European Journal of Medicine and Natural Sciences
Volume 7, Issue 3, 2024 · ISSN 2601-6397 (Print) · ISSN 2601-6400 (Online)
Uterine Leiomyofibroma in the Gynecological Pathology of the Emergency County Clinical Hospital Saint Andrew the Apostle Constanta
1"‘’Ovidius’’ University of Constanta, Faculty of Medicine, County Clinical Emergency Hospital ”Sf. Ap. Andrei”, Constanta, Romania"; 2"County Clinical Emergency Hospital ”Sf. Ap. Andrei”, Constanta, Romania"; 3“Ovidius” University of Constanta, Faculty of Pharmacy, Constanta, Romania"
*tomescucezarlaurentiu@gmail.com
Submitted: 2024-08-28 · Accepted after Revision: 2024-11-28 · Published: 2024-12-28
DOI: 10.2478/ejnsm-2023-0006
Abstract
Benign pelvic-abdominal tumor formations are an important part of female pelvic pathology. Uterine fibroids occupy an important place in gynecological benign pathology, among pelvic-abdominal tumors, A retrospective study was performed for a period of 5 years (2015-2019) on a number of 1505 patients admitted to the Clinical Emergency Hospital St. Andrew the Apostle Constanta, on the two departments of Obstetrics-Gynecology OG I and OG II. The patients were followed according to the following criteria: age, origin, symptoms, and the type of surgery performed.
Keywords: Uterine Fibroid, Fractional Biopsy Curettage, Hysterectomy, Hysteroscopy, Laparoscopy, Myomectomy
Introduction
Leiomyomas are benign smooth muscle tumors originating in the myometrium (Hoffman et. al., 2015).
Incidence: 20-25 % (Cramer et. al., 1990). Currently, by using histological and ultrasound criteria, studies demonstrate their presence in approximately 70-80% of women (Day Baird et. al., 2003). Risk factors: older age, nulliparity, early menarche, overweight, polycystic ovary syndrome, and race (African- American women) (Day Baird et. al., 2003), (Wise et. al., 2007), (Ishikawaet. Al., 2009).
Protective factors: combined oral contraceptives, smoking, teenage girls, women who give birth at a young age or with increased parity, Asian or Hispanic women (Parazzini et. al., 1992), (Michnovicz et al., 1986). The European Society of Hysteroscopy divides submucosal leiomyomas into: type 0 - tumor located entirely in the uterine cavity, type I - tumor located less than 50% in the myometrium, type II - more than 50% of the tumor in the myometrium (Wamsteker et. al ., 1993).
In rare cases, the symptomatology may involve myomatous erythrocytosis syndrome which is due to the increased secretion of renin by the fibromatous nodule or pseudo-Meigs syndrome, manifested by ascites and even hydrothorax. Both pathologies remit after hysterectomy (Vlasveld et. al., 2008), (Yokoyama et. al., 2003).
The diagnosis of uterine fibroids is clinical and paraclinical through abdominal or transvaginal ultrasound, ultrasonography and hysterosalpingography, hysteroscopy and Nuclear Magnetic Resonance (De Kroon et. al., 2004), (Fleischer et. al., 2003). Currently, in the case of asymptomatic leiomyomas, the main option is their monitoring (Stovall et. al., 1994). Since most leiomyomas develop during menopause, drug treatment is recommended to improve symptoms until the onset of menopause (Hoffman et. al., 2015).
Figure 2. Subtotal histerectomy for a giant myoma developed in the cervix [Personal Collection]
Figure 2. Giant myoma developed in the cervix [Personal Collection]
Drug therapy includes, non- steroidal anti-inflammatory drugs (NSAIDs), androgenic therapy, Gn-Rh agonists, Gn- Rh antagonists, combined oral contraceptives, progestogens, and antiprogesterones (Hoffman et. al., 2015). In the treatment of symptomatic leiomyomas, uterine artery embolization and focused ultrasound therapy under Magnetic Resonance Imaging guidance (MRgFUS) can be performed. The surgical treatment of leiomyomas consists in hysterectomy, which may be performed laparoscopically, abdominally, or vaginally. For patients who wish to preserve fertility a myomectomy can be performed (Whiteman et. al., 2008).
Other possibilities of treatment are laparoscopic or hysteroscopic myomectomy, endometrial ablation, laser vaporization or cryotherapy (Agdi et. al., 2008), (Levy et. al., 2008).
Experimental methods that produce occlusion of the uterine artery or in the application of temporary clips to the level of the uterine arteries have also been used with important success (Hald et. al., 2009), (Holub et. al., 2008), (Vilos et. al., 2010), (Sharp, 2006).
Material and Method
The present study was aimed to analyze the incidence of uterine leiomyofibroma in the County Emergency Clinical Hospital "Sfântul Apostol Andrei" Constanța within the Obstetrics-Gynecology I and II departments.
The study was a retrospective one, over a period of 5 years, between 01.01.2015 and 31.12.2019, and the data were collected from the observation sheets and from the operative protocols of the two departments. Between 01.01.2015 and 31.12.2019, a total number of 10,602 patients were admitted to the Obstetrics-Gynecology I and Obstetrics-Gynecology II departments. The total number of patients included in the study was 1505, all of whom presented to the hospital for symptoms mainly related to the symptoms of uterine leiomyoma.
The incidence of uterine leiomyoma in the period presented was 14.19% of all hospitalizations in the two departments of Obstetrics-Gynecology. Out of 10602 patients, 1505 were diagnosed with uterine leiomyoma.
A) Distribution of the Studied Group by Age Groups
The studied over the five years was classified into age groups between 20 and 60 years old.
