FACTOR Abnormal uterine bleeding

PRESENCE IN PATIENT

RATIONALE Fibroids may appear singly or in clusters, and be as small as a grape or as big as an orange. They are comprised of muscle and fibrous tissue, and may cause excessive flow during menstruation or bleeding between periods. Continuous enlargement of tumors can cause distruption of uterine lining and devascularization, wherein capillaries will be injured thus leading to abnormal uterine bleeding. The pressure exerted by fibroid mass compresses the nerve endings on the uterus causing pain. Pain occurs coincide with menstruation due to disruption of uterine bleeding. Large fibroids will exerts pressure to the abdomen causing feeling of fullness of abdomen. Urinary frequency happens because of compression of the bladder of the patient causing feeling of fullness in bladder that would result to urinary urgency and frequency of urination This is due to compression of the ureter. Urine cannot pass through the ureter because of the pressure cause by myoma. Pressure on the rectosigmoid would result to decrease in peristalsis in the intestine causing constipation.

Hypogastric Pain ` Dysmenorrhea Abdominal Distention Urinary frequency Urinary urgency Dysuria

Constipation

Difficulty breathing Cyanosis

of

Pain

Presence mass in the lungs can cause pressure that would lead to compromise in oxygen in the patient. There is decrease in oxygen supply in the tissue causing cyanosis. Blood vessels become engorged with blood and the swollen endometrial tissue irritates organs in surrounding areas; blood pockets can form in various locations where there is no outlet for blood flow, and any collection of blood will create local pressure

Menstrual irregularities

Dyspareunia

The displaced endometrial tissue responds to estrogen and progesterone, so bleeding can come from the cervix, vagina, fallopian tubes, ovaries, or any other affected location Internal thrusting will precipitate pain when there is local congestion and tissue irritation from ectopic tissue in the culde-sacs (little pockets on either side of the cervix) in and Endometrial tissue can attach to the elimination intestine or bladder; adhesions can block the intestines causing bowel obstruction This symptom occurs because of decrease oxygen in the body. The body would try to compensate to fill in the insufficiency of oxygen. The heart increase in cardiac output to increase blood travelling in the body which carries oxygen. There is increase carbon dioxide in the lung which is acidic and cannot be excreted if patient has problem in lungs. There is impaired gas exchange. Oxygen saturation in the body is decreasing because of lack of supply. Decrease in oxygen in the body causes exhaustion of the cells causing lack of energy to the person. Due to exhaustion due to hyperventilation

Changes bowel bladder elimination Tachypnea

Tachycardia Respiratory Acidosis

Desaturation

Restlessness Diaphoresis

Symptomatology

Predisposing FACTOR Advance age PRESENCE IN PATIENT RATIONALE Fibroids usually affect women over age 30. They are rare in women under 20, and often shrink and cause no symptoms in women who have gone through menopause. Hormones during late age are increase especially in women getting pregnant at this stage.

Genetics

Race

Women are more likely to develop uterine fibroids if a close female family member such as your mother or sister had them. You may have inherited genes that can promote the growth of fibroids. African-American women are more prone to fibroids than are women of other ethnic groups. Black women also tend to get fibroids at an earlier age and are at a greater risk of developing multiple and/or larger fibroids

Precipitating FACTOR Obesity PRESENCE IN PATIENT RATIONALE In obese premenopausal women, decreased metabolism of estradiol by the 2-hydroxylation route reduces the conversion of estradiol to inactive metabolites, which could result in a relatively hyperestrogenic state Uterine fibroids are estrogen- and progesteronesensitive masses. The mass itself creates an estrogenic surrounding, which seems to aid its growth. Thus, hyperestrogenic states favor growth of uterine fibroids. Elevated diastolic blood pressure may increase fibroid risk through uterine smooth muscle injury. Elevated blood pressure has an independent, positive association with risk for clinically detected uterine leiomyomata among premenopausal women. In multiparous women, risk for developing fibroids is more common because of frequent exposure in estrogen which contributes in formation of fibroid. Women approaching menopause have been exposed to high levels of estrogen for years, they have a greater risk of getting fibroids or of developing symptoms from fibroid tumors that previously had no symptoms. Various researchers believe that women with fibroids, due to the estrogen load that a contraceptive delivers, should avoid oral contraception. Other practitioners, who believe the only notable association with oral contraception is a significantly increased risk among women who

