CASE 13: BENIGN LESIONS OF THE UTERUS
Uterus: POLYP, HEMATOMETRA, MYOMA, & ADENOMYOMAS
Common complaints may bring a patient to the clinic?
1. Menorrhagia: Regular, prolong duration, profuse
amount (diapers & overnight pads) aka HMB
2. Hypogastric / lower abdominal mass/ pelvic mass
3. Pressure Effect of Mass: leading to compression
anteriorly & posteriorly
 A: Frequency of urination, Dysuria due to UTI,
Extremes: ANURIA or urinary retention (no voiding
for the past 12 - 24 hours), pain in the lower
extremities (sciatic or femoral nerves causing
numbness or tingling sensation of the nerves),
 P: Constipation & Obstipation (not diarrhea)
o C: Infrequent, difficult evacuation of feces
o O: Intractable C refractory to cure or control
HMB:
 Get Menstrual History (LMP, PMP): To r/o pregnancy
 In MIDAS (Menarche, Interval, Duration, Amount & SX)
expound on SX ass. w/ menstruation which is presence
of progressive dysmenorrhea
O
 If 1 Dysmenorrhea: it would be due to PG which is
physiologic,
 If Progressive Dysmenorrhea: R/o organic or systemic
pathology
MYOMA UTERI
 Most common pathology that causes most of these SX
 Benign tumor of the uterus
 Proliferation of the smooth muscle of the myometrium,
 An E dependent tumor (reproductive age women) but it
may still persist on post-menopausal but will not exist as
a new growth
 80% Asymptomatic, An “Incidental” finding
 Symptoms would depend on the size & location
 Myoma located near the Fallopian Tube, would obstruct
the meeting of sperm & ovum causing INFERTILITY
Types of Myoma:
 Submucous: notorious for causing HMB
o Causes recurrent pregnancy loss
 Intramural: where all types originate
MASS
 Subserosal:
Where else could it grow?
 Parasitic: can grow out & attach to the omentum
 Broad Ligament Myoma:
1. Difficult to differentiate from solid ovarian tumor,
2. Transection of the ureter, ↑ the morbidity creating
ureteroileostomy (transposition in the abdominal
wall with urinary bob on the side)
 Pedunculated Myoma: Submucous myoma have a long
pedicle either (sessile: wide base or pedunculated: thin)
that can grow out into the cervix
 Cervical Myoma: Remember cervix is made up of
collagen, smooth muscles. It can block the ureterovesical
junction causing marked accumulation of the urine in the
bladder palpated as a nodule at the cervical area
reaching out to the umbilical area & cause urinary
retention (an emergency situation).
Abdominal exam: MASS
 Consistency: Firm (not cystic);
 Location: Lower area extending upwards
 Size: Variable (> 12 weeks: Abdominal organ)
 Tenderness: Usually asymptomatic but if it is tender, it
O 
may be 2 to degenerative changes
 Surface: Nodular or Irregular (Singular or Multiple),
 Mobility: Depending on the size (small: movable, large:
immobile, no more space)
Speculum Exam:
 IF with prolapsed myoma or nodule in the cervix,
definitely speculum should be helpful. You may not
totally see the cervix, as the mass protrudes in the vagina
as a pinkish nodule plugging at the os
 Probe the cervix & feel the consistency. Feel for the base
if it’s on the cervix or deep in the cavity,
 If base is attached to the cervix, definitely it is a
CERVICAL MYOMA (vaginal approach)
 Will tell you TX to approach if it is vaginal or abdominal
RVE
 IF there is some nodules on the posterior surface, mass
at the cul de sac
 Do bowel preparation to prevent sepsis intraoperatively
DX:
UTZ:
 TVS/ TRS/ PUS (Abdominal Pelvic UTZ)
 HYPERECHOIC nodule within the myometrium (white)
MRI:
 Costly,
 Advantage: if trying to do conservative TX, you have to
map out properly where the myomas are with MRI
Tumor marker: CA 125 is not specific therefore not helpful
DDX:
Myoma Adenomyoma
Nodular Smooth
Firm Soft, Doughy
Asymmetrical Symmetrical
Lighter (Creamy white) Darker
Whorled/ Trabeculated No whorled pattern
Pseudocapsule w/ serosa Capsule not present
But for Adenomyoma: (Adenomyosis + Myoma); capsule is
not well defined & becomes adherent due to inflammation
recognized as foreign body.
MX:
 Consider: Age & future child bearing plans (G_P_)
 Not all are managed: depend on the size, location & SX
Medical: GnRH agonist
 Myoma is E dependent: Create Pseudo-menopausal state
 Administration: IM or SC (Abdomen), Intranasal
(Goserelin is not available in the Philippines)
 Drugs: Leuprolide, Buserelin, Histrelin, Goserelin,
Deslorelin, Nafarelin (Synarel) & Triptorelin
 Give maximum of 6 months (To prevent menopausal
symptoms: dyspareunia, osteoporosis)
 Monthly injection: 2 - 3 cycles (40 - 50% ↓ Size)
 Disadvantage: After discontinuing, there will be rebound
of size, myoma can even grow bigger in the original size.
 GnRH cannot stand alone so there should be indications:
1. If the original size: 6 months size: young, wants to have
children. Pre-operatively shrink the myoma so by the
time of myomectomy it would have ↓ vascularity having
higher chance of success)
2. If the patient is bleeding or anemic, correct the anemia
st O
1 by creating 2 amenorrhea.
Surgery
Conservative: Myomectomy
 Radical: TAH (↑ Age with no future childbearing plans)
 Abdominal: robot assisted laparotomy or a laparoscopy
 Vaginal: hysteroscopy
Surgical Indications:
1. HMB, Dysmenorrhea, or other S & Sx ass/ with infertility
2. Menopausal Age + > 8 cm (can be confused with ovarian
pathology)
3. Uterine mass > 12 weeks causing pressure Sx, discomfort
& disruption of daily activities.
Myomectomy
 M + BSO (IF menopausal or with factors of malignancy)
 If young: do not remove ovaries to prevent surgical
menopause
 Removal of the myoma by cutting through the surface &
scooping it out.
How to remove myoma thru minimally invasive incision in the
abdomen if you have a large myoma about 4 months size (12
– 16 weeks)?
 Answer: MORCELLATION (Grinds the myoma)
Case 1 Submucous Myoma
 Uterus: Normal size, Speculum: Bleeding, IE: nodular
UTZ: filling defect as hypoechoic displacing the lining
inside:
 MX: Approach it from below thru the vagina called
Transcervical Transection of Myoma (TCR M)
 Advantage: Direct visualization
 With the loop attach to the cautery machine, shave off
the myoma & do laparoscopy to see if there is
perforation from the other side.
 Remember myoma is avascular so with heat it would
ligate the vessels having no need for suture.
 Hysteroscopic TCR M ideally should be done on early
proliferative, immediately after the menses or if not
ASAP, give suppressants to make the lining thin &
schedule at once because if the lining is too thick, you
can miss out the myoma.
Case 2 Submucous Myoma
 48, post stroke, post MI with bleeding uterine site, 3
months size, mass compressing to the point that she has
hydronephrosis & creatinine is increasing
 MX: Remove but if not given clearance, give GnRH
agonist then re-evaluate after 6 months
 If there is no improvement: Do UAE (Uterine artery
embolization) done by interventional radiologist
 Since myoma’s main supply of uterus: Uterine Artery,
place some gels or coils which emits substance causing
VC depending where the big vessels of the myoma are
which will coagulate then block the blood supply causing
shrinkage of myoma or mass to be atrophic & necrotic.
 Done ONLY if patient is not desirous of pregnancy
Excision for Adenomyoma: Adenomyomectomy
Complication:
 After removal of the benign tumor, there would be a
filling defect. That filling defect is to be repaired, sutured
& reinforced.
 Clinical Significance: The depression or filling defect is a
weak point as possible site for uterine rupture from the
force of labor or uterine contractions. This rupture will
compromise the health of both mother & baby.
 What to do: Schedule CS
Unless the patient had only myomectomy, and it’s only a
pedicle in which it did not go under the muscles, there is no
need for CS.

