Submucosal Myoma

Overview

Fibroids, also known as leiomyomata, are benign tumors of the uterine muscle that are classified according to their location in the uterine wall: submucous myomas (located beneath the mucosal layer and protruding into the uterine cavity), subserosal myomas (located beneath the serosal layer and protruding into the abdominal cavity), and intramural myomas (located beneath the serosal layer and (in the uterine wall).

 

Submucosal Myoma definition

Submucosal uterine leiomyomas are a form of uterine leiomyoma that predominantly extends into the endometrial cavity. They are the least prevalent form of leiomyoma, yet they are the most symptomatic.

Myomas' specific etiology is uncertain. However, some evidence suggests that leiomyomas develop from a single neoplastic stem cell of the myometrium's smooth muscle tissue. Although the specific causes of myomatous neoplasia are unknown, estrogens, progestins, and growth factors all appear to have a role in the development of fibroids.

There is growing evidence in the literature that supports a genetic component in the etiology of uterine leiomyomata, both in terms of primary origin and growth potential. The autosomal dominant hereditary illness hereditary leiomyomatosis and renal cell carcinoma is perhaps the most clinically significant condition for myomas currently recognized.

 

Epidemiology

Fibroids can cause clinical symptoms in up to 25% of cases; asymptomatic myomas have been shown to present in 20%, up to 70% of cases, according to one research. Myomas are nearly entirely seen throughout the reproductive phase, with a gradual rise beyond the fourth decade.

Unfortunately, the investigations are not appropriately stratified by pathologic site. The literature mentions a variety of risk factors for both the presence (positive family history, black race, radiation) and development (nulliparity, obesity) of fibroids. These, however, are not particular to the submucous localization and, in part, are understudied.

 

Etiology

While the actual etiology of fibroids is unknown, various risk factors have been discovered.

Age

Fibroids grow increasingly frequent as people's uteruses age, especially around the age of 30 and continuing into menopause. Fibroids often diminish after menopause.

Menopause occurring later than usual may raise the incidence of fibroids. The age at which the first menstruation occurs also influences the likelihood of fibroids. Fibroids seldom appear before a woman has had her first menstrual cycle.

Those who begin menstruation before the age of 10 appear to be at a higher risk of getting fibroids later in life. A first menstrual cycle after the age of 16 has been linked to a lower risk.

 

Family History

A person with a uterus who has another family member or members who have had fibroids is more likely to get uterine fibroids. If one of your parents had fibroids, your risk is around three times higher than the norm.

 

Ethnicity

Fibroids have a substantially greater influence on black women with uteruses than on white women with uteruses. Black individuals are up to three times more likely than white persons to have uterine fibroids, and they are more likely to experience severe symptoms and problems from fibroids.

Standard medical therapy for fibroids affects Black individuals differently than it does white people, implying that treatment strategies must be adjusted to account for this.

 

Uterine Fibroids in Black Women

While the specific source of this disparity is unknown, health inequalities associated with medical racism are virtually likely a factor.

More research on the etiology, diagnosis, and treatment of fibroids in Black women with uteruses is required. Medical procedures for uterine fibroids must be designed with these distinctions in mind in order to improve the diagnosis, prevention, and treatment of fibroids in Black individuals.

 

Hormones

The sex hormones estrogen and progesterone appear to be important in the development of uterine fibroids. This notion is backed by facts such as the fact that artificial hormones (such as those found in birth control pills) and menopause (when estrogen levels fall) are linked to fibroids decreasing.

 

Body Size/Shape

Overweight people with uteruses are more likely to develop fibroids, with those who are extremely overweight being at a larger risk than those who are less overweight.

Obesity is connected with a higher risk of uterine fibroids, according to research, however it is unclear if obesity causes fibroids or if fibroids are just more prevalent in persons who are overweight.

