BENIGN LESIONS OF THE

UTERUS
ANNIE RUTH B. DAYU MD, DPOGS
 ENDOMETRIAL POLYPS
• They are localized
overgrowths of
endometrial glands and
stroma that project
beyond the surface of the
endometrium.
• They are soft, pliable and
may be single or multiple
• Most arise from the fundus
of the uterus
• Endometrial polyps
may have a broad
base ( sessile ) or the
attached by a slender
pedicle
( pedunculated )
• Prevalence is 22 to 25%
in reproductive women
 ENDOMETRIAL POLYPS
- Cause is unknown
-Often associated with endometrial hyperplasia,
and unopposed estrogen maybe one cause
- Majority are asymptomatic
-Symptoms include menorrhagia, premenstrual
and post menstrual staining

Histology – 3 components : endometrial glands,

endometrial stroma, and central vascular
channel
Management: removal by hysteroscopy w/ D&C
 LEIMOYOMA
• Benign smooth muscle tumor
• From myometrium
• Fibrous consistency – “fibroids”
• Incidence: 20-25%
• Symptoms depend on the location and size
• Initially, most myomas LEIOMYOMAS
arise from the
myometrium, beginning
as intramural myomas.
As they grow, they
remain attached to the
myometrium with a
pedicle of varying width
and thickness.
• Small myomas are
round, firm, solid tumors
• With continued growth,
the myometrium at the
edge of the tumor is
compressed and forms a
pseudocapsule.
• Myomas do not have a
true capsule 
psuedocapsule is a
valuable surgical plane
during myomectomy
LEIOMYOMAS
 LEIOMYOMAS
• Rare before menarche and diminish following
menopause with a reduction in estrogen
• Most often enlarge during pregnancy and
secondary to OCP use – however, serial ultrasound
examinations have also demonstrated the most
(80%) myomas do not change in size during
pregnancy. If a change in size does occur, it is
usually asymptomatic
• Most common symptoms:
• pressure, dysmenorrhea, abnormal uterine
bleeding – related to the number, location and size
• Urinary symptoms are more common than rectal
symptoms.
• Diagnosis: confirmed by physical examination;
Ultrasound
 PATHOLOGY
• GROSS FINDINGS:
• Round, pearly white, firm, rubbery
• Whorled pattern on cut section
• Single or multiple mass/es with thin outer connective
tissue layer
• HISTOLOGIC FINDING:
• Elongated smooth muscle cells
• Aggregated in bundles
• Swirl, intersect
• Mitotic activity, rare
 MYOMA WITH CYSTIC
DEGENERATION
• Increase in size, compromised blood supply
• Pelvic pain due to ischemia and necrosis
• No vascularization
 ROLE OF HORMONES
• ESTROGENS
• Greater number of Estrogen Receptors
• Greater Estradiol binding
• Convert less Estradiol to weaker Estrone
• Greater number of cytochrome P450
• Converts androgen to estrogen
 CLASSIFICATION
• Subserosal leiomyomas
• Pedunculated leiomyomas
• Parasitic leiomyomas
• Intramural leiomyomas
• Submucous leiomyomas
• Cervical leiomyomas
• Rare: ovary, fallopian tubes, broad ligament, vagina,
vulva
 SYMPTOMS OF MYOMA
• BLEEDING
• PAIN
• PRESSURE SENSATION
• INFERTILITY
 BLEEDING
• Dilatation of venules
• Myoma exert pressure, impinge on venous system
• Dysregulation of local vasoactive growth factors –
promote vasodilatation
• During menses, bleeding from markedly dilated venules
overwhelms hemostatic mechanisms
 PELVIC DISCOMFORT
AND DYSMENORRHEA
• Enlarged uterus cause:
• Pressure sensation
• Urinary frequency
• Incontinence
• Constipation
• Obstruct ureter – hydronephrosis
• Dysmenorrhea
• Dyspareunia
• Non cyclical pelvic pain
 INFERTILITY AND
PREGNANCY WASTAGE
• 2-3% of infertility cases
• Occlusion of tubal ostia
• Disruption of normal uterine contractions that propel
sperm or ova
• Distortion of endometrial cavity disrupt implantation
• Submucous myoma cause more subfertility
• Improved fertility with removal of SM myoma
 DIAGNOSTICS