Case 13
45 year old G3P3 (3003) complained of progressive increase in the amount & duration of her menses since 2 years ago. LMP: 1
week ago; Menses still regular. Abdominal examination: (+) firm nodular, non-tender movable mass in the hypogastric area,
the upper pole of which is halfway between the symphysis pubis & umbilicus. Speculum examination: cervix was pink,
smooth, w/ minimal bloody mucoid discharge from the os. IE: cervix – firm long closed, movable, non-tender; Uterus: nodular,
firm, enlarged to about 3 months size, movable, non-tender, Adnexa: no mass nor tenderness

Impression: MYOMA (Nodular, Non-tender, Abdominal mass)

 Submucous Myoma (HMB)

DDX:
1. Adenomyoma, Adenomyosis
To rule out: No progressive dysmenorrhea felt to be
persistent orincreasing intensity
2. Cancer
To rule out: Weight loss, RF

Malignant Myoma
 Leiomyosacoma
 Degeneration: Sarcomatous (Others: During pregnancy)
 For menopausal who have been regularly menstruating
 Incidence: 0.7 %

3. Adnexal pathology:
 Ovarian enlargement in the hypogastrium can be
pedunculated to the point in the midline by IE.

WORK-UPS:
 TVS : will not change the management but you can still
request for treatment planning to map out where the
myomas are & dictate the difficulty (big myoma) at the
posterior part compared from fundal or anterior part for
the patient

DEFINITIVE SURGICAL INTERVENTION: TAH