THEORY OF MYOMA

UTERI
GEDE NANDA SURYA WIJAYA
 DEFINITIONS

Most common neoplasm of the uterus.

Benign monoclonal tumors.
Derived from the smooth muscle cell of the
myometrium.
Found in women reproductive age
Asymptomatic symptoms
Can be found with routine gynecological
examination
Cause is unknown
 ETIOLOGY

Unknown
Each individual myoma is unicellular in origin
Estrogens no evidence that it is a causative factor , it
has been implicated in growth of myomas
Myomas contain estrogen receptors in higher
concentration than surrounding myometrium
Myomas may increase in size with estrogen therapy & in
pregnancy & decrease after menopause
They are not detectable before puberty
Progestrone increase mitotic activity & reduce apoptosis
There may be genetic predisposition
Theory : Stimulation theory, and Cellnest or genitoblas
theory
TERMINOLOGY & LOCATION
ANATOMIC LOCATION
CLASSIFICATION
 SUBMUCOSAL

Submucosal myomas
These myomas derive from myometrial cells just below
the endometrium.
These neoplasms protrude into the uterine cavity.
 SUBMUCOSAL

a. The location is under the endometrium and grows

protruding toward the uterine cavity.
b. Menorrhagia is a common symptom, due to the vast
increase endometrial and uterine contractions disrupted.
c. Uterine myomas submucosal often grow over long
stems that protrude from the cervix called myoma
Geburt.
d. Submucosal myoma uteri time perceived as a protrusion
curettage curette bump.
e. Submucosal myoma uteri larger, likely to form the
"degeneration sarcoma".
 INTRAMURAL

Intramural myomas
These myomas develop from within the uterine wall.
They may enlarge sufficiently to distort the uterine cavity
or serosal surface.
Some fibroids can be transmural and extend from the
serosal to the mucosal surface.
 SUBSEROSAL

Subserosal myoma
These myoma originate from the myometrium at the
serosal surface of the uterus.
They can have a broad or pedunculated base and may
be intraligamentary (ie, extending between the folds of
the broad ligament).
 SUBSEROSAL

a. It is growing under the tunica serosa and

protruding to the surface of the uterus.
b. Sometimes the surface veins rupture and intra-
abdominal hemorrhage.
c. Myoma can grow between ligament myoma
intraligamenter pressing ureter and iliac artery
carefully timing the operation.
d. If there vascularization of the omentum, gradually
separated from the uterine parasitic myoma /
uterine wandering.
e. If the swabs may be torque.
 CERVICAL

Cervical myoma
These leiomyomas are located in the cervix, rather than
the uterine corpus
 RISK FACTORS

Estrogen
- Estrogen plays an important role for the occurrence of
uterine myoma
- it is associated with: myomas never found before
menarkhe, commonly found in reproduction, growth faster
myomas in pregnant women and will shrink at menopause
- estrogen receptors in myomas more available than normal
myometrium

Obesity
- Most studies show a relationship between fibroids and
increasing body mass index. The relationship is complex
and is likely modified by other factors, such as parity, and
may be more related to change in body habitus as an adult.
 RISK FACTORS

AGE
- Women diagnosed with myoma uteri mostly in their 40s
- Myoma uteri occurs in 20-25% of women of productive age
with a unknown factor
- Myoma uteri is rare in women before the age of puberty, is
heavily influenced by reproductive hormones

Menstruation Cycle
- Myoma uteri is most common in women aged 35-45 years
who are still menstruating
- decreases after menopause
- Myoma is commonly found in women of reproductive age,
and has never been reported before menarkhe
 RISK FACTORS

Family History
- Women with first-degree lineage with myoma uteri patients
have an increased risk 2.5 times more likely to suffer from
myoma uteri compared with women without lineage patients
with myoma uteri.
- has 2 times the power of expression of VEGF- (a myoma-
related growth factor) compared with patients with myoma
who do not have a family history of uterine myoma