Table 1. Distribution of the studied group by age
| Age | Number of Patients | Incidence | |
| 20-29 | 5 | 0,33% | |
| 30-39 | 211 | 14% | |
| 40-49 | 957 | 63,58% | |
| 50-59 | 270 | 17,94% | |
| >60 | 62 | 4,11% | |
| Total | 1505 | 100% | |
Graphic 1. Distribution of the studied group by age
It can be seen from the graphic analysis above that the highest incidence of symptoms related to uterine leiomyoma is in the 40-49 age group, most of the time, in this age period overlapping both the associated symptoms leiomyoma and that associated with perimenopause.
B) Distribution of the Studied Batch by Provenance Environment
The studied batch of patients was divided into rural and urban environments.
Table 2. Distribution of the studied group by provenance environment
| Frequency | Procent | |||
| Rural | 390 | 26% | ||
| Urban | 1115 | 74% | ||
| Total | 1505 | 100% | ||
Both from the table 2 above and from the graphic 2 representation, a higher incidence of leiomyofibroma can be observed in the urban population. Urban population incidence is 74%, compared to the rural population, which is only 26% of cases.
Graphic 2. Distribution of the studied group by provenance environment
These results can be explained by the low parity in the urban environment compared to the one in the rural environment and also by the low addressability of rural women to the gynecologist compared to urban women.
C) Distribution According to Symptoms
The most common reason women presented to the Emergency Department was vaginal bleeding.
Table 3. Distribution of the studied group by symptoms
| Main Symptom | Number | Incidence |
| Menometrorrhagia | 1131 | 75,14% |
| Compression | 232 | 15,41% |
| Septic Necrobiotic | 92 | 6,11% |
| Sterility/ Infertility | 50 | 3,32% |
| Total | 1505 | 100% |
Graphic 3. Distribution of the studied group by symptoms
About 75% of women with leiomyoma experienced abnormal bleeding, followed by those with abdominal symptoms related to compression of surrounding organs, which accounted for 15%. Bleeding can occur both in the context of leiomyoma and because of perimenopause but most of the time the two overlap. Bleeding is often profuse and can lead to severe anemia.
D) Distribution of the Studied Batch According to the Type of Surgical Intervention Performed
After we analyzed the observation sheets and operative protocols, we found that of the 1505 patients hospitalized with the diagnosis of leiomyofibroma, during the years 2015-2019, 528 of them underwent surgical intervention and 802 benefited by a hemostatic uterine curettage and biopsy. Among the 528 patients that had surgical intervention, 361 underwent radical intervention (total hysterectomy) via the abdominal route and 62 via the laparoscopic route. Subtotal hysterectomies by the abdominal way were performed to 41 patients and 2 subtotal hysterectomies using the laparoscopy. There were also 17 vaginal hysterectomies and 45 uterus-conserving interventions- myomectomies.
Table 4. Distribution of the studied group by intervention type
| Medical Treatment | Surgical Intervention 528 (35.08%) | Curettage with biopsy | ||||||
| Laparoscopy | Abdominal intervention | |||||||
| Total HT | Subtotal HT | Miomectomy | Total HT | SubtotalHT | Miomectomy | Vaginal HT | ||
| 175 (11,62%) | 62 11.74% | 2 0.13% | 15 2,84% | 361 68.37% | 41 7,76% | 30 5,68% | 17 3.21% | 802 (53,28%) |
Graphic 4. Distribution of the studied group by intervention type
Discussions
Benign uterine pathology occupies a very well-defined place in gynecological practice, given its increasing incidence. The incidence of uterine leiomyoma in the Emergency County Clinical Hospital "Saint Andrew the Apostle" Constanta was 14.19%.
Out of 10602 patients, 1505 were diagnosed with uterine leiomyoma. In terms of age, most of the patients in the studied group belong to the 40-49 years old category, which represents a percentage of 63.58%, followed by the patients located in the 50-59 years old age category with a percentage of 17.94%. Specialized studies have shown a maximum incidence in the 45-50 age group (Marshall et. al., 1997), (Wise et. al., 2016).
The patients from the studied group who came from the urban environment were more numerous, respectively, 1115 patients, which represents 74% of all patients, from this fact a better medical education and a greater addressability to the gynecologist emerges. Data collected from the literature also demonstrated the same increased prevalence of patients from the urban environment, compared to the patients from the rural environment (Wise et. al., 2016), (Parazzini et. al., 1988).
The most common reason for presenting to the emergency room was represented by abnormal vaginal bleeding. That beeinf said, 75.14% of the patients of the studied group presented to the emergency department for appreciable vaginal bleeding, which decreases the quality of life with severe anemia and urgent need for transfusion. Studies have also shown vaginal bleeding as the main reason for presentation to the Emergency Department (Wegienka et. al., 2003), (Schwartz et. al., 2000).
Conclusions
Preferred surgical intervention in the Emergency Clinical Hospital " Saint Andrew the Apostle " Constanta was total abdominal hysterectomy 361, with a percentage of 68.37% of all surgical interventions, followed by laparoscopic hysterectomy 62 cases, with a percentage of 11.74% and 41 cases of subtotal hysterectomy by abdominal way, respectively 7.76%% of all cases.
For patients with special obstetric conditions, especially nulliparous patients, conservative therapy was chosen, 45 cases benefiting of a myomectomy, performed laparoscopically or abdominally, which amounts to 8.52% of all interventions surgeries performed.
However, the Cochrane Meta-analyses demonstrated a better post-operative recovery in the case of patients who opted for laparoscopic intervention, followed by vaginal interventions and, as a last resort, abdominal hysterectomy was reserved for private cases (Nieboer et. al., 2009).
Unfortunately, laparoscopic interventions require qualified personnel and expensive equipment, which are not easily found in all hospital units in the Romanian health system.
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© 2024 The Author(s). Published by Mentisia under CC BY-NC-SA 4.0.