OBSTETRIC AND GYNECOLOGIC MEDICAL FACULTY CHRISTIAN UNIVERSITY OF INDONESIA DECEMBER, 3RD 2012 FEBRUARY, 2ND 2013

Menorrhagia, Pain, and Constipation in Uterine Myoma

Tigor P. Simanjuntak,1 Katarina Maria 2

1 2

Obstetric and Gynecology Department Christian University of Indonesia College Student Medical Faculty Christian University of Indonesia

Abstract
Uterine myoma are benign neoplasms of uterine smooth muscle cells, that typically originate from the myometrium. It also known as myomas or fibroids. The insidence in Indonesia was 2,39-11,7 %, happened between 36 and 49 years old women. 20% of all women of reproductive age. The highest proportion was 5-10 cm (67,5%). Multipara parity women 45,2% . Intramural myoma 41,9%, Prolonged menstruation 37,3%. Heavy menstrual bleeding 59,8%. Chronic pelvic pain was 14.5%. 28,8% pressure symptom cause intestinal obstruction. Pain during menstrual period 59,7%. Uterine myoma still become one of the problem in Gynecology. This paper will report the menorrhagia, pain, and constipation in P3A1 woman.

Keyword : Uterine Myoma, menorrhagia, pain, constipation

Introduction
Uterine myomas are benign neoplasms of uterine smooth muscle cells, that typically originate from the myometrium. It also known as leiomyomas or fibroids, are by far the most common benign uterine tumors. The uterine leiomyomas are the most common pelvic tumors in women of reproductive age. (1-10) The etiology of this common tumor is not known.(1) However, the relative contributions of estrogen vs. progesterone and their functions in the pathogenesis of uterine leiomyomas are still controversial.(9) Leiomyomas develop during the reproductive years and regress in size and incidence after menopause.(3) So that, Leiomyomas are not detectable before puberty and being hormonally responsive, normally grow only during the reproductive years.(1) There are some conditions associated with increased estrogen production that encourage leiomyoma formation. For example, the increased years of estrogen exposure found with early menarche and with an increased body mass index (BMI). Obese woman who poduce more estrogens from increased adipose conversion of androgens to estrogen are each linked with a greater risk of leiomyomas. Because the pregnancy is a progesterone dominant state,it should provide an interlude from chorionic estrogen exposure, and intuitively at least, should discourage leiomyoma development.(3) While the role of progesterone in leiomyoma growth is less clear, and indeed both stimulatory and inhibitory effects have been reported. For example, exogenous progestins have been shown to limit leiomyoma growth. For example, antiprogestin induces athrophy in most leiomyomas.(3) Beside the hormone, the etiology of leiomyomas are related to the cytogenetic abberation. Although most of uterine leiomyomas have a normal karyotype, there have been reports suggesting that 50% of these tumors bear specific chromosomal abberations including chromosome 3,6,7 trisomy 12, reciprocal translocation and monosomy 22. Such chromosomal rearrangements may be responsible for initiatin as well as the growth of these tumors with a significant relationship between clonal cytogenetic abnormalities and myoma size. (5)
During the reproductive years, the incidence of Leiomyomas increases with age.(3) They are estimated to be present in at least 20% of all women of reproductive age, may be discovered incidentally during routine annual examination.(2) In the studies at 2011, the uterine myoma happened between 36 and 49 years old women.(7) The cumulative incidence by age 50 years was nearly 70% in Caucasians and over 80% in African- American women.(9) So that,Leiomyomas are more common in African-American women compared with Caucasian, Asian, or Hispanic women. (3) Proportion uterine myoma in Indonesia 2,39-11,7% from all hospitalized benign gynecology.(12) Family and twin studies have shown the risk of leiomyoma formation to be approximately two times greater in women with affected first- degree relatives.(3) Thus far, the only known genetic factor

conferring a high risk for developing uterine leiomyomas are the germline mutations in the fumareate hydratase (FH) gene, an enzyme of the tricarboxylic acid cycle.(4) For the women who smoke generally have a lower risk for leiomyoma formation because the smoking alters estrogen metabolism and lowers physiologically active serum estrogen levels. (3) The study at Pirngadi Hospital reported that based on the parity the highest proportion was multipara parity women 45,2% and the lowest was primi parity with 13,4%. (12)

