IJCRR

IJCRR - 4(7), April, 2012

Pages: 104-107

Date of Publication: 18-Apr-2012

STUDY OF SYMPTOMATOLOGY OF UTERINE LEIOMYOMAS WITH DEGENERATIVE CHANGES

Author: Ramesh B.H, Shashikala P

Category: Healthcare

Abstract:A clinical and pathologic study of 314 patients with uterine leiomyomas revealed no significant
relationship between the presenting symptoms and degenerative changes in the tumors. Some form of degeneration was demonstrated in 44% of specimens. Correlation of symptomatology with the type of degenerative change showed that the hyaline change was the commonest type associated with each symptom or group of symptoms; whereas the other types of degeneration occurred at random. The commonest associated pathology contributing to symptomatology includes adenomyosis (39.22%), followed by follicular cyst in 24.11% of patients and endometrial hyperplasia in 57 cases.

Keywords: Leiomyoma; degenerative changes; symptomatology.

Full Text:

INTRODUCTION
Uterine leiomyomas is the most common benign neoplasm of the female reproductive tract1,2 . Though ulterine leiomyomas are common, it is difficult to obtain much information regarding clinical and pathological aspects of it in Indian literature3 . The exact incidence is difficult to assess as most of the patients do not come to the hospital unless and until there is presence of progressive symptoms of some duration4 . Unfortunately their symptomatology continues to be variable5 . Leiomyomas can undergo various secondary changes including hyaline degeneration, cystic change, myxoid, infection, necrosis, calcification and rarely ossification6, 7 . This is a clinicopathological study of degenerative changes in leiomyomas and to correlate any specific symptoms associated with any particular type of degeneration.

MATERIAL AND METHOD This is a prospective study consisting of 314 cases of leiomyomas , which included three myomectomies collected over a period of 2 yrs at J.J.M Medical college, Davangere,Karnataka. The clinical details were extracted from the records of patients treated. All tissues were embedded in paraffin and stained with hematoxylin and eosin.

RESULTS
Of the 314 specimens studied, associated degenerative changes were seen in 136 leiomyomas (43.3%). Hyaline changes in the commonest form of degeneration were seen in 131 (41.71%) of leiomyomas. Grossly the mean size of these leiomyomas was 4.8cms.

Cystic change was seen in 3.5% of cases. Myomas with mucoid degeneration (1.91%) also result in cystic change. Fatty and Myxoid change was seen in 2 cases each (0.64%). Out of 7 patients (2.22%) with calcareous degeneration, 4 were detected grossly and 3 showed microscopic foci of calcification. Leiomyoma with haemorrhage was observed in 2 cases, which included a case of red degeneration, occurred in absence of pregnancy. Necrosis was found in 2 cases (0.64%). Leiomyoma with infection and infarction was detected microscopically in one case each (0.32%).There was no case of sarcomatous degeneration in the present study. Menorrhagia was the only representing symptom in 67 patients, but 50% of these showed no evidence of degeneration. Menorrhagia associated with abdominal mass occurred in 108 patients, and in 57.4% of these had some form of degeneration. Of the 40 patients with pain abdomen, 15 patients presented with degenerative changes, when pain associated with other symptoms degenerative change occurred in 56.3% of 110 patients. Of the 10 patients with abdominal mass, 6 patients showed degenerative changes and when the complaint of mass was associated with other symptoms, degenerative change was found in 58.3%. Mass/Vagina was the presenting compliant in 33 cases and White discharge per vagina(WDPV) in 24 cases of which 3 cases each had some form of degenerative changes.Of the 11 patients presenting with pressure symptom like Bladder disturbances and backache, 2 patients showed degenerative changes. Of the 5 patients with fever, 3 patients showed degenerative changes. Proliferative phase was found in 150 cases (48.23%) followed by secretary phase in 95 cases (30.54%), endometrial hyperplasia in 57 cases (18.34%) and atrophic in only 9 cases. Adenomyosis was associated with leiomyomas in 122 (39.22%) patients followed by follicular cyst in 75 patients (24.11%).