Ethnic
- African-American ethnic groups have the possibility of risk to
suffer 2.9 times as high as myoma uteri
- African-American women suffer from myoma uteri in younger
age and have myomas and larger as well as clinical symptoms
 RISK FACTORS

Diet, Caffeine, Alcohol & smoking

Beef and other reds meats is associated with an increased

relative risk of fibroids and consumption of green vegetables
and fruit (especially citrus fruit) with a decreased risk, There
is increasing evidence that vitamin D deficiency or
insufficiency is linked to fibroid risk

Consumption of alcohol, especially beer, appears to increase

the risk of developing fibroids.

Caffeine consumption is not a risk factor.

Smoking decreases the risk of having fibroids

 RISK FACTORS

Hormonal contraception
Use of low dose oral contraceptives (OCs) does not cause
fibroids to grow, therefore administration of these drugs
is not contraindicated in women with fibroids
Long acting progestin-only contraceptives (eg, depot
medroxyprogesterone) protect against development of
myoma
 CLINICAL MANIFESTATIONS

Heavy or prolonged menstrual bleeding

Most common fibroid symptom
Degree of uterine bleeding are determined by the
location of the fibroid, size is of secondary importance
Submucosal myomas that protrude into the uterine cavity
are most frequently related to significant menorrhagia
 CLINICAL MANIFESTATIONS

Pelvic pressure and pain

Bulk-related symptoms
Urinary frequency, difficulty emptying the bladder, and,
rarely, urinary obstruction can all occur with fibroids
Fibroids that place pressure on the rectum can result in
constipation.
Back pain may, on occasion, be related to the presence of
myomas
Very large uteri may compress the vena cava and lead to
increase in thromboembolic risk
Dysmenorrhea
Dysmenorrhea is also reported by many women with fibroids.
This pain in many women appears to be correlated with
heavy menstrual flow and/or passage of clots.
 CLINICAL MANIFESTATIONS

Myoma degeneration or torsion

Infrequently, fibroids cause acute pain from degeneration
or torsion of a pedunculated tumor.
Pain may be associated with a low grade fever, uterine
tenderness on palpation, elevated white blood cell count,
or peritoneal signs.
The discomfort resulting from degenerating fibroids is
self-limited, lasting from days to a few weeks, and usually
responds to nonsteroidal antiinflammatory drugs.
 CLINICAL MANIFESTATIONS

Reproductive dysfunction
Myoma that distort the uterine cavity (submucosal or
intramural with an intracavitary component) result in
difficulty conceiving a pregnancy and an increased risk of
miscarriage.
Adverse pregnancy outcomes (placental abruption, fetal
growth restriction, malpresentation, and preterm labor
and birth)
 DIAGNOSIS

Pelvic exam
Bimanual pelvic examination, an enlarged, mobile uterus
with an irregular contour
Infrequently, on speculum exam, a prolapsed submucosal
fibroid may be visible at the external cervical os
 DIAGNOSIS

Imaging
Ultrasound
Transvaginal ultrasound has high sensitivity (95 to 100
percent) for detecting myomas in uteri less than 10 weeks'
size
Most widely used modality due to its availability and cost-
effectiveness
MRI
Best modality for visualizing the size and location of all
uterine myomas. Due to the expense of this modality, its
use is best reserved for surgical planning for complicated
procedures
 DIFRENTIAL DIAGNOSIS

Abdominal tumour Choriocarcinoma

Adenomyosis Endometrial carcinoma
Inversio Uteri Metastatic disease
Pregnancy (typically from another
reproductive tract primary
Hematometra
 MANAGEMENT

The type and timing of any intervention should be

individualized, based upon the following factors:

Type and severity of symptoms

Size of the myoma(s)
Location of the myoma(s)
Patient age
Reproductive plans and obstetrical history
 MANAGEMENT