Leiomyomas contain estrogen receptors in higher consentrations than the surrounding myometrium. Progesterone increases the mitotic activity of myomas in young women, progesterone may also allow for tumor enlargement by downregulating apoptosis in the tumor. Leiomyomas are usually multiple, discrete, and either spherical or irregularly lobulated. Leiomyomas have a false capsular covering, and they are clearly demarcated from surrounding myometrium. Which allows easy enucleation at the same time of surgery. There is usually one major blood vessel suplying each tumor. The cut surface is characteristically whorled. (2) They are usually less than 15 cm in size.(1) The study at RS Pirngadi Medan reported, based on the size, the highest proportion was 5-10 cm (67,5%) and the lowest was > 10cm (11,1%).(12) The appearance of leiomyomas may vary when normal nuscle tissue is replaced with various degenerative substances following hemorrhage and necrosis. This proces is termed degeneration and these gross changes should be recognised as normal variants. Degeneration in leiomyoma because of the limited blood supply within these tumors. Leiomyomas have a lower arterial density compared with the surrounding normal myometrium. (3) Uterine leiomyomas are classified by anatomic location. Submucous leiomyomas lie just beneath the endometrium and tend to compress it as they grow toward the uterine lumen. Their impact on the endometrium and its blood supply most often leads to irreguler uterine bleeding. Intramural or interstitial leiomyomas lie within the uterine wall, giving it a variable consistency. Subserous leiomyoma may also become pedunculated. If such a tumor acquires an extrauterine blood supply from omental vessels, its pedicle may athrophy and resorb. (2)
Based on anatomic location, the most was intramural myoma 41,9%, submucous 37,2%, and subserous was32,6%.(12)

Symptoms are present in only 35-50% of patients with leiomyomas. Thus, most leiomyoma do not produce symptoms, and even very large ones may remain undetected, particularly in obese patient. Symptoms from leiomyomas depend on their location size, state of preservations, and whether or not the patient is pregnant. Abnormal uterine bleeding is the most common and most important clinical manifestation of leiomyomas, being present in up 30% of patients.(1) The bleeding related to dilatation of venules. Bulky tumors are thought to exert pressure and impinge on the uterine venous system, which causes venular dilatation within the myometrium and endometrium. Accordingly, intramural and subserous tumors have been shown to have the same propenstiy to cause menorrhagia as mucous ones. Dysregulation of local vasoactive growth factors are also thought to promote vasodilatation.

When engorged venules are disrupted at the time of menstrual sloughing, bleeding from the markedly dilated venules overwhelms usual hemostatic mechanisms.(3) The abnormal bleeding commonly produces iron deficiency anemia, which may not be uncontrollable even with iron therapy if the bleeding is heavy and protracted. Most commonly, the patients has prolonged,menorrhagia, premenstual spotting, or prolonged light staining following menses; however, any type of abnormal bleeding is posible. Metrorrhagia may be assosiated with a tumor that has areas of endometrial venous thrombosis and necrosis on its surface, particularly if it is pedunculated and partially extruded through the cervical canal.(1) 37,3% of women with diagnosed uterine myoma reported a significantly longer duration of period (5.6 3.1 days, n = 1,245) than women without a diagnosis of uterine myoma. Shortened duration of menstrual bleeding 13,1%. Heavy menstrual bleeding 59,8% ,
irregular periods 36,3%, Frequent periods (periods occur more often than just every 24 days) 28.4%, Infrequent periods (periods occur less often than every 38 days) 16,7%. (11)

