Uterine leiomyoma, also known as fibroid, leiomyofibroma, fibromyoma, myoma etc. is the commonest benign tumor of the pelvic in women worldwide with incidence increasing with every decade in the reproductive age group[1,2]. These tumors originate from myometrium, composed of extracellular matrix consisting of type 1 and type 2 collagen fibers[2,3]. Though the exact cause of the genesis of leiomyomas is still unknown to us, many theories including genetics, hormonal, immunological and various growth factors are said to be responsible for the etiopathogenesis of leiomyomata[1,3,4].

Though many leiomyomas may remain asymptomatic for a long time, some may be incidentally diagnosed during some investigation e.g. USG/CT/MRI or during some procedure e.g. cesarean section or laparotomy for some other indication- these are then termed as ‘Incidentaloma/ Incidentoma’. The size of the tumor, along with their location and sometimes the number are the main determinant factors for the symptomatology and clinical presentation of the patients[1,4,5]. The different locations of uterine leiomyoma are intramural (most common), sub-serosal and sub-mucosal. Different myomas located in different areas might present with different kinds of symptoms varying from abnormal uterine bleeding (AUB) e.g.heavy menstrual bleed ( HMB),inter menstrual bleeding (IMB) to infertility and subfertility e.g. recurrent pregnancy loss (RPL) or recurrent miscarriages, dysmenorrheal etc.

It is usually recommended that uterine leiomyomas which are large, causing pain, pressure symptoms, abnormal and heavy menstrual bleeding, significant endometrial cavity distortion causing infertility or recurrent miscarriages should be removed. Also, many studies have proved that the chances of having a successful pregnancy after myomectomy in properly selected cases significantly and especially if it is of submucous variety, myomectomy improve the fertility rate to near baseline rates of age-adjusted women population of the same race[1,4,5].

Abnormal Uterine Bleeding (AUB) – mainly HMB & IMB are the most common complaints of patients having intramural and submucosal leiomyomas – mostly because of increased surface area of endometrium, interference with normal uterine contractility, congestion and dilatation of the venous plexuses, Endometrial Hyperplasia (due to hypoestrogenism (anovulation)), Pelvic congestion, Imbalance of  Thromboxane A₂ (↓ TXA_{2 )} &  ↑ PGE₂ whereas sub-serous varieties present mainly with pressure symptoms e.g. abdomino-pelvic mass, urinary symptoms e.g. dysuria, frequency, recurrent urinary tract infections (UTI) and bladder tenesmus, rectal symptoms e.g. constipation, rectal tenesmus, sometimes frank obstipation. 

Leiomyomas cause infertility due to several factors including:

• Physical factors – distortion and elongation of uterine cavity à difficult sperm ascent.

• Altered uterine contraction (impaired sperm ascent)

• Defective nidation due to congestion & dilatation of endometrial venous plexuses.

• Cytokine abnormalities

• Genetic factors

• Altered endo-myometrial junction (EMJ) à defective nidation zone à structurally and functionally [1,7,8]

Although only 1-25 % of infertility is due to fibroid ^(1,10), still fibroids do cause sub-fertility and infertility and removal f the same increases the chances of pregnancy by many folds. Accelerated mid-luteal peristalsis was established in patients having leiomyomas and approximately 45 % pregnancy rate was achieved after 1 year follow up post –myomectomy [9,1,9].

Pressure symptoms might occur in a very large broad ligament or pseudo-broad ligament fibroid pressing on ureter leading to reno-pelvic features e.g. hydroureter / hydronephrosis and pelvic vascular congestion presenting with gross pedal edema and venous thromboembolism and their sequelae[1,10-12].

Apart from the size, site (location) of the leiomyoma, other factors e.g. number, weight/ mass of the fibroid, volume and secondary changes can also play a key role in producing the spectrum of symptoms. The main purpose of this study was to study symptomatic fibroids in women and correlate other parameters which might have influenced these symptoms thereof.

• Study Type: Hospital based, observational, cross-sectional study.

• Study Population: Reproductive age group women presenting with uterine leiomyoma in dept. of OBGYN in a tertiary care medical college of rural Haryana in North India.

• Study Sample Size: 100 women who fulfilled the inclusion and exclusion criteria.

Inclusion Criteria:

• Reproductive age group women with symptomatic uterine leiomyomas

Exclusion Criteria:

• Age < 15 years and >45 years.

• Women with uterine leiomyoma >16 weeks size

• H/O bleeding disorder, heart/renal disease 

• Leiomyoma with pregnancy

• K/c/o malignancy

The following variables were studied:

• Age

• Symptom/symptoms

• Volume of leiomyoma 

• Size of myoma

• Type of myoma

• Number of myomas

After detailed history and thorough physical examination these patients underwent USG pelvis to evaluate the size, number, location (site) and volume of the leiomyomas. And the other blood investigations, preoperative, intra-operative and postoperative findings were noted.

All the data thus collected were entered in excel work-sheet and then statistical analysis of the same was done. Findings and follow up notes after myomectomy were collected.

Table 1: Age Distribution:

Table 2: Type of Myoma:

Table 3: Volume of Leiomyoma:

Table 4: Site (location) of myoma :

Table 5: Presenting Complaints

Many patients had more than one symptom especially the ones with pressure symptoms.