Medical therapy
Gonadotropin-releasing hormone agonists
Most effective medical therapy for uterine myomas.
Work by initially increasing the release of gonadotropins,
followed by desensitization and downregulation to a
hypogonadotropic, hypogonadal state that clinically
resembles menopause.
Most women will develop amenorrhea, improvement in
anemia and a significant reduction (35 to 60 percent) in
uterine size within three months of initiating this therapy.
 MANAGEMENT

Surgical therapy
Myomectomy
Myomectomy is an option for women who have not
completed childbearing or otherwise wish to retain their
uterus.
Disadvantage of this procedure is the risk that more
leiomyomas will develop from new clones of abnormal
myocytes
Hysteroscopic myomectomy is the procedure of choice
for removing intracavitary myomas
 MANAGEMENT

Surgical therapy
Hystrectomy
Women with acute hemorrhage who do not respond to other
therapies
Women who have completed childbearing and have current
or increased future risk of other diseases.
Women who have failed prior minimally invasive therapy for
leiomyomas
Women who have completed childbearing and have
significant symptoms, multiple leiomyomas, and a desire for
a definitive end to symptomatology.
 IDENTITY
Name : Ny. N
Age : 21 tahun
Address : Sunan Ampel Street
Religion : Muslim
Ethnic group : Java
Job : Personel Dental Laboratory
Edification : Senior High School
Inpatient date : 10-01-2017, 15.00
SUBYEKTIF
Chief Complaint : Patients come to the hospital as an elective
patients
Anamnese : Patients come to the hospital as an elective
patients complaining of occasional pains in the lower abdomen
and menstruation is not reguler. Patients complain of menstrual
noncurrent / outside of the menstrual cycle. Initially the patient
complained of menses is not reguler at the beginning of october,
mens patients in October starting on October 5 to 12, then the
patient says more blood out as menses on October 19, out only
once on the day and not come out again until the menstrual
cycle in the next month. In November, the patient mens starting
at 1 to 6 november, on November 15, patients get more blood
out of his genital, now out of blood mixed with mucus bit and
not feel pain at all. And then patients consult a doctor Sp.OG
and athen diagnosed of myoma uteri.
 In March 2014, patients experiencing vaginal
discharge, and then patient went to the doctor and was told
that there was a cyst measuring 3 cm, then got drugs to
remove cyst. Patients have history of vaginal discharge from
2014, but intermittent. Patients also have history that she
was used IUD from 13 years ago, in 2015 had been bleeding
and eventual removal of an IUD and also have diabetes
mellitus since 5 years ago. Patients also said that the
families who suffered like this. During these days, the
patient does not feel any complaints, did not feel any lump
in the abdomen, did not feel any changes that happen to
her and did not know that suddenly she have myoma uteri
in her body.
 OBSTETRIC ANAMNESE
Obstetric Anamnese : P2001 Ab0 with Myoma Uteri

Menstrual period : Regular, 1 time a month, every 28 days, for 5-6 days,
dismennorrea before menstruation

Menarche : 14 years old

Fluor albus : (+) early 2014 until 2016, the colour is white, smelly (-), itchy (-), make
little wet the underwear

Contraseption history : Wear IUD from 2002 until 2015

Past Disease history : DM (+) , HT (-), Asthma (-), Patological bleeding (+)

Family disease history : DM (-) , HT (-), Asthma (-), family with Mioma Uteri (+)