A sufficiently enlarged uterus can cause pressure sensation, urinary frequency, incontinance, and constipation. Rarely, leiomyomas extend laterally to compress the ureter and lead to obstruction and hydronephrosis. (3) Pressure on the bladder or inside the abdomen (12) 32,6%. (11) Pressure symptom happened in 28,8% women with uterine myoma. Pressure effects may cause intestinal obstruction if they are large or involved omentum or bowel. Although dysmenorrhea is common, in a population based cross sectional study, Lippman and co-workers reported thatwomen with leiomyomas more frequently had dyspareunia or noncyclical pelvic pain than dysmenorrhea.(3) Leiomyomas may cause pain when vascular compromise occurs. Thus, pain may result from degeneration associated with vascular occlusion, infection, torsion of a pedunculated tumor, or myometrial contraction to expel a subserous myoma from the uterine cavity. The pain associated with infarction from torsion or red degeneration can be excruciating and produce a clinical picture consistent with acute abdomen. Large tumor may produce sensation of heaviness or fullnes in the pelvic area, a feeling of a mass in the pelvis, or a feeling of a mass palpable through the abdominal wall. Tumors that become impacted within the bony pelvis may presson nerves and create pain radiating to the back or lower extremities.(1) The incidence of chronic pelvic pain was 14.5%. Pain during menstrual bleeding or period was 59,7%. Cramping during menstrual period was 50.2%. Pain after menstrual period was 16,7% while painful sexual intercourse was 23,5%. (11) Although the mechanism are not clear, leiomyomas can be associated with infertility. It is estimated that 2 to 3 % of infertility cases due sorely to leiomyomas. Their putative effects include occlusion of tubal ostia and disruption of the normal uterine contractions that properl sperm or ovum. Distortion of the endometrial cavity may diminish implantation and sperm transport. Importantly, leiomyomas are associated with endometrial inflammation and vascular changes that may disrupt implantation.(3) There is a stronger association of subfertility with submucous leiomyomas than with tumors located elsewhere. Improved pregnancy rates following hysteroscopic resection have

provided most of the indirect evidance for this link. In one study, Garcia and Tureck reported pregnancy rates approaching 50% following myomectomy in women with submucos leiomyomas as their sole source of infertility.(3) The incidence of spontaneous abortion secondary to leiomyoma is unknown but is possibly 2 times the incidence in normal pregnant women. For example, the incidence of spontaneous abortion prior to myomectomy is approximately 20%. (1) Most myomas are discovered by routine bimanual examination of the uterus or sometimes by palpation of the lower abdomen. Uterine retroflexion and retroversion may obscure the physical examination diagnosis of even moderetly large myoma. When the cervix is pulled up behind the symphisis, large fibroids are usually implicated. The diagnosis is obvious when the normal uterine contour is distorted by one or more smooth, spherical, firm masses, but often it is difficult to be absolutley certain that such masses are part of the uterus.(1) As noted earlier, anemia is a common consequence of leiomyomas due to excessive uterine bleeding and depletion of iron reserves. However, occasional patients display erythrocytosis. The hematocrit returns to normal levels following removal of the uterus, and elevated erythropoietin levels have been reported in such cases.Moreover, the recognized association of polycythemia and renal disease has led to speculation that leiomyomas may compress the ureters to cause ureteral back pressure and thus induce real erythropoietin production. Leukocytosis, fever, and an elevated sedimentation rate may be present with acute degeneration or infection. Pelvic ultrasound examination are useful in confirming the diagnosis of leiomyomas. While ultrasound should never be a substitute for a thorough pelvic examination, it can be extremely helpful in identifying leiomyomas, detailing the cause of other pelvic masses, and in the identification of pregnancy. Moreover, the ultrasonography is particularly useful in the obese individual. (1) The sonographic appearance of leiomyomas vary from hypo to hyperechoic, depending on the ratio of smooth muscle to conective tissue and whether there is degeneration. If menorrhagia, dysmenorrhea, or infertility accompanies a pelvic mass, then the endometrial cavity should be evaluated for submucous leiomyomas, endometrial polyps, congenital anomalies, or synechiae. Leiomyoma have characteristic vascular patterns that can be identified by color flow Doppler. A peripheral rim of vascularityfrom which few vessels arise to penetrate into the center of the tumor is traditionally seen. Doppler imaging can be used to differentiate an extrauterine leiomyoma from other pelvic masses or submucous leiomyoma from endometrial polyp or adenomyosis. (3) In the diagnosis of myomas, MRI demonstrated sensitivity of 94,1 %, specificity of 68,7%,PPV pf 95,7%, and NPV of 61,1%. The Area Under the Curve (AUC) for the diagnostic perfomance of MRI in the detection of mymoas was 0,81, respectively. MRI exhibits a high AUC for the diagnosis of myomas. MRI seems to be a useful technique in

