Leiomyoma

Background

• Leiomyomas, also called fibroids, are the most common benign tumor in women
  • By age 50, incidence of up to 70% of white women and 80% of black women
  • Arises most commonly in women of reproductive age, with decreasing rates in postmenopausal women
• Fibroids may be located in different layers of the uterus: subserosal, intramural, or submucosal
• Pathogenesis: Primarily an estrogen-dependent myometrial proliferation, with varying fibrous connective tissue
• Consider leiomyosarcomas in postmenopausal women, as they can present similarly

Risk Factors

• Any condition that increases cumulative estrogen exposure
  • Early menarche
  • Nulliparity
  • Estrogen-containing OCP use
  • Obesity

Clinical Features

• Vaginal bleeding
• Pelvic pain, including dyspareunia
• Urinary incontinence/retention
• Constipation/diarrhea
• Symptomatic anemia
• Infertility

Alternatively, may be asymptomatic and show as incidental finding on imaging

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand disease, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Anticoagulants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Hypothyroidism
• Polycystic Ovary Syndrome
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Leiomyoma (Fibroid)
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

PALM-COEIN Classification of Vaginal Bleeding

• PALM: structural causes
  • Polyp (AUB-P)
  • Adenomyosis (AUB-A)
  • Leiomyoma (AUB-L)
  • Malignancy and hyperplasia (AUB-M)
• COEIN: nonstructural causes
  • Coagulopathy (AUB-C)
  • Ovulatory dysfunction (AUB-O)
  • Endometrial (AUB-E)
  • Iatrogenic (AUB-I)
  • Not yet classified (AUB-N)

Evaluation

• Evaluate with speculum and bimanual exam

Workup

• bHCG/urine pregnancy
• CBC
• Transvaginal ultrasound is the preferred modality for diagnosis
  • Shows as well-circumscribed, hypoechoic masses with varying calcification and shadowing
• CT has less utility compared to pelvic ultrasound, but MRI may be performed for surgical planning in specific cases

Management

• NSAID
• Fluids and blood products, if indicated
• Hormonal agents such as OCPs or GnRH agonists may be initiated with consultation with OB/GYN
• Expectant management, if asymptomatic

Disposition

• Depends on severity of symptoms and hemodynamic stability
• Refer to OB/GYN for further medical management such as hormonal agents
  • Also for surgical management including myomectomy vs hysterectomy vs IR-guided uterine artery embolization

See Also

• Nonpregnant vaginal bleeding