Psycososial history : patients drink jamu and coffee

Alergic history : there is no alergic history

OBJECTIVE
Generalis
General condition : Enough
Consciusness : Compos mentis
Blood pressure : 120/80 mmHg
Heart Rate : 80 bpm
Temperature : 36,5C
Respiration Rate : 20 times/minute
Head and Neck : a/i/c/d -/-/-/- Limfe gland Swelling (-)
Thorax : Simetrical (+), retraction (-)
- Pulmo : vesikuler/vesikuler Rh -/- Wh -/-
- Cor : S1S2 single regular, murmur (-)
Abdomen : Peristaltic (+) normal, hepar and lien unpalpable
Ekstremity : Warm (+), CRT < 2 second, oedem (-)
 Laboratorium
Examination Date Date Date Date
28/11/2016 05/12/2016 26/12/2016 28/12/2016
Hemoglobin 13,8 g/dl - - 13,8 g/dL
Leukosit 10.190/mm3 - - 8.990 mm3
Trombosit 380.000/mm3 - - 375.000/mm3
Glukosa Darah Puasa 127 mg/dL 117 mg/dL 144 mg/dL -
Glukosa Darah Acak - - - 190 mg/dL
Glukosa Darah 2 Jam PP 239 mg/dL 206 mg/dL 195 mg/dL -
HBsAg Negative (-) Negative(- Negative(-) Negative (-)
)

-Uterus: Anteflexi, slightly enlarged with solid nodules 3x4 cm

in the posterior corpus uteri
-Conclusions The results of USG: Uterus Myomatous with Myom
3x4 cm posteriorly Corpus uteri
 ASSESMENT

P2001 Ab0 with Myoma

Uteri
USG EXAMINATION
 PLANNING

Consult to dr. Hytriawan Posma, Sp.OG

Inf. Ringer lactate 20 drops/minute
Inj. Cefazol 1gr/Pz 100 ml before operation
Observation in Maternity room (melati).
Follow Up
Date : 11-01-2017

S : Patients feel nausea to vomiting, the patient also complained of his body limp, and a
little pain in the scar, a little blood out of shyness. There is no complaint about
defecation and urination.

O : General condition : good enough, Consciusness : CM

Blood pressure : 110/80 mmHg Temperature : 36,0C
Heart rate : 80x/min RR : 20x/min
Head/neck : A/I/C/D +/-/-/-
Thorax : simetric (+), retraction (-)
Cor : S1S2 single regular, murmur (-)
Pulmo : Vesikuler/vesikuler Rhonki -/- Wheezing -/-
Abdomen : Peristaltic (+) Normal, Feel pain in scar (+)
Ekstremity : warm (+), CRT < 2 second
Genetalia : Pervag fluxus (-)

A : P2001 Ab0 Post Total Histerectomi on indication Myoma Uteri

P : Inf. Ringer laktat 20 dpb Inj. Ondansetron 4 mg/iv

Kaltrop supp Inj. Ceftriaxone 1 gr
Inj. Fentanyl 25 mg/iv Inj. Asam Tranexamat
Follow Up
Date : 12-01-2017

S : Patients feel nausea to vomiting, the patient also complained of his body limp, and a
little pain in the scar, a little blood out of shyness. There is no complaint about
defecation and urination.

O : General condition : good enough, Consciusness : CM

Blood pressure : 110/70 mmHg Temperature : 36,0C
Heart rate : 80x/min RR : 20x/min
Head/neck : A/I/C/D +/-/-/-
Thorax : simetric (+), retraction (-)
Cor : S1S2 single regular, murmur (-)
Pulmo : Vesikuler/vesikuler Rhonki -/- Wheezing -/-
Abdomen : Peristaltic (+) Normal, Feel pain in scar (+)
Ekstremity : warm (+), CRT < 2 second
Genetalia : Pervag fluxus (-)

A : P2001 Ab0 Post Total Histerectomi on indication Myoma Uteri

P : Inf. Ringer laktat 20 dpb

Kaltrop supp
Inj. Ceftriaxone/iv
Follow Up
Date : 13-01-2017

S : Patients no nausea, and a little pain in the scar, no blood outcome from genital. There is
no complaint about defecation and urination. Appetite is good.