everyday clinical practice in the diagnosis approach of these common condition, enabling clinicians to select the most appropriate management.(6) Choice of treatment depends on the patients age, parity, pregnancy status, desire for fture pregnancies, general heath, and symptoms, as well as the size, location, and state of preservation of the leiomyomas. Blood transfusins ma be necessary to correct anemia. Transfusion of packed red cells is preffered over whole blood. (1) In some women with symptomatic leiomyomas, medical theraphy may be preffered. Women with dysmeorrhea have higher endometrial levels of prostaglandins than asymptomatic women. Accordingly, treatment of dysmenorrhea and menorrhea assosiated with leiomyomas is based in the role of prostaglandins as mediators of these symptoms. A number of NSAIDs have proved effective for dysmenorrhea, yet there is not one considered to be superior. Prostaglandin are also associated with menorrhagia. (3) The gonadotropin releasing hormone (GnRH) agonist have proven very useful for limiting growth or to cause a temporary decrease in tumor size. GnRH induce hypogonadism through pituitary desensitization, downregulation of receptors, and inhibition of gonadotropins. (1) Table 1 : Dosages of GnRH Agonists Brand Name Decapeptyl Lupron Zoladex Synarel Generic Name Triptorelin Leuprolide acetate Goserelin Nararelin Dosage 3,75mg depot IM monthly 3,75mg depot IM monthly 3,6 mg depot SC monthly 200 mg taken twice daily as 1 spray

The progesterone receptor modulators make up an interesting group of compounds. The almost pure antagonist of the progesterone receptors, such as mifepristone with 5 or 10 mg daily during 6 months had a similar efficacy in reducing the uterine myoma volume, 48,1% and 39,1%. (7) Two randomised double-blind studies have shown the effectiveness of the progesterone receptor modulator ulipristal acetate (UPA) in the preoperative treatment of uterine fibroids and in the control of a concomitant hypermenorrhea. A dosage of 5 or 10 mg UPA over three months has produced no significant sideeffects. A cessation of the hypermenorrhea has been observed after only seven days, a volume reduction of the uterine myoma by 40% within three months seemed to be visible even six months after stopping the therapy. (10)

Some indication for surgery are abnormal uterine bleeding with resultant anemia, unresponsive to hormonal management. Chronic pain with severe dsmenorrhea, dyspareunia, or lower abdominal pressure or pain. Acute pain as in torsion of a pedunculated leiomyoma

or prolapsing submucosal fibroid, urinary symptoms or signs such as hydronephrosis after complete evaluation. Infertility with leiomyomas as the only abnormal finding. Markedly enlarged uterine size with compression symptoms or discomfort. (2) Removal of the uterus is the definitive and most common surgical treatment for leiomyomas. Hysterectomy for leiomyoma can be performed vaginally, abdominally, or laparoscopically.(3) Uterine with small myomas may be removed by total vaginal histerectomy, particularly if vaginal relaxation demands repair of cystocele, rectocele, or enterocele. When numerous large tumors especially intraligamentary myomas are found,total abdominal histerectomy is indicated. Other considerations prior to hysterectomy include uterine size and preoperative hematocrit. In some cases,preoperative GnRH agonist may provide advantages.(1) Myomectomy should be planned for the symptomatic patient who wishes to preserve fertility or conserve the uterus or for those who decline histerectomy, but one can never be certain before operation that myomectomy can accomplished easily. Myomectomy is quite succesful for control of chronic bleeding association with leiomyomas. Increasingly myomectomy is being performed through the histeroscope in cases of submucous leiomyoma and through the laparoscope of subserous leiomyoma. (1) Myolysis is one of the procedures that is claimed to provide significant improvement in myoma status without hysterectomy. Myolysis procedures have been generally performed via laparoscopy, and there are limited data on transvaginal radiofrequency (RF) myolysis. Mean baseline volume of the dominant myomas was 304.6+229.1 cm3 and its volume at 3 months following RF myolysis decreased compared with the previous examination (P 0.002). An improvement of menorrhagia occurred 1, 3, 6 and 12 months after operation (all P , 0.001 versus baseline). Overall symptoms at 1, 3, 6 and 12 months after RF myolysis also improved (all P , 0.001 versus baseline). No major complications were observed or reported. After 12 months, three patients had successfully conceived and delivered and there were no complications during labor or delivery. Transvaginal ultrasound-guided RF myolysis might be a safe, effective and minimally invasive outpatient procedure for uterine myoma in terms of size reduction, symptom improvement and safety. (8)