• Transvaginal ultrasound
• Transrectal ultrasound
 MANAGEMENT
• Observation
• Drug therapy
• Uterine artery embolization
• Surgery
• Hysterectomy
• Myomectomy
• Hysteroscopic
• Laparoscopic
• Robotic
• Abdominal
• Endometrial Ablation
• Myolysis
 DRUG THERAPY FOR
MYOMA
• Dysmenorrhea
• Menorrhagia
• Dyspareunia
• Pelvic Pressure
• Infertility
 NSAIDS
• Dysmenorrhea;
• higher endometrial levels of Prostaglandins F2 and E2
• Menorrhagia ? Unknown benefit, conflicting results
 HORMONES
• Combination oral contraceptive pills
• Induce endometrial atrophy
• Decrease prostaglandin production
• Progestins
• Not recommended due to unpredictable effects on
growth
 ANDROGENS
• Danazol, Gestrinone
• Effectively shrink myoma
• Hirsutism, acne
 GNRH AGONISTS
DRUG NAME GENERIC NAME DOSE AND
ADMINISTRATION

DECAPEPTYL TRIPTORELYN 3.75mg depot IM,

monthly
LUPRON LEUPROLIDE 3.75 mg depot IM,
ACETATE monthly
ZOLADEX GOSERELIN 3.6 mg depot SC
monthly
SYNAREL NARARELIN 200 mg BID, spray
intranasal
 GNRH AGONIST
• Shrink myoma directly (GnRH receptors in myoma)
• Feedback mechanism:
• Stimulate receptors on pituitary gonadotropes
• Release LH and FSH (flare); 1 week
• Downregulate receptors in gonadotropes
• Desensitization to GnRH stimulation
• Decrease gonadotropin secretion
• Decrease estrogen and progesterone
• 1-2 weeks after
 GNRH AGONISTS EFFECTS
• Volume decrease by 40-50%
• Pain relief
• Diminished menorrhagia; amenorrhea
• Repair red cell mass
• Increase iron stores
• Give 3-6 months
• Resume menses 4-10 weeks after
• Myoma may grow back upon stopping
 GNRH AGONIST BAD SIDE
EFFECTS
• Vasomotor symptoms
• Libido changes
• Vaginal epithelium dryness
• Dyspareunia
• ~6% dec in trabecular bone
• Don’t give > 6 months
• “ADD BACK THERAPY”
• 1-3 months upon starting GnRH
• MPA 10 mg (D16-25) + equine estrogen 0.625 mg (D1-25)
• Continuous daily MPA 2.5 mg + EE 0.625 mg
• SERMS (tibolone, raloxifene)
 GNRH ANTAGONISTS
• Rapid and no flare involved
• Cetroreliz, Nal-glu
• Subcutaneous injections effective
• Depot no effect on myoma
 ANTIPROGESTINS
• Mifepristone / RU 486
• Progestins bind to either Progesterone receptor A or B
• Favors progesterone receptor A
• Given 5, 10, 25, 50 mg orall, daily x 12 weeks
• Better tolerated than leuprolide acetate
• Vasomotor symptoms
• Simple hyperplasia in endometrium (unopposed
estrogen)
• Inc. liver transaminases (4%)
UTERINE ARTERY
EMBOLIZATION
 UTERINE ARTERY
EMBOLIZATION
• Angiographic, interventional procedure
• Polyvinyl alcohol into both uterine arteries
• Necrosis, pain – Postembolization Syndrome
• 2-7 days
• Pelvic pain, cramping
• Nausea and vomiting
• Low grade fever
• malaise
 SURGICAL
MANAGEMENT
• Hysterectomy
• Abdominal
• Laparoscopic
• Vaginal
• Myomectomy
• Laparoscopic
• Hysteroscopic
• Robotic
• Endometrial Ablation
• Myolysis
 ABDOMINAL
HYSTERECTOMY
LAPAROSCOPIC
HYSTERECTOMY
VAGINAL HYSTERECTOMY
 ABDOMINAL
MYOMECTOMY
 ABDOMINAL
MYOMECTOMY
HYSTEROSCOPIC
MYOMECTOMY
LAPAROSCOPIC
MYOMECTOMY
 LEIOMYOMATOSIS
• INTRAVENOUS
LEIOMYOMATOSIS
• Rare, benign smooth
muscle tumor
• Invades, extends
serpiginously
• Uterine, pelvic veins,
vena cava, cardiac
chambers
 LEIOMYOMATOSIS
• BENIGN METASTASIZING LEIOMYOMATOSIS
• Disseminate hematogenously
• Found in lungs, GI tract, spine, brain
• History of pelvic surgery

• DISSEMINATED PERITONEAL LEIOMYOMATOSIS

• Multiple small nodules on peritoneal surfaces of abdominal
cavity
• Reproductive age; 70% assoc with pregnancy or OCP
 TREATMENT FOR
LEIOMYOMATOSIS
• Hysterectomy with salpingo-oophorectomy
• Tumor debulking
• GnRH agonists
• Aromatase inhibitors
• SERMs (selective estrogen receptor modulators)
 HEMATOMETRA
• Distended uterus