O : General condition : good enough, Consciusness : CM

Blood pressure : 110/70 mmHg Temperature : 36,0C
Heart rate : 80x/min RR : 20x/min
Head/neck : A/I/C/D +/-/-/-
Thorax : simetric (+), retraction (-)
Cor : S1S2 single regular, murmur (-)
Pulmo : Vesikuler/vesikuler Rhonki -/- Wheezing -/-
Abdomen : Peristaltic (+) Normal, Feel pain in scar (+)
Ekstremity : warm (+), CRT < 2 second
Genetalia : Pervag fluxus (-)

A : P2001 Ab0 Post Total Histerectomi on indication Myoma Uteri

P : Inf. Ringer laktat 20 dpb

Kaltrop supp
Inj. Ceftriaxone/iv
 CASE ANALYSIS
In this case the patient comes as an elective patients who will
surgery on January 11st, 2017 at 10:00 AM oclock. Patients
complain of disturbed menstrual cycle. In October outside of
the menstrual cycle, patients complain of blood from the
genitalia. In November, the patient also complained of the
same thing, and her blood a little more than last month.
Patients history of experiencing vaginal discharge and have
diagnosis a cyst size 3 cm in 2014. In 2015, patients have
experienced bleeding, it is because the IUD is separated from
the implantation and since it does not use an IUD again.
Patients also have a history of diabetes mellitus since 5 years
ago. Lately, the patient had no complaints such as abdominal
pain, lump in the abdomen and the changes that happened to
her before being diagnosed with myoma uteri. Then the
patient went to the doctor Sp.OG and got the diagnosis that
the patient is suffering from myoma uteri.
 CASE ANALYSIS
From anamnesis it was found that the age of patients
was 43 years old and still having menstrual periods, which at
that age are susceptible to the occurrence of myoma uteri,
because estrogen plays an important role for the occurrence of
myoma uteri, it is associated with myomas never found before
menarche, are found in the future reproduction, growth faster
myomas in women who are still menstruating and will shrink at
menopause

In the line of the patient's family obtained their family

members were ever exposed to myoma uteri, in which women
with first-degree lineage with myoma uteri patients have an
increased risk 2.5 times more likely to suffer from myoma uteri
compared with women without lineage patients with myoma
uteri. Patients who have a family history of uterine myoma has
2 times the power of expression of VEGF- (a myoma-related
growth factor) compared with patients with myoma who do not
 CASE ANALYSIS
Irregular menstrual cycles patient and every menstrual
bleeding more than usual. Excluding patients complain of
menstrual cycle out of his genital and little spots. The patient
does not feel a lump and there is no pain in the abdomen that
feels enlarged and prop. This is consistent with the findings
that the subjective symptoms of the uterine myoma only felt
by 35-50% of patients, and most commonly asymptomatic and
found incidentally during ultrasound. Abdominal pain, nausea,
constipation and micturition disorders is one of the symptoms
of fibroids although not typical.

From the results of the ultrasound has been ascertained

that: Uterus Anteflexi, slightly enlarged with solid nodules
3x4 cm in the posterior corpus uteri. Conclusion Results of
Ultrasound: Uterine Myomatous with Myom 3x4 cm
posteriorly Corpus uteri
 RESUME
In this case the patient comes as an elective patients who will carry out
the operation on January 11, 2017 at 10:00 AM Patients complain of
disturbed menstrual cycle. that the age of patients was 43 years old and
still having menstrual periods, which at that age are susceptible to the
occurrence of myoma uteri, because estrogen plays an important role
for the occurrence of myoma uteri, In the line of the patient's family
obtained their family members were ever exposed to myoma uteri, in
which women with first-degree lineage with myoma uteri patients have
an increased risk 2.5 times more likely to suffer from myoma uteri
compared with women without lineage patients with myoma uteri. The
subjective symptoms of the uterine myoma only felt by 35-50% of
patients, and most commonly asymptomatic and found incidentally
during ultrasound. Conclusion Results of Ultrasound: Uterine Myomatous
with Myom 3x4 cm posteriorly Corpus uteri and surgery of Total
Hysterektomi and salphingoooforektomi dextra.
THANK YOU