Leiomyosarcoma are reported to developed with a frequency of 0,1- 0,5% that of diagnosed leiomyomas. (1,2) Disadvanageously, postoperative intra abdominal adhesions leiomyoma recurrence are more common after myomectomy compared with hysterectomy. Recurrence rates following myomectomy range from 40 to 50%. New leiomyoma development, however,diminished in women who become pregnant following myomectomy, perhaps because of protective effect of increasing parity.(3) While in the other study, reported a rate of 2-3% per year of symptomatic myomas after myomectomy. (1). Myomectomy usually improves pain, infeertility, or bleeding. Menorrhagia improves in approximately 7080% of patients.(3) Ureteral injury or ligation is a well- recognized complication of surgery for leiomyomas, particularly cervical.(1)

Case Report
Patient Identity: Name MR Age Address : Miss. Rohayati : 01.03.04.00 : 42 Years 10 months : Cawang 3 Jl. Usman Harun no 8 RT 01/05, Kebon Pala, Jakarta Timur.

Date of Entry : December, 17th 2012. Main Complaint Additional Complaint History of Present Illness : Vaginal Bleeding. : Lower Abdominal Pain. :

The patient came to UKI hospital with complaints of vaginal bleeding since about 6 days before entering the hospital. The patient said that the blood was blackish red and she had a prolonged menstruation, 6 days. Within a day, the patient changes the bandage around 3-4 times. The first day of the last menstruation was December,11th 2012. Sometimes, she complained of pain when menstruation. In addition, the patient complained of pain in the lower abdomen, such as knead. Besides, the patient said that she had a constipation but has no complained about bladder.

Previous Disease History:

The patient once had a complaint of vaginal bleeding in March 2010. The blackish red blood came out. Within a day, the patient can change the bandage about 4 times. Patients also complained of lower abdominal pain. The patient was treated to Kartika Pulomas hospital with a diagnosis of uterine myoma. The Patient also underwent surgery in April 2010. None of her family has the same complaint.

Menstrual History : The first period of menstruation : 16 years old. Menstrual Cycle :

Cycle Duration Quantity

: Regular ( 30 days). : 6 days : 4x changes the bandage/ 200 cc. :+ take the medicine :-

Pain during menstruation Menstruation last 3 months

Table 2 : Menstruation last 3 months Date 11 11 11 Month 12 11 10 Year 2012 2012 2012 Lenght 6 days 6 days 6 days Amount 200 cc 200 cc 200 cc

History of Marriage Marriage Last marriage old : one time : 16 years.

History of Pregnancy and Childbirth Ago Previous Pregnancies :P 3 A 1

The number of children alive : 2 children

General examination Vital Signs General State Awareness Blood Pressure Pulse Temperature Respiration Rate Body Weight Eyes Ears : Looks Moderate Illness : Composmentis : 160/ 70 mmHg : 80x / menit : 36,5 C : 20 x / minute : 70 kg : Conjunctiva was not pale, no jaundice sclera, tear + : Normotia, spacious ear canal, serumen -/-

Nose Mouth Tonsil

: Spacious nose canal, sekret -/-, septum deviasi (-), : Lips mucosa moist : T1 T1, Calm

Faring Neck Toraks inspection

: Not hiperemis : Trachea in the middle, no palpable lymph glands enlarge

: Movement of the chest wall left and right symmetric

Intercostal retraction (-) Palpation Percussion : Vocal fremitus left and right : Percussion comparison of left and right symmetric resonant

Auscultation : Basic breath sounds vesicular Ronkhi -/-, Wheezing -/Heart sounds I and II normal, murmurs (-), gallop (-) Abdomen Inspection : Abdomen looks flat

Auscultation : Bowel sounds (+) normal: 4x/minute Palpation Percussion : Supple stomach, liver and spleen not palpable enlarged. Turgor enough : Tympani

Extremities : Warm Acral + / +, capillary refill <2 seconds, good movement in all directions, muscle tone normotonus. Ginecology Examination Face Breast : looks symetric : Retraction (-), tenderness (-).