This study was conducted on women of reproductive age group presenting with symptomatic uterine leiomyomas. The incidence was highest in the age group of 36-45 years (52 %)  and least in the 18-25 years age group (18 %) (table -1). This can be explained by the fact that ovarian hormones i.e. estrogen and progesterone have the most influence on the growth and development of leiomyomas and thus they regress in size and number after the woman attains menopause [1,13-16]. Growth factors and cytokines, along with the ovarian hormones play a significant but yet not fully understood role in pathogenesis of uterine leiomyomas, as evidenced by many researches[1,4,5].

Abnormal uterine bleeding (AUB) especially heavy menstrual bleeding (HMB) followed by inter-menstrual bleed (IMB) were the most common presenting complaint of our patients (85 %). This is well consistent with literary evidences over the years. The explanations can be done as increased endometrial surface area, congestive and local coagulative factors derangement, defective and ineffective myometrial contractility, cognitive factors and various effects of estrogen. Other common complaint was dysmenorrhea of varying degrees- mostly were congestive or spasmodic type, causing significant loss of working hours and affecting the overall quality of life in these women (38 %). Some presented as chronic pelvic pain, dyspareunia and intermenstrual lower abdominal dragging or stretching kind of pain (2%)

Most common type of leiomyoma encountered were intramural, followed by sub-mucosal and least common were subserosal type. Many women had more than one variety of leiomyomas. Submucosal and intramural leiomyomas presented more with AUB and infertility whereas subserosal and cervical leiomyomas had mostly abdominal lump and pressure symptoms (table-5).

From our study we conclude that uterine myomas is very common in reproductive age group women with maximum presenting symptoms being menstruation related namely heavy menstrual bleeding  and dysmenorrhea. The size, location and volume of the leiomyomas are important factors determining their presenting symptoms and therefore the management thereof.

None

Nil 

The study was approved by the SGT Medical College, Gurugram, Haryana, India

1. Samanta, S., et al. "An Observational Study on Uterine Myoma in Search of Factors Contributing to Its Symptoms." Journal of Contemporary Medical Research, vol. 6, no. 1, 2019, pp. A1-A4.

2. Parker, W. H. "Etiology, Symptomatology, and Diagnosis of Uterine Myomas." Fertility and Sterility, vol. 87, no. 4, 2007, pp. 725-736.

3. Stewart, E. A., et al. "Relative Overexpression of Collagen Type I and Collagen Type III Messenger Ribonucleic Acids by Uterine Leiomyomas during the Proliferative Phase of the Menstrual Cycle." The Journal of Clinical Endocrinology & Metabolism, vol. 79, no. 3, 1994, pp. 900-906.

4. Flake, G. P., et al. "Etiology and Pathogenesis of Uterine Leiomyomas: A Review." Environmental Health Perspectives, vol. 111, no. 8, 2003, pp. 1037-1054.

5. Wallach, E. E., and N. F. Vlahos. "Uterine Myomas: An Overview of Development, Clinical Features, and Management." Farrer-Brown, 2004, pp. 393-406.

6. Shokier, T. A., et al. "Hysteroscopic Management of Submucous Fibroids to Improve Fertility." Archives of Gynecology and Obstetrics, vol. 273, no. 6, 2015, pp. 50-55.

7. Havryhiik, Y., et al. "Symptomatic Fibroid Management." Journal of Laparoendoscopic Surgeons, vol. 21, no. 3, 2017.

8. Purohit, P., et al. "Fibroids and Infertility." Current Obstetrics & Gynecology Reports, vol. 5, 2016, pp. 81-88.

9. Yoshino, O., et al. "Myomectomy Decreases Abnormal Uterine Peristalsis and Increases Pregnancy Rate." Journal of Minimally Invasive Gynecology, vol. 19, no. 1, 2012, pp. 63-67.

10. Donnez, J., and P. Jadoul. "What Are the Implications of Myomas on Fertility? A Need for Debate?" Human Reproduction, vol. 17, no. 6, 2002, pp. 1424-1430.

11. Whitaker, L., et al. "Abnormal Uterine Bleeding." Best Practice and Research Clinical Obstetrics and Gynecology, vol. 34, no. 4, 2016, pp. 54-65.

12. Huang, H. K., et al. "Increased Risk of Venous Thromboembolism in Women with Uterine Leiomyoma: A Nationwide, Population-Based Case-Control Study." Acta Cardiologica Sinica, vol. 34, no. 1, 2018, p. 66.

13. Cramer, S. F., and A. Patel. "The Frequency of Uterine Leiomyomas." American Journal of Clinical Pathology, vol. 94, no. 4, 1990, pp. 435-438.

14. Rein, M. S., et al. "Progesterone: A Critical Role in the Pathogenesis of Uterine Myomas." American Journal of Obstetrics and Gynecology, vol. 172, no. 1, 1995, pp. 14-18.

15. Lippman, S. A., et al. "Uterine Fibroids and Gynecologic Pain Symptoms in a Population-Based Study." Fertility and Sterility, vol. 80, no. 6, 2003, pp. 1488-1494.

16. Faleon, T., et al. "Surgical Anatomy of the Abdomen and Pelvis." Clinical Reproductive Medicine and Surgery, Mosby Elsevier, Philadelphia, 2017, p. 123.