The participants in the study who showed the highest risk were those with higher:

• Body mass indices
• Waist-to-hip ratios
• Body fat percentages (greater than 30%)

 

Diet

The foods that persons with uteruses eat may influence their risk of fibroids. An increased prevalence of uterine fibroids has been linked to:

• A diet high in red meats (such as beef and ham)
• The consumption of alcohol
• A diet that lacks an adequate amount of fruits and vegetables
• Vitamin D deficiency
• Food additives
• Use of soybean milk
• Dairy and citrus fruits appear to decrease the risk of fibroids.

 

Parity

Parity (the number of children a person has) may influence the chance of getting fibroids. People who have had numerous births have a lower chance of getting fibroids, but nulliparity (never having given birth) may increase the risk.

 

History and Physical

Only 20–50% of all myomas cause symptoms, and the authors believe that the submucous types are over-represented in this statistics, while having the lowest incidence (5–10% of all myomas). In addition, due to diagnostic difficulties, there is inadequate evidence on the true prevalence of submucous myomas and their contribution to overall symptomatology.

In the literature, numbers ranging from 7.8 percent to 29.9 percent have been reported for this frequency. Most publications, however, do not distinguish between patients who attend their center directly or who are referred to their center by a general practitioner for abnormal uterine blood loss and secondary referrals by colleagues.

Abnormal uterine blood loss

In situations of fibroids, around 30% of women are claimed to complain about heavy menstrual cycles without further specifying the location. Myomas, on the other hand, are discovered in 40% of women who have more than 200 ml of monthly blood loss. Only in a secondary referral group were more submucous myomas discovered in a group of menorrhagic patients than in a group of metrorrhagic patients.

Although some researchers believe that bleeding difficulties in myomas are especially connected with a submucous location, others remain skeptical. In recent investigations, for example, only 40% of individuals undergoing hysterectomy for fibroids and menorrhagia had submucous myomas discovered.

Little is known about the potential link between fibroids and blood loss. Earlier investigations suggested that the bleeding was caused by ulceration of the mucosa overlaying a submucous myoma or the opposing endometrium. This occurrence, however, is rarely noticed during a hysteroscopic examination.

Other investigations have also failed to substantiate the previously proposed link between myomas and hyperplastic alterations in the endometrium. Other probable causes include uterine surface expansion and venous congestion caused by compression, which might explain how entities other than submucous myomas can induce bleeding.

 

Dysmenorrhea

Dysmenorrhea appears to be a more specific symptom related with submucous myomas. It is considered that contractions caused by the uterus's proclivity to expel an intracavitary structure are the primary cause of the present pain sensations.

There is a considerable over-representation of submucous myomas in instances with dysmenorrhea.

 

Subfertility

A submucous myoma discovered in a woman with an unsatisfied desire for childbirth is an appealing reason to address the anomaly as a probable cause of her condition. There have been reports of pregnancy rates ranging from 31% to 66% following (hysteroscopic and laparoscopic) myomectomy.

The similar paucity of evidence exists regarding the association between miscarriage rate and the existence of myomas. There is a decrease in loss following myomectomy, from 73 percent to 13 percent and 60 percent to 24 percent in retrospective investigations, however there are no prospective or randomised trials to back up these findings. Submucous myomas are more likely to induce recurrent miscarriage, however evidence for this is considerably less.

Surprisingly, the outcomes of hysteroscopic, laparoscopic, and open surgery are not significantly different. A causal link has never been established. Although 27–40% of women with numerous fibroids are regarded as infertile, in the majority of instances, other plausible explanations may be discovered. Only myomas with a submucous or intracavitary component are related with decreased procreational potential, according to a recent meta-analysis, and hysteroscopic therapy may be advantageous in these circumstances.

 

Diagnosis

• Laboratory studies

The initial assessment should include a beta-human chorionic gonadotropin test to rule out pregnancy, as well as a CBC, TSH, and prolactin level to rule out non-structural reasons .