External Genitalia Distribution of pubic hair Fluksus Fluor : prevalent : (+) not active : (+)

Vulva

: Bump (-) Pain (-)

Internal Examination V-U-V :Calm, mass (-), portio springy, bouncy pain (-).

The uterus of an adult fist, tenderness (-). Adnexal mass - / -, tenderness - / -, not prominent cavum of Diagnosis: Uterine myoma + Menorrhagia. Working Diagnosis: Uterine myoma +Myomectomy history 1x + DM type II + Hypertension. Prognose : Ad vitam Ad Functionum Ad Sanationam Therapy : 1. hospitalization bleeding. : Ad bonam : Dubia ad malam : Dubia ad malam Douglas.

2. Observation of general condition, vital signs, abdominal pain, and 3. Complete blood lab tests, SGOT, SGPT, MP3, urea, creatinine,

Electrolytes, Present blood sugar, HBsAg, complete urine, plano test, chest X-ray, ECG. 4. Pro USG 5. Diet: Regular 6. IVFD: RL 7. mm/ : Ciprofloxacin Kalnex Mefenamic Acid 2 x 500 mg. 3 x 1 ampul. 3 x 500 mg.

8. Total hysterectomy with General Anesthesi planning : January, 2nd 2013. Uterus of the fist with adhesions. The left tuba, left ovary, and portio was left.

Table 3: Daily Follow Up Date SOAP

December, 18th 2012

S: Lower abdominal pain Blood of the pubic O: GC: Look Moderate Illness (LMI) Awareness : composmentis Blood Pressure : 100/ 60 mmHg Pulse : 80x/ minute Temperature : 37, 1 oC RR : 16 x/ minute Eyes : Anemis -/-, Jaundice -/-. Extremity : Warm, CRT < 2. Abdomen: Abdomen looks flat, flexible, palpable mass of an adult fist, Tender (-), timpani, word of pain (-). Noisy intestine (+) Genital: fluorine (-), fluksus (+) is not active. Hb : 13,6 g/ dL Leukocyt : 22 thousand/uL Hematocryt: 40,5 % Trombocyt : 284 thousand/uL Bleeding time :1.3 minutes Clotting time : 12 minutes Protrombin time : 12 seconds GOD - POD : 145 mg/dL HbA1c : 7,8 % USG: Uterus : 12 x 9 x 9.5 cm Myoma : 7,01 x 5,9 cm Impression: Uterine myoma A: Uterine myoma + myomectomy history+ DM type II + Hypertension P: Pro Gynecology USG Diet : Reguler IVFD : I RL Mm/ : Ciprofloxacin 2 x 50 mg. Tranexamat Acid 3 x 1 ampul Mefenamic Acid 3 x 500 mg Norelut 3x1 Captopril 2 x 2,5 mg (stop) S: Blood of genitals reduced O: GC : Looks Mild illness Awareness: CM Eyes : anemis -/-, Jaundice -/Extremities : warm, CRT <2 Mammae : tenderness -, retraction -, massAbdomen: Abdomen looks flat, supple, muscular defense (-), timpani, tenderness (+), palpable mass (+) flat surface, smooth, mobile, assertive, bowel (+) 3x / min. Genitals: Fluor (-), fluksus (+) slightly. Natrium : 154 mmol/L

