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Leiomyoma — Clinical Guidelines

Overview

Uterine leiomyomas (fibroids) are benign smooth muscle tumors of the uterus, often associated with symptoms such as abnormal uterine bleeding, pelvic pain, and reproductive complications. They are influenced by hormonal factors and may exhibit varied presentations depending on location and size 1 5.

Diagnosis

Imaging: Ultrasound, MRI, and CT scans are essential for assessing size, number, and location of leiomyomas 3 4.

Histopathology: Biopsy or surgical specimens confirm diagnosis through characteristic smooth muscle cell morphology 4.

Blood Tests: Vitamin D levels may be evaluated, especially in cases where vitamin D deficiency is suspected 1 5.

Angioarchitecture: Specialized imaging techniques can assess vascular patterns within fibroids 4.

Management

Medical Therapy:

- Selective Progesterone Receptor Modulators (SPRMs): Ulipristal acetate (UPA) for symptom relief and myoma reduction 2. - Vitamin D: Supplementation may inhibit proliferation via mechanisms involving catechol-O-methyltransferase 1 5.

Interventional Procedures:

- High-Intensity Focused Ultrasound (HIFU): Effective for large symptomatic fibroids, with follow-up imaging to monitor response 3. - Uterine Artery Embolization (UAE): Considered for symptomatic relief, though long-term efficacy data is still accumulating 7.

Surgical Options:

- Myomectomy: Surgical removal of fibroids while preserving the uterus, suitable for carefully selected patients including those in pregnancy 9. - Hysterectomy: Indicated for severe, intractable symptoms or when other treatments fail 7.

Special Populations

Pregnancy: Laparoscopic myomectomy can be performed safely during pregnancy for symptomatic fibroids 9.

Comorbidities: Management may need adjustment in patients with significant comorbidities, considering risks of surgical interventions 7.

Key Recommendations

Consider Ulipristal Acetate (UPA) for symptomatic relief and reduction of uterine leiomyoma size in appropriate patients (Evidence: Moderate 2).

Evaluate vitamin D levels and consider supplementation in patients with leiomyomas, particularly in those with deficiency (Evidence: Moderate 1 5).

Use high-intensity focused ultrasound (HIFU) as a non-invasive option for treating large symptomatic uterine leiomyomas, with close follow-up imaging (Evidence: Weak 3).

Laparoscopic myomectomy can be a viable surgical option during pregnancy for managing symptomatic uterine leiomyomas (Evidence: Expert opinion 9).

Uterine artery embolization (UAE) should be considered for symptomatic relief, though long-term outcomes require further study (Evidence: Moderate 7).

References

1 Cross CI, Driggers PH, McCarthy BE, Diab M, Brennan J, Segars JH. A-kinase anchoring protein 13 interacts with the vitamin D receptor to alter vitamin D-dependent gene activation in uterine leiomyoma cells. F&S science 2021. link 2 Palaia I, Del Negro V, Fracassi A, Schiavi M, Di Donato V, Fischetti M et al.. Efficacy of ulipristal acetate (UPA) for the treatment of expulsion uterine myomas: report of two cases. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology 2020. link 3 Hou R, Wang L, Li S, Rong F, Wang Y, Qin X et al.. Pilot study: safety and effectiveness of simple ultrasound-guided high-intensity focused ultrasound ablating uterine leiomyoma with a diameter greater than 10 cm. The British journal of radiology 2018. link 4 Bereza T, Lis G, Mitus J, Sporek M, Chmielewski P, Kolber W et al.. Blood vessels of the intratumoral septa in uterine leiomyomata. Folia medica Cracoviensia 2013. link 5 Sharan C, Halder SK, Thota C, Jaleel T, Nair S, Al-Hendy A. Vitamin D inhibits proliferation of human uterine leiomyoma cells via catechol-O-methyltransferase. Fertility and sterility 2011. link 6 Challa R, Irion KL, Hochhegger B, Shackloth M, Elsayed H, Gosney JR et al.. Large pulmonary masses containing varicose veins: a rare presentation of benign metastasising leiomyomas. The British journal of radiology 2010. link 7 Marshburn PB, Matthews ML, Hurst BS. Uterine artery embolization as a treatment option for uterine myomas. Obstetrics and gynecology clinics of North America 2006. link 8 Wei JJ, Chiriboga L, Arslan AA, Melamed J, Yee H, Mittal K. Ethnic differences in expression of the dysregulated proteins in uterine leiomyomata. Human reproduction (Oxford, England) 2006. link 9 Melgrati L, Damiani A, Franzoni G, Marziali M, Sesti F. Isobaric (gasless) laparoscopic myomectomy during pregnancy. Journal of minimally invasive gynecology 2005. link 10 Lun KR, Spelman LJ. Multiple piloleiomyomas. The Australasian journal of dermatology 2000. link 11 Karnak I, Akçören Z, Senocak ME. Endobronchial leiomyoma in children. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2000. link 12 Bozlu M, Orhan D, Baltaci S, Müftüoğlu YZ, Tulunay O. Leiomyoma of the epididymis. International urology and nephrology 2000. link 13 Tavecchio L, Bedini AV, Di Palma S, Andreani SM. Intrathoracic benign metastasizing leiomyoma with extrapulmonary growth pattern. A case report. Tumori 1999. link 14 Sheikh HH. Uterine leiomyoma as a rare cause of acute abdomen and intestinal gangrene. American journal of obstetrics and gynecology 1998. link70097-3) 15 Jacobson TZ, Rainey EJ, Turton CW. Pulmonary benign metastasising leiomyoma: response to treatment with goserelin. Thorax 1995. link 16 Lauwers G, de Roux S, Terzakis J. Leiomyoma of the breast. Archives d'anatomie et de cytologie pathologiques 1990. link 17 Allison JG, Dodds HM. Leiomyoma of the male nipple. A case report and literature review. The American surgeon 1989. link 18 Nicoll JJ, Cox PJ. Leiomyoma of the ovary with ascites and hydrothorax. American journal of obstetrics and gynecology 1989. link90260-3) 19 Witz M, Bernheim J, Griffel B, Dinbar A. Leiomyoma of the anal canal: report of two cases. Journal of surgical oncology 1986. link 20 Heald J, Moussalli H, Hasleton PS. Diffuse leiomyomatosis of the oesophagus. Histopathology 1986. link 21 Phipps RF. Gastric leiomyoma presenting with intraperitoneal haemorrhage. Journal of surgical oncology 1986. link 22 Zaitoon MM. Leiomyoma of ureter. Urology 1986. link90182-2) 23 Zaitoon MM. Retroperitoneal parasitic leiomyoma causing unilateral ureteral obstruction. The Journal of urology 1986. link45543-1) 24 Tsujioka K, Kashihara M, Imamura S. Cutaneous leiomyoma of the male nipple. Dermatologica 1985. link 25 Honoré LH, Reid DW. Uncomplicated, spontaneous expulsion of a uterine leiomyoma postpartum. A case report. The Journal of reproductive medicine 1985. link 26 Powell JL, Fuerst JF, Tapia RA. Leiomyoma of the appendix. Southern medical journal 1980. link 27 Falsafi A. Leiomyoma of duodenum: report of a case. International surgery 1979. link 28 Williams JL. Leiomyoma of the urethra. European urology 1979. link 29 Wani NA, Bhan BL, Guru AA, Garyali RK. Leiomyoma of the female urethra: a case report. The Journal of urology 1976. link58708-x) 30 Russell RC, Wood BA. Exogastric leiomyomata. Postgraduate medical journal 1972. link

Leiomyoma