Disease process Hyperestrogenic state

-Hypertension

Multiparity

Menopause

Contraceptives

Stress

used oral contraceptives at age 13-16 years, question this theory .The risk of developing a uterus that is not strong physically appears to increase with an early menarche, parity, or a history of infertility. It seems prudent to select an alternative form of birth control other than oral contraceptives if health of the reproductive system is questioned. Stress acts on the hypothalamus which regulates hormones such as estrogen and progesterone. Frequent alteration in the thalamus would change/ alter the hormonal production in the body.

Presdisposing Factors -Advanced age (> 40 y/o) * -Genetics * -Race (African) - Gender *

Idiophatic

Precipitating Factors -Obesity -Disease process Hyperestrogenic state Hypertension -Multiparity -Menopause * -Contraceptives - Stress *

Increase progesterone and other growth factor

Increase estrogen

Estrogen modulates its effects Cell proliferation and inhibition of cell death Bind to estrogen receptor in the immune target cell

Decrease cytokine production

Increase cell mitotic rate

S/Sx: -Asymptomatic

Formation of neoplasm

S/Sx: -Abnormal uterine bleeding * - Dysmenorrhea * -Hypogastric pain * - Abdominal Distention

Continuous growth of neoplasm caused by estrogen and lack of tumor suppressor cell Diagnostic exam: -Bimanual examination -Transvaginal sonography -MRI - Laparoscopy

Formation of benign tumor/ fibroids: Subserous, submucous and intramural.

If treated:

-Oral Contraceptive -GnRH Antagonist -Myomectomy - Dilitation and Curretage

If not treated: Continuous growth of tumor

Fibroids tends to make the uterine larger

Fibroids outgrows its own blood supply

Good prognosis

Thus increasing in the endometrial surface/large fibroids

Pedunculated fibroid becomes twisted

Compression of the adjacent structure Excessive blood loss Pressure in the urinary bladder Signs and symptoms: -Urinary frequency* -Urgency -Dysuria Pressure on rectosigmoid Hypovolemia Signs and symptoms: -Constipation

Cutting its own blood supply

Fibroid cell degeneration

A B

Tissue Necrosis
D

hypovolemic shock Impairi ng Uterine lining Blocking Fallopian tube Distorting uterine shape Death Impaired Uterine Function (Prevent sperm reaching

Fibroid breaks away from uterus travels to other area

Neoplasm from uterus adheres to lung tissue

Infertility

Proliferation of abnormal cell

Formation of lung tumor/ benign metastasizing leiomyoma If treated -Oxygen administration Lobectomy -Mechanical ventilation -Lung transplant If not treated Compression of lung structures

Fair prognosis

Signs and symptoms: -Dyspnea -Cyanosis - Tachypnea -Tachycardia - Respiratory Acidosis - Desaturation - Restlessness - Diaphoresis

Decrease blood supply in the lung

Hypoxia in the lung tissue C

C Tissue necrosis Obstruction of the menstrual flow

Backflow of menstrual fluid draining in the peritoneal cavity ,

Decrease pulmonary function

Atelectasis Estrogen and progesterone are withdrawn to its normal circulation Respiratory Arrest Estrogen and progesterone stimulate the regeneration and proliferation cell Multi-system organ failure Formation of puckered scar tissue Death

Larger masses may form if smaller lesions coalesce

Formed lesion/ mass continuously perform the endometrial cells normal function

Bleeding occurs in conjugation with normal menstrual cycle.