19 December 2012

December,20th 2012

Kalium : 3,5 mmol/L Chloride: 112 mmol/L Total protein 7,19 g/dL Albumin : 3, 06 g/dL Globulin : 3, 33g/dL SGPT : 25 U/L SGOT : 31 U/L Total Cholesterol : 343 mg/ dL Trigleseride : 123 mg/dL HDL Cholesterol 52 mg/dL LDL Cholesterol 174 mg/dL A: Uterine myoma + post miomektomy + DM + Hypertension P: Diet : DM IVFD : RL ( 20 drop/minute) Mm/ : Ciprofloxacin 2 x 500 mg (III) Tranexamat Acid 3 x 500 mg Mefenamic Acid 3 x 500 mg Norelut 3 x 10 mg Examination : Elektrolit, Hb, HbA1C. S: difficult defecation O: GC: Looks Mild Illness Awareness: CM Blood Pressure: 140/90 mmHg Pulse : 84x/ minute Temperature : 36, 5 oC RR : 22x /minute Eyes : anemis -/-, Jaundice -/Ekstremities : Warm, CRT <2 Edema -/-/+/+. Mammae : tenderness -, retraction -, massAbdomen: Abdomen looks flat, supple, muscular defense (-), tenderness (-), palpable mass (+), bowel sounds (+) 3x / min. Genitals: fluorine (-), fluksus (-). GOD POD :124 g/dL A: Uterine myoma + post miomektomy + DM + Hypertension. P: Diet : DM + papaya extra. IVFD: RL ( 20 drop/minute) + KCl 50 meq Mm/: Ciprofloxacin 2 x 500 mg Tranexamat Acid 3 x 500 mg Mefenamic Acid 3 x 500 mg Norelut 3 x 10 mg Metformin 2 x 500mg

Discussion
In the studies at 2011, the uterine myoma happened between 36 and 49 years old women, while the patient is 42 years old.(7). The patient complaints of vaginal bleeding since about 6 days. This complaints due to the symptoms based on the theory that abnormal uterine bleeding is the most common and most important clinical manifestation of leiomyomas, being present in up 30% of patients.(1) The bleeding related to dilatation of venules. Bulky tumors are thought to exert pressure and impinge on the uterine venous system, which causes venular dilatation within the myometrium and endometrium. Accordingly, intramural and subserous tumors have been shown to have the same propenstiy to cause menorrhagia as mucous ones.(3) The patients also had a prolonged menstruation, it was reported that 37,3% of women with diagnosed uterine myoma had a significantly longer duration of menstruation period (5.6 3.1 days, n = 1,245). (11) The patient complained of pain in the lower abdomen. Its suitable with the symptom that Leiomyomas may cause pain when vascular compromise occurs. Thus, pain may result from degeneration associated with vascular occlusion, infection, torsion of a pedunculated tumor, or myometrial contraction to expel a subserous myoma from the uterine cavity. The pain associated with infarction from torsion or red degeneration can be excruciating and produce a clinical picture consistent with acute abdomen.(2). The incidence of chronic pelvic pain was 14.5% while pain during menstrual bleeding or period was 59,7%. (11) The patient also complained of constipation because pressure effects may cause intestinal obstruction if they are large or involved omentum or bowel.(1) Pressure symptom happened in 28,8% women with uterine myoma. (12) The abnormal bleeding commonly produces iron deficiency anemia, which may not be uncontrollable even with iron therapy if the bleeding is heavy and protracted. This symptom didnt happened in this patient. (1). A sufficiently enlarged uterus can cause pressure sensation, urinary frequency, incontinance, and constipation. Rarely, leiomyomas extend laterally to compress the ureter and lead to obstruction and hydronephrosis. (3) Pressure on the bladder or inside the abdomen happened in 32,6% women with uterine myoma (11) but the patient didnt complained it.
Although the mechanism are not clear, leiomyomas can be associated with infertility. It is estimated that 2 to 3 % of infertility cases due sorely to leiomyomas. Their putative effects include occlusion of tubal ostia and disruption of the normal uterine contractions that proper sperm or ovum. Distortion of the endometrial cavity may diminish implantation and sperm transport. Importantly, leiomyomas are associated with endometrial inflammation and vascular changes that may disrupt implantation. (3) The study at Pirngadi Hospital reported that based on the parity, the highest proportion was multipara parity women 45,2%. (12) This symptom possibly didnt happened in this P3A1 woman because she got the myoma after she had 2 children.