• Radiologic studies

The gold standard for visualizing uterine fibroids is transvaginal ultrasonography. It has a sensitivity of 90 to 99 percent in detecting uterine fibroids. The use of saline-infused sonography can aid improve ultrasound sensitivity for the identification of subserosal and intramural fibromas. Fibroids have a solid, well-circumscribed, hypoechoic appearance. There is a varying degree of shadowing on ultrasonography, and calcifications or necrosis may affect the echogenicity.

Hysteroscopy is a procedure in which a physician uses a hysteroscope to examine the interior of the uterus. This imaging technique improves visibility of fibroids within the uterine cavity. During the process, this technology enables for the direct excision of intrauterine growths.

Magnetic Resonance Imaging (MRI) provides the advantage of providing a more accurate view of the quantity, size, vascular supply, and borders of the fibroids in relation to the pelvis. Nonetheless, when fibroids are suspected, it is unnecessary to do a conventional diagnostic. It has not been demonstrated to distinguish leiomyosarcoma from leiomyoma.

 

Management

When choosing on uterine fibroids treatment choices, the patient's age, presenting symptoms, and desire for fertility preservation should all be taken into account. The various treatment choices will be determined by the location and size of the fibroids. With increasing severity of symptoms, care options can be divided into three groups, beginning with monitoring and progressing to medicinal management or surgical therapy.

 

Medical Management 

Medical Management primarily revolves around decreasing the severity of bleeding and pain symptoms:

• Hormonal contraceptives: Oral contraceptive pills (OCP) and the levonorgestrel intrauterine device are included in this therapeutic category (IUD). OCPs are commonly used to treat abnormal uterine bleeding caused by symptomatic fibroids. However, there is minimal evidence of their efficacy in uterine fibroids, and bigger randomized controlled trials are required. Because of its lack of systemic effects and minimal side effect profile, the levonorgestrel IUD is presently the preferred hormonal treatment for symptomatic fibroids. When treating fibroids that deform the intrauterine cavity, extreme caution is advised since they can result in a greater risk of ejection.
• GnRH Agonist (leuprolide): This treatment works by working on the pituitary gland to reduce gonadal hormone production, hence reducing the fibroid's hormone-stimulated growth. Friedman et al. found that after 24 weeks of therapy with a GnRH agonist, uterine size decreased by 45 percent, with a recovery to pretreatment size 24 weeks later. Long-term GnRH agonist treatment has also been proven to cause statistically significant bone loss. Because of this, as well as its relatively short-term impact, the American College of Obstetricians and Gynecologists (ACOG) has suggested that it be used for no more than 6 months. When administered as a pre-surgical treatment for symptomatic fibroids, leuprolide is most successful.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Anti-inflammatories have been demonstrated to lower prostaglandin levels, which are high in women who have excessive menstrual flow and are responsible for the unpleasant cramping that occurs during menstruation. They have not been demonstrated to reduce the size of the fibroids.

Other potential medical therapies include aromatase inhibitors, and selective estrogen receptor modulators (SERM), such as raloxifene or tamoxifen. There is little evidence supporting the use of these medications in the treatment for symptomatic uterine fibroids. Tranexamic acid has been approved for the treatment of abnormal and heavy uterine bleeding but has not been approved or shown to decrease the disease burden in uterine fibroids. 

 

Surgical Therapy:

• Endometrial Ablation. In patients whose major complaint is severe or abnormal bleeding, it provides an alternative to surgery. Submucosal fibroids have a higher risk of treatment failure because they distort the uterine cavity and can hinder effective cauterization of the whole endometrium.
• Uterine Artery Embolization. For people who want to keep their fertility, this is a minimally intrusive option. This procedure works by reducing the overall blood supply to the uterus, which reduces the flow to the fibroids and reduces bleeding symptoms. 
• Myomectomy. An invasive surgical treatment for people who want to preserve their fertility. There has been no big randomized controlled research demonstrating that myomectomy improves fertility in people. Furthermore, the result is extremely reliant on the fibroid's location and size. Nonetheless, for individuals who want to avoid hysterectomy, it might be a successful therapy choice.
• MRI guided focused ultrasound surgery. This method focuses MRI and ultrasound waves on the fibroid, resulting in cauterization. As a relatively new medication, there is not yet enough clinical evidence to confirm its long-term efficacy.
• Hysterectomy. Remains the definitive treatment for fibroids.