Diagnostic exam: -Physical examination -Laparoscopy Exploratory surgery

Bleeding causes inflammation on the peritoneal lining

Bleeding and inflammation may lead to fibrosis, scarring and adhesion to peritoneal cavity or other organ Signs and symptoms: -Pain * -Menstrual irregularities* -Dyspareunia * -Changes in bowel and bladder elimination *

Fixation of involved pelvic structure.

If treated Treatment: -Adhesiolysis/Enterolysis -Analgesic -GnRH antagonist -Hysterectomy -Surgery/ Laparoscopy

If not treated Scar lesion may shrink

Bleed into enclose space

Good prognosis

Chocolate cyst may form/ Cystoadenoma

Cell transformation occur

Altered DNA structure

Proto Oncogenes Transform to Oncogenes

Inactivation of tumor suppressor cell/ Genetic disability

Additional mutation of the malignant cell

Formation of carcinoma in situ

Mechanical expansion of the carcinoma

Hypoxia of the carcinoma

Cell produces some cell factors specific to affected area

Angiogenesis

Proliferation of the abnormal cell due to repeated exposure to promoting agent.

Increase malignant rapid proliferation of cancer cell which becomes irreversible

Cancer cells metastasize to other organs

Impairing the organ function

Multi organ failure

DEATH

Narrative Pathophysiology

Myomatous or fibroid tumors of the uterus are estimated to occur in 25% of women over age 30. The exact mechanism/ etiology of the disease process is unknown/ idiopathic. Numerous predisposing factors can be associated with uterine myoma, which include genetics, age, race, and gender. Moreover, precipitating factors such as obesity, hyperestrogenic state, hypertension, multiparity, stress, contraceptives, and menopause have been identified to be related to the increase risk of developing this disease. Researchers have proposed several theories pertaining to the etiology of the occurrence of uterine myoma. One of the comprehensive theories discussed by the researchers is the relation of increase estrogen to the formation of fibroids at specific area. This theory states that increase in estrogen will directly cause increase in progesterone levels in the body which is responsible for cell proliferation and inhibition of cell apoptosis(cell death).

On the other hand, estrogen modulates its effect and binds to estrogen receptor in the immune target cell. With this, it can lead to shifting of cytokine production which is in- charge of cell-to-cell communication. As this occurs, impairment of immune response against foreign agents, thats why the body doesnt have the ability to recognize the tumor antigen. Due increase estrogen, progesterone and other growth factor, proliferation of abnormal tissues also hastens thus it increase the cell mitotic rate.

Formation of neoplasm (abnormal tissue formation) happens. Because the body has the inability to recognize the impending formation of excess and abnormal tissue, it progresses to the formation of tumor, which an abnormal neoplasm formation. At this stage, the patient appears to be asymptomatic. Fibroid benign tumor can be classified according to their location, subserous (outside surface), submucous (intracavity) and intramural (muscle wall). Signs and symptoms of growth of tumor in the uterus include abnormal uterine bleeding, hypogastric pain, dysmenorrhea and abdominal distention. Diagnostic tests such as bimanual examination, pelvic sonography and MRI would

detect fibroid formation. Treatments for uterine fibroid are the following: oral contraceptive, GnRH antagonist and myomectomy. At this stage, the patient can achieve a good prognosis.

If the uterine fibroid left untreated, it would lead into three complications. First, fibroids tend to make the uterus larger, thus increasing the endometrial surface. As the tumors size and endometrial surface increase, it would lead to the compression of the adjacent structures. When the pressure is exerted towards the urinary bladder, the patient will manifest the following signs and symtoms: urinary frequency, urgency and dysuria. On the other hand, if pressure is exerted in the recto-sigmoid, constipation will be manifested by the patient. Compression to this certain area would not lead to further complications due to the fact that the fibroids naturally grow slowly. Also, the body has the tendency to compensate with the increase in pressure by displacing other organ structure.