DISCUSSION
Degenerative changes was observed in 43.31% of leiomyomas in our study.Persaud & Arjoon (1970) found secondary changes in 65% of leiomyomas while Reddy & Malathy(1963) found secondary changes present in all leiomyomas (325 cases)4, 7 . Hyaline change (41.71%) is the commonest form of degeneration seen in leiomyomas4,7,8,9,10.The mean size of leiomyomas with hyaline change was 4.8 cms, which is in accordance with Shaw (1971), states that some degrees of hyaline degeneration present in all leiomyomas more than 4 cms diameter11 . Persaud & Arjoon4 (1970) & Reddy & Malathy (1963,)7 reported low incidence of fatty change1,6, similar to the low incidence of present study(0.64%). Reddy & Malathy (1963, 2.5%), Torpin et al (1942, 2.4%) & Persaud & Arjoon (1970, 7.0%) found low incidence of calcification in their respective studies4,7 . Cystic change in present study (3.5%) is comparable to Norris & Zaloudek (1981, 4%) & Persaud & Arjoon7,9 (1970, 4%). Myomas with mucoid degeneration (1.91%) is low,when compared to Persaud & Arjoon7 (1970) who reported higher incidence of 5.36%.Myxomatous degeneration in leiomyomas is considered to be rare,while Persaud & Arjoon (1970) reported higher incidence of 12%7 . Leiomyoma with haemorrhage was reported in 2 cases in our study, while Norris & Zaloudek (1981)9 observed in 11% of cases. Rosario pinto (1968, 1.2%), Persaud & Arjoon (1970, 3.3%) and Reddy & Malathy (1963, 2.5%) found low incidence of red degeneration without pregnancy4,7,8. Harshmohan et al (2003) reported 0.55% of incidence of ossification in leiomyomas10 . Sarcomatous change in leiomyomas is rare. Incidence of leiomyomas with this change varies from 0.04% to 0.5% in different studies done over many decades7,12 . The symptomatology continues to be variable. Many patients presented with more than one symptom13 . Menorrhagia (46.07%) was the commonest clinical symptom as noted by various studies 7, 8, 13. Menorrhagia does not occur in every case, but when the growths are deep intramural or submucous, it is a constant symptom. Increased blood loss often cause severe anaemia.Excessive bleeding may be from increased surface of the endometrium or from thickened polypoidal endometrium. Multiple intramural growths by hindering effective uterine contractions result in prolonged & profuse loss12. Dysmenorrhoea due to irregular uterine contractions12 found in 22.29% of cases. Mass per Abdomen in the present study in comparable to Rosario pinto (1968, 17.7%) studies8 .White discharge per vagina (WDPV) in our study in majority of cases was caused by excessive mucus secretion from the hyperplastic endometrium12 . Bladder disturbances (1.27%) were due to cervical fibroids or those arising from lower part of the body getting impacted into the pelvic cavity elongate & distort the urethra & displace the bladder upwards12 . Majority of patients with fatty change, calcification, cystic change, mucoid & myxoid change do not cause any symptoms and are diagnosed only after removal by operation or at postmortem12 . Red degeneration is considered to be more common in pregnancy when it may produce severe pain often accompanied by vomiting and pyrexia12. It is however difficult to give an accurate estimate of the incidence of red degeneration in pregnancy since surgical intervention is not always required and pathologic confirmation cannot therefore be obtained7 . Red degeneration in fibroid is usually associated with pregnancy though absence of pregnancy does not exclude red degeneration4 . It would thus appear that red degeneration is not as severe in the non-pregnant as in the pregnant patient7 . Adenomyosis , follicular cyst and endometrial hyperplasia were some of the commonly associated pathological lesions which may also contribute to the symptomatology3,8 .

CONCLUSION
Hyaline change was the commonest degenerative change associated with each symptom or group of symptoms ; whereas the other types of degeneration occurred at random.Associated pathology may also contribute to the symptomatology. Majority of leiomyomas being symptomless and especially when small & progress slowly. There appears to be no relationship between the presenting symptoms and the type of degeneration. Symptomatology and severity usually depend on the size and location of leiomyomas rather than degenerative changes.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in reference of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journal and books from where the literature for this article has been reviewed and discussed.

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