The patient is Asian which is Asian was at the third races that possible to get uterine myoma.(3) Family and twin studies have shown the risk of leiomyoma formation to be

approximately two times greater in women with affected first- degree relatives, but the patient didnt have the familial history of uterine myoma.(3) Most myomas are discovered by routine bimanual examination of the uterus or sometimes by palpation of the lower abdomen. In this case, the mass was palpable in this patient lower abdomen. (1) The Pelvic ultrasound examination are useful in confirming the diagnosis of leiomyomas. While ultrasound should never be a substitute for a thorough pelvic examination, it can be extremely helpful in identifying leiomyomas, detailing the cause of other pelvic masses, and in the identification of pregnancy, the USG result for this patient was myoma uterine 7,01 x 5,9 cm. (1) In the diagnose of myomas, MRI demonstrated sensitivity of 94,1 %, specificity of 68,7%,PPV pf 95,7%, and NPV of 61,1%. The Area Under the Curve (AUC) for the diagnostic perfomance of MRI in the detection of mymoas was 0,81, respectively. MRI exhibits a high AUC for the diagnosis of myomas. In this case, we didnt use it for the patient. (6) In this case, the total hysterectomy was planned for this patient at January, 2nd 2013. This is based on the theory that removal of the uterus is the definitive and most common surgical treatmet for leiomyomas. Hysterectomy for leiomyoma can be performed vaginally, abdominally, or laparoscopically. Uterine with small myomas may be removed by total vaginal histerectomy, particularly if vaginal relaxation demands repair of cystocele, rectocele, or enterocele. When numerous large tumors especially intraligamentary myomas are found, total abdominal histerectomy is indicated. (1) Myomectomy should be planned for the symptomatic patient who wishes to preserve fertility or conserve the uterus or for those who decline histerectomy, but one can never be certain before operation that myomectomy can accomplished easily. In this case, the patient preffered total hysterectomy than myomectomy. (1) Postoperative intra abdominal adhesions leiomyoma recurrence are more common after myomectomy compared with hysterectomy. Recurrence rates following myomectomy range from 40 to 50%. New leiomyoma development, however,diminished in women who become pregnant following myomectomy, perhaps because of protective effect of increasing parity.(3) While in the other study, reported a rate of 2-3% per year of symptomatic myomas after myomectomy.(1) In this case, the patient have a uterine myoma with myomectomy history in 2010.

Conclution
The conclution of these case report is Uterine Myoma are benign neoplasms composed primarily of uterine smooth muscle cells, that typically originate from the myometrium. It also known as myomas or fibroids. (1-10).

Incidence of uterine myoma in Indonesia 2,39-11,% from all hospitalized benign (12) gynecology. , happened between 36 and 49 years old women (7) , 20% of all women of reproductive age. (2) The cumulative incidence by age 50 years was nearly 70% in Caucasians and over 80% in African- American women.(9) The incidence in multipara parity women 45,2%. (12) The highest proportion was 5-10 cm (67,5%). (12) The most happened location was Intramural myoma 41,9% (12)).

Abnormal uterine bleeding is the most common and most important clinical manifestation of leiomyomas, being present in up 30% of patients.(1) The incidence of heavy menstrual bleeding 59,8%, , Prolonged menstruation 37,3% (11) While the incidenceof chronic pelvic pain was 14.5%, pain during menstrual period 59,7%.. (11) The incidence of pressure symptom cause the intestinal obstructin was 28,8%. (11) It is estimated that 2 to 3 % of infertility cases due sorely to leiomyomas.(3) Pelvic ultrasound examination are useful in confirming the diagnosis of leiomyomas. MRI demonstrated sensitivity of 94,1 %, specificity of 68,7%. (6) The gonadotropin releasing hormone (GnRH) agonist have proven very useful for limiting growth or to cause a temporary decrease in tumor size. (1) Progesterone receptors, such as mifepristone with 5 or 10 mg daily during 6 months had a similar efficacy in reducing the uterine myoma volume, 48,1% and 39,1%. (7).
(1)

Leiomyosarcoma are reported to developed with a frequency of 0,1- 0,5% that of diagnosed leiomyomas. (1,2) Recurrence rates following myomectomy range from 40 to 50%. (3) Ureteral injury or ligation is a well- recognized complication of surgery for leiomyomas, particularly cervical.(1) .

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