Furthermore, large fibroids impair the uterine lining, blocking the fallopian tube, distorting uterine and disruption of uterine function (prevent sperm reaching the uterus), thus causing infertility. At this point, if fibroids left untreated, the fibroid will outgrow and form its own blood supply. The pedunculated fibroid becomes twisted, leading to the cut down of the blood supply. If cutting of blood supply will not be treated immediately, it will lead to excessive bleeding. As the said condition persists, increase loss of fluid can lead to hypovolemia progressing to hypovolemic shock, wherein the blood supply in the body is insufficient to nourish the cells leading to multi-organ failure causing death.

On the other hand, the pedunculated fibroid, can degenerate and progress to tissue necrosis. Fibroid breaks away from uterus and travel to other area and produce new fibroid. Neoplasm from uterus adheres to lung tissue then there would be proliferation of abnormal cells. It would progress to formation of tumor in the lungs or also known as benign metastasizing leiomyoma (BML). Treatments for BML include surgery, mechanical ventilation and lung transplant. These said management can help the patient fully recover leading to good prognosis. If BML is left untreated, the tumor

compresses the lung structures, causing distinct respiratory signs and symptoms such as difficulty in breathing, cyanosis and dyspnea. In addition, compression in the lung structures will decrease the blood supply in the said organ. Tissue hypoxia will happen due to lack of oxygen supply in the tissue thus leading to tissue necrosis. Due to the necrosis, the lung function will be impaired causing lung atelectasis followed by respiratory arrest. As this occurs, multi-organ failure persist leading to death.

Moreover, endometriosis is one of the rare complications of large fibroid/ uterine myoma. As the uterine myoma enlarges, it can cause obstruction on the menstrual flow pathway. Also, excessive bleeding due the disruption of the endometrial lining can increase the risk of menstrual block flow. This said phenomenon is known as retrograde menstruation. Usually, it can occur to most women, without adverse reactions, however there are instances wherein it can progress to endometriosis. In endometriosis, a benign lesion or lesions with cells similar to those lining the uterus grow aberrantly in the pelvic cavity outside the uterus. Often, extensive endometriosis causes few symptoms, whereas an isolated lesion may produce severe symptoms. In order of frequency, pelvic endometriosis involves the ovary, uterosacral ligaments, cul-de-sac, rectovaginal septum, uterovesical peritoneum, cervix, outer surface of the uterus, umbilicus, laparotomy scar tissue, hernial sacs, and appendix.

Estrogen and progesterone withdrawn from its normal circulation causing formation of puckered scar lesions, larger masses may from if smaller lesion coalesces or aggregates. Due to formation of endometrial tissue in the peritoneal cavity, mass continuously performs the endometrial cells normal function. Thus, bleeding occurs in conjugation with normal menstrual cycle. Bleeding can trigger irritation and inflammation in the peritoneal lining leading to fibrosis, scarring and adhesion to peritoneal cavity or other adjacent organ. Several treatments such as Adhesiolysis/Enterolysis, Analgesic, and GnRH antagonist, Hysterectomy and Surgery / Laparoscopy can be utilized in achieving a good prognosis.

At this condition progresses, the scar lesion may shrink. It would lead to bleeding inside the scar tissue or lesion because theres no point of exit for the blood. Trapping of blood inside cell will happen. Chocolate cyst or cytoadenoma occurs because of the old blood retained from enclosed tissue. Cell transformation occurs because of DNA structure alteration, proto oncogenes transform into oncogenes wherein cell may be malignant. Tumor cell inactivation and genetic disability will occur causing additional mutation of the cancer cell. The first stage of the cancer formation is carcinoma in situ, wherein malignant cell are formed in the epithelial tissue. Mechanical expansion happens causing hypoxia of the carcinoma. Cell produces some cell factors specific to the affected site causing angiogenesis wherein there is proliferation of the abnormal cell due to repeated exposure to promoting agent. Rapid malignant proliferation of cancer cell which becomes irreversible, cancer cells metastasize to other organs causing impairment of the organ function. Thus, it would lead to multi-organ failure, leading to body organ dysfunction ending with death.