonly caused by other conditions, such as endometriosis. However, because of the broad range of presenting symptoms of fibroids, gynecologic evaluation is needed to confirm the diagnosis. If fibroids cause symptoms related to the pressure they exert on other structures, they most commonly cause a sensation of pressure or discomfort in the pelvis. This may feel like heaviness, bloating, a dull ache, or mild tenderness of the fibroids themselves. The discomfort may be greater with exercise, while bending over or during sexual intercourse. As fibroids grow, they may

compress nerves that supply the pelvis and the legs, causing pain in the back, flank, or legs. Patients also report increasingly severe menstrual cramps with the growth of their fibroids. Urinary Symptoms and Other Symptoms Pressure on the urinary system also may be caused by fibroids. Typically, this results in urinary frequency (increased frequency of urination, including the need to get up at night to urinate). Fibroids may also contribute to incontinence (urine leakage) or rarely, they may partially block the outflow of the bladder, making it difficult to empty the bladder. Occasionally, an enlarged uterus may press on other urinary structures resulting in partial blockage of the urine flow from the kidneys. On occasion, fibroids may also cause rectal pain or pressure. Many of these symptoms may be cyclic, worse in the days leading up to the menstrual period and during the period. If the fibroids get large enough, the pressure and discomfort they cause may occur at any time. Fibroids and Fertility It has often been suggested that infertility and/or repeated miscarriage can be caused by fibroids. However, the statistical evidence for infertility is lacking and other factors are more likely to cause infertility in fibroid patients. Some researchers have suggested that the presence of fibroids may predispose a patient to miscarriage, but again firm statistical evidence to support this possibility is not yet available. There have been studies in infertile women in whom the only identifiable cause is the presence of fibroids. After myomectomy (surgical removal of the fibroids, leaving the uterus in place), these studies have shown that 40 to 60 % of these women have been able to become pregnant. However, because large studies have not been completed and infertility may have many causes, it is imprudent to assume that fibroids are the cause without a careful evaluation for other problems. Fibroids and the Risk of a Malignant Tumor A common question is whether a large mass in the uterus, presumed to be a benign fibroid, could be a malignant tumor. The answer is yes, although these tumors, called leiomyosarcomas, are very rare. They occur in about 1 in 1000 cases. Based on recent genetic studies, it does not appear that these malignant tumors result from a preexisting benign tumor. It appears that they arise separately from any existing fibroids. The problem is that it can be impossible to tell a benign fibroid from a malignant tumor without surgery. No imaging test, such as ultrasound or MRI, can reliably distinguish these tumors. There is no blood test that can detect them. By history, they are often suspected when a presumed fibroid grows very rapidly. However, the majority of rapidly growing "fibroids" are just that, benign fibroids. Biopsy also cannot reliably distinguish benign from malignant tumors of the uterus, because the sample may be taken from a relatively benign appearing portion of the mass. Unfortunately, the reliable means of detecting malignant solid tumors of the uterus is surgery. This would either be by removal of the fibroids alone (myomectomy) or hysterectomy. Hysterectomy, with surgical removal of lymph nodes near the uterus is the primary treatment for leiomyosarcoma.