 

Differential Diagnosis

The signs and symptoms of uterine leiomyomas are shared by many different disease processes, the majority of which are prevalent etiologies of abnormal uterine bleeding (AUB) and pelvic discomfort. The AUB mnemonic is divided into structural and non-structural reasons, which include the following:

• Polyps
• Adenomyosis
• Leiomyoma
• Cancer
• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Unclassified

Adenomyosis, in particular, has been demonstrated to coexist with uterine fibroids at a significant rate. Adenomyosis, unlike fibroids, is more oval-shaped and has unclear edges on ultrasonography. They seldom have a large-scale impact.

It is critical to understand that leiomyosarcomas can manifest similarly to leiomyomas. After surgery, one in every 340 women is diagnosed with a sarcoma in suspected fibroids. In women aged 75 to 79, the ratio rises to one in 98. Although there is no reliable way to distinguish between the two without a biopsy, a few studies have identified risk factors for sarcoma, which include but are not limited to postmenopausal status, a predominantly subserosal mass, a solitary fibroid, rapid growth, and T2-weighted signal heterogeneity on magnetic resonance imaging.

 

Prognosis

Fibroids can be a difficult diagnosis to manage for any patient who wishes to become pregnant, has limited access to healthcare, or has one of the disease's non-modifiable risk factors. While hormone and anti-inflammatory medication can help delay the spread of fibroids, the focus has been on improving outcomes through less invasive and fertility-preserving surgeries.

 

Complications

Although the specific influence of fibroids on fertility is uncertain, there is a clear link between fibroids and infertility that varies according to the location and size of the fibroid. Pritts et al. discovered that submucosal fibroids resulted in lower rates of implantation and pregnancy, as well as higher rates of spontaneous loss, due to endometrial deformation.

However, Purohit and Vigneswaran recently reported that their study found no indication that subserosal fibroids had any influence on fertility. Anemia, persistent pelvic discomfort, and sexual dysfunction are some of the other consequences.

 

Coping with disease

If you have symptomatic fibroids, talk to your doctor about treatment options because symptom relief may not be adequate. You may do the following to assist cope with fibroid symptoms while you wait for treatment:

• Apply a hot water bottle to your stomach.
• Use a low-temperature heating pad (protect your skin by putting a thin cloth between the heating pad and your skin, and never go to sleep with a heating pad turned on).
• Take a hot bath.
• Lie down and place a cushion between your knees.
• Lie on your side with your legs up to your sternum.
• Use stress-reduction and relaxation practices like yoga and meditation.
• To the best of your abilities, get at least 2.5 hours of exercise every week.
• Count the number of sanitary pads or tampons you use each day.
• If you have excessive or extended menstrual bleeding, take a multivitamin with iron on a regular basis.

 

Conclusion 

Submucosal fibroids are also the most likely to interfere with pregnancy and fertility. Heavy menstrual flow and extended periods are common in people with submucosal fibroids. Depending on the size of your fibroid and the symptoms you're having, your doctor may advise you to merely monitor it, or he or she may advise you to treat it with medication or a surgical operation. A biopsy (sample) of the fibroid may also be taken by your doctor to ensure that it is not malignant.

Patients must recognize that fibroids are a benign condition the vast majority of the time. When discussing fibroids, words like neoplasm might have a negative influence on the patient's mental health. Furthermore, fibroids can carry a substantial illness load, which manifests as in its influence on future fertility and general quality of life.

In the care of these individuals, it is critical to discuss and control modifiable risk factors. Although there are potentially perfect less invasive methods for the treatment of symptomatic fibroids, there is no evidence from large randomized controlled studies demonstrating favorable long-term effects.