• Trapped blood
Inside due to obstruction
in cervix or higher up
• Hematocolpos
• hematosalpinx
• Secondary to gynatresia
which is partial or
complete obstruction of
any portion of the lower
genital tract
• Obstruction of the isthmus
of the uterus, cervix or
vagina may be
congenital or acquired
 HEMATOMETRA

• 2 most common congenital causes:

• imperforate hymen and a transverse vaginal septum
• Aquired causes:
• senile atrophy of the endocervical canal and
endometrium, scarring of the isthmus by synechiae,
cervical stenosis associated with surgery, radiation
therapy, electrocautery, endometrial ablation, malignant
disease of the endocervical canal
 DIAGNOSIS
• Cyclic, midline pain
• Amenorrhea (total obstruction)
• Scanty dark bleeding (partial obstrcution)
• Fever, tachycardia if infected (pyometra)
• Enlarged corpus
• Do Transvaginal ultrasound!
• REMEMBER!!!
• suspected by the history of amenorrhea and cyclic abdominal
pain;
• confirmed by:
• ultrasound
• probing the cervix with a narrow metal dilator with release
of dark brownish black blood from the endocervical canal
 HEMATOMETRA
(TREATMENT)
• Relief of obstruction
• Evacuation of blood
• Cervical dilatation
• Hysteroscopy
• Access blood pockets
• Lyse adhesions
• Congenital anomaly correction
 ADENOMYOSIS
• Globally enlarged uterus
• Ectopic rests of endometrium in myometrium
• Diffuse adenomyosis
• Focal adenomyosis – pseudocapsule
• Spongy with focal areas of hemorrhage on cut section
Pathology:
-diffuse involvement of both
anterior and posterior walls
of the uterus, more common
involved is the posterior wall
-there is focal area or
adenomyoma which results
in an asymmetrical uterus
Diffuse adenomyosis is found
in 2/3 of cases
Histology: benign endometrial
glands and stroma within
the myometrium
- Standard criterion in
diagnosis is the finding of
endometrial glands and
stroma more than one low-
powered field(2.5mm) from
the basalis layer of the
endometrium.
 PATHOGENESIS
• Downward invagination of endometrial basalis layer
into myometrium
• No intervening submucosa between myometrium and
endometrium OR associated with disruption of the barrier
between the endometrium and myometrium

• Myometrial weakness caused by prior pregnancy,

surgery or dec immunologic activity at the myometrial-
endometrial interface
• Metaplasia of pluripotent mullerian tissues
 RISK FACTORS
• Parous women
• 40s-50s
• Assoc with cytochrome P450 aromatase expression
• Hyperestrogenism (ie., myoma, endometriosis,
endometrial cancer)
• Tamoxifen use
 ADENOMYOSIS
Clinical Diagnosis:
- 50% women are asymptomatic or have minor symptoms
- Classic symptoms are dysmenorrhea and menorrhagia,
dyspareunia which is midline in location and deep in the
pelvis.
-On pelvic exam, uterus is diffusely enlarged, usually 2-3x
from normal size.
- The uterus is tender and globular immediately before and
during menstruation
 Ultrasound and MRI – useful to help differentiate between
adenomyosis and uterine myomas
 MRI – poorly defined junctional zone markings in the
endometrial-myometrial interface

Diagnosis: biopsy of the hysterectomy specimen

 MEDICAL TREATMENT
• NSAIDS
• Combination oral contraceptive pills
• Progestin only pills
• Levonorgestrel containing IUD (Mirena)
• GnRH agonists (danazol)
 INTERVENTIONAL
TREATMENT
• Hysterectomy
• Endometrial ablation
• Hysteroscopy
• Uterine artery embolization ?
✗Pregnancy and adenomyosis – increased risk of low
birthweight, premature labor and delivery, preterm
premature rupture of membranes
 MYOMETRIAL
HYPERTROPHY
• High parity
• Global enlargement of uterus
• No identifiable pathology in specimens
• Myometrial fiber enlargement
• 120 gm – nulliparas
• 210 gm for multiparas
• Menstrual irregularities; menorrhagia
 UTERINE OR CERVICAL
DIVERTICULA
• Rare, ballooned sacculations
• from uterine or cervical wall
• extend out of the endometrial cavity or endocervical
canal
• Collect blood during menses
• Pain, intermenstrual bleeding
• Infection
• Transvaginal UTZ, hysterosalpingogram, hysteroscopy,
MRI
• Excision of diverticulum or hysterectomy
THE END