Refleksi Kasus

MIOMA UTERI

Fakultas Kedokteran Universitas Tarumanagara

Kepaniteraan Obstetri dan Ginekologi
RSUD RAA SOEWONDO PATI
 KASUS

S: Pasien perempuan, 51 th, P3A1 datang

dengan keluhan nyeri perut dan banyaknya
darah menstruasi sejak 1 tahun terakhir. Nyeri
perut hilang timbul, dirasa memberat saat
darah keluar, nyeri pinggang(+).
• Riwayat HT(+), pelvic inflammatory disease(+) urinary tract infection(+), KB suntik
tiap 3 bulan

O:
• KU:CM
• TD:140/90mmHg RR: 18x/menit N:82x/menit S: 37 C
• Abdomen: Nyeri tekan (+) kuadran kanan bawah dan kiri bawah
PEMBAHASAN MIOMA UTERI
 Definition
The terms fibroid, myoma, and leiomyoma are
synonymous and are the commonest
gynaecological tumours
Myoma is a benign neoplasm originated from
connective tissues of the uterine smooth muscle
 INCIDENCE
The prevalence increases with age, peaking in women in their 40.
A hysterectomy study has found leiomyomas in 77% of uterine specimens
Leiomyoma  most common benign uterine tumors
Incidence of 20%–40% reproductive years

Myomas are more common as women age, and have been identified in
4% of women aged 20 to 30 years,
11% to 33% of women aged 30 to 40 years,
33% of women aged 40 to 60 years.
They are more common in African American women, nulliparous women, obese women, and women with a
positive family history of myomas

James Shwayder, MD, JD. Imaging for Uterine Myomas and Adenomyosis. JMIG. 2014
 Etiology
Unknown etiology
Uterine muscle cells or arteries, that originate
from metaplastic connective tissue
transformations, and from persistant residual
embryonic cells.
Several available evidence indicate an increase in
progesterone receptors, epidermal growth factor
and insulin-like growth factor 1 production
stimulated by estrogen.
Estrogen stimulated gene are higher in cases of
 Risk factor

Early menarche
Increased frequency of menses
Dysmenorrhea
Family history of uterine fibroids
Obesity
Age

Caterine A, Laberge PY, et al, Uterine Leiomyomas Management. SOGC Clinical practice guideline. J
Obstet Gynaecol Canada 2015
 Pathogenesis
 Genetic factors, growth factors (vascular endothelial growth
factor[VEGF], acidic fibroblast growth factor, basic fibroblast
growth factor, activin, and myostatin), cytokines, chemokines, and
extracellular matrix (ECM) components are known factors
involved in the pathogenesis of leiomyoma.

Soriful, MD. Uterine Leiomyoma: Available Medical Treatments and New Possible Therapeutic Options. J
Endocrinol Metab, March 2013, 98(3):921–934
 CLASSIFICATION

Sub mucosal Intramural Subserosa

Frequently characterized by
vaginal bleeding. The
bleeding is frequently
difficult to stop, eventually
resulting in a hysterectomy.
->intraepithelial
myomas
->frequently
asymptomatic except
for minor signs that
include mild lower
abdominal discomfort.
 presented as a simple bump
or as a single mass
connected to the uterus with
a rod
 Growth towards the latum
ligament known as an
intraligamenter myoma.

Fidel
Thompson
Ganis.MJ,
When
CarrMyoma
BR. Myomas: to treat or not
Causes Infertility. to treat.
Journal International
of Natural journal
Sciences of women’s
Research. health2013
Vol.3, No.4,
2016;8:145-149
George A.Vilos, MD. The Management of Uterine Leiomyomas. JOGC . February 2015
 Clinical presentation

 Abnormal Uterine Bleeding

 Heavy menstrual bleeding(Presentation  woman’s menstrual cycle )
 Pelvic pain
 Pelvic pressure, bowel dysfunction, and bladder symptoms such as
urinary frequency and urgency may be present with larger fibroids

Infertility and abortion

 Infertility as a result of myomas nest closure or intertitial tubal
supression, whereas sub mucosal myomas may facilitate an abortion due
to the presence of a distorted uterine cavity.

George A.Vilos, MD. The Management of Uterine Leiomyomas. JOGC . February 2015
Fidel Ganis. When Myoma Causes Infertility. Journal of Natural Sciences Research.
Vol.3, No.4, 2013
 Diagnosis

1. History taking
A history taking is conducted to determine the
chief complaint together with other clinical
symptoms, risk factors, and other possible
complications.
2. Physical examination.
Palpating the abdomen. Physical examination
presented as a solid tumor, irregularly shaped,
highly mobile on examination.
a. Transabdominal and transvaginal sonography Uterine myoma typically produce a sonographic
enlargement image with irregular borders.
b. Gold standard diagnostic  gray-scale ultrasonography

b. Laparscopic examination
 which are highly beneficial to diagnose
 due to the direct acces it provides.

c. MRI (Magnestic Resonanse Imaging)

 highly accurate in describing the amount and location of myomas
 In an MRI, a myoma is visualized as a dark, well bordered mass clearly differentiable from the normal
myometrium.

James Shwayder, MD, JD. Imaging for Uterine Myomas and Adenomyosis. JMIG. 2014
 Management

1. Conservative
2. Medical
3. Surgical

George A.Vilos, MD. The Management of Uterine Leiomyomas. JOGC . February 2015
 Concervative

Small fibroids, close to menopause

or who are trying to conceive
conservative treatment 
analgesics and hematinics

Thompson MJ, Carr BR. Myomas: to treat or not to treat. International

journal of women’s health 2016;8
 Medical
 Indications:
 Symptomatic fibroids /not suitable for surgery
 Pre-operative adjunct (reduce the size, control bleeding, and improve
hemoglobin levels.
 in research, evaluation of new potential therapies.

Medical management
 Oral Contraceptives
 Reducing menstrual bleeding in the short-term and may prevent the
development of uterine fibroids.
 Progestins/Levonorgestrel Intrauterine System
 Significantly reduces menstrual blood loss and uterine volume in women with
menorrhagia, with and without fibroid
 Antifibrinolytics agents (tranexamic acid)
 Selective progesterone receptor modulators (SPRMs)
 Aromatase inhibitors (letrozole)has added more armamentarium to the medical
options of treatment.
 Surgical

 Hysteroscopic myomectomy
 Laparoscopic myomectomy
 Abdominal myomectomy

 Hysterectomy
 In women who have completed childbearing, hysterectomy is
indicated as a permanent solution for symptomatic leiomyomas
 Hysterectomy is the most effective treatment for symptomatic
uterine fibroids.

 Standard treatment for symptomatic myoma  surgical