Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

doi:10.1016/j.ejogrb.2012.01.018

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 162, Issue 1, May 2012, Pages 87-90

https://doi.org/10.1016/j.ejogrb.2012.01.018 Get rights and content

Abstract

Objective

To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas.

Study design

We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated.

Results

In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as <8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone.

Conclusions

Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.

Introduction

Endometriosis is one of the most common gynecologic diseases, and is known to affect 2–10% of reproductive-age women [1], [2]. While many patients are asymptomatic [3], endometriosis is frequently associated with infertility and pain symptoms including chronic pelvic pain, dysmenorrhea, dyspareunia, and dyschezia [3], [4], [5], [6], [7]. Pelvic examination, ultrasound, magnetic resonance imaging (MRI), and laboratory tests are utilized as non-invasive diagnostic tools with a high degree of reliability [3], [6], [7], [8], [9], but direct visualization of endometriotic implants is the mainstay for the definite diagnosis of endometriosis [3], [6], [7]. Current treatment strategies include surgery, ovarian suppression therapy, or both.

Uterine leiomyoma is also one of the most common gynecologic diseases, and is known to affect 20–50% of reproductive-age women [10], [11], [12]. Menstrual disorders (menorrhagia and dysmenorrhea), mass effects (pelvic pressure and urinary frequency), and infertility are representative symptoms associated with uterine leiomyoma [13]. Transvaginal ultrasound is commonly utilized to detect uterine leiomyoma with a high degree of sensitivity [14]. Surgery is the mainstay for the treatment of symptomatic leiomyomas, and approximately 175,000 hysterectomies and 20,000 myomectomies are performed for the management of leiomyomas in the United States each year [10], [11].

Recently the presence of uterine leiomyoma has been identified as an independent risk factor for the presence of endometriosis [1], [4], [15]. Both uterine leiomyoma and endometriosis are estrogen-dependent diseases [16], [17]. One possible mechanism of their association would be the obstruction theory: obstruction of menstrual flow caused by leiomyomas may promote reflux of menstrual flow, finally resulting in the implantation and/or transplantation of endometrial tissue according to the Sampson's theory [17]. Although endometriosis can be diagnosed during operations for leiomyomas, the rate of endometriosis in patients with leiomyomas has been poorly studied because there have been no large well-defined studies with adequate adjustment for confounding factors.

The aim of this retrospective study was to clarify the frequency of discovering endometriosis during surgery for symptomatic leiomyomas and to identify the risk factors for coexistence of these enigmatic diseases. We found that the diameter of the dominant leiomyoma is a possible factor for the prediction of coexisting endometriosis.

Section snippets

Materials and methods

Subjects who underwent surgery for symptomatic leiomyomas between January 2001 and December 2010 were included in this study and the medical records of 1133 patients were reviewed retrospectively. All the patients were confirmed to have pathologically proven leiomyomas. This study protocol was reviewed and approved by the Human Ethical Committee of The University of Tokyo Hospital.

Inclusion criteria included being of premenopausal age and having regular menstrual cycles. Exclusion criteria

Results

Of 829 patients diagnosed with leiomyomas, 105 patients were confirmed to possess both leiomyoma and endometriosis, and 724 patients were without endometriotic lesions. Of the 105 patients, 80 subjects were diagnosed with stages I–II (mild) endometriosis. The frequency of discovering endometriotic implants was not different between abdominal surgeries and laparoscopic surgeries (12.2% in 188 cases vs. 12.8% in 641 cases; P = 0.878).

The relationship between the characteristics of largest

Comment

Uterine leiomyoma is a benign gynecological disease, and the diagnosis of uterine leiomyoma can be made by transvaginal ultrasound. In general, asymptomatic leiomyomas can be followed without intervention [20], [21], since relief of symptoms is the major goal in the management of uterine leiomyoma [22]. Considering the fact that uterine leiomyoma is a significant risk factor for the presence of endometriosis [1], [4], it would be beneficial for women with leiomyoma to undergo investigation for

Conflict of interest

These authors declare no possible conflict of interest.

Acknowledgment

This study was supported by Grant-in-Aid for Scientific Research from the Ministry of Education, Science and Culture and Kanzawa Medical Research Foundation, Japan.

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We reviewed the medical records of 432 patients with TLH and 93 patients with RALH from January 1, 2015, to December 31, 2022. In this analysis, we excluded certain cases with concomitant laparoscopic cystectomy (LC) and a heavy uterus (> 400 g). First, the patient characteristics of the TLH and RALH groups, including operation time and blood loss amount, were compared. Then, among these cases, we sought to predict difficult cases for TLH and RALH by identifying risk factors related to each of the following three categories of operational complications: “long operation time”, “massive blood loss” and “other complications”. For this purpose, multivariate logistic regression analyses were performed to assess the influence of each of 7 representative factors, namely, “advanced age”, “high body mass index (BMI)”, “nulliparity”, “concomitant pelvic lymphadenectomy (PLA)”, “heavy uterus”, “abdominal adhesion”, and “large leiomyoma”.
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Citation Excerpt :
Among the 264 patients who underwent LM, we assessed the influence of the following 11 factors: 1) High BMI, defined as a body mass index (BMI) ≥ 25 (kg/m2); 2) Nulliparity, defined as no previous delivery; 3) Gynaecological surgical history; 4) Concomitant surgery, defined as concomitant LC, HM or HP, or other surgery; 5) Single leiomyoma; 6) Large leiomyoma, defined as a dominant leiomyoma with a size ≥ 8 cm, as determined by magnetic resonance imaging (MRI); 7) Abdominal adhesion/endometriosis, defined as the presence of abdominal adhesions or endometriosis that was detected by laparoscopic inspection immediately after the start of surgery; 8) Menstrual disorder, defined as hypermenorrhoea or dysmenorrhea; 9) Abdominal pressure, defined as the presence of abdominal pain, frequent urination, constipation or other symptoms; 10) Infertility; and 11) TUAL, defined as a concomitant procedure used to bind the uterine artery. The criteria for a large leiomyoma were determined based on past reports [16,17]. High BMI was defined was according to the Japanese definition of obesity, which is a BMI ≥ 25 (kg/m2) [18].
To reduce intraoperative blood loss in laparoscopic myomectomy, uterine artery occlusion or temporary uterine artery clipping have been employed. Recently, in addition to these techniques, temporary uterine artery ligation has been reported as a new method that has less invasive effects on fertility and needs no special devices to be used. This study aimed to evaluate the effect of temporary uterine artery ligation to minimize intraoperative blood loss during laparoscopic myomectomy.
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Citation Excerpt :
Our finding that myoma size did not affect prevalence of endometriosis was consistent with some [18] but not all previous studies [14,19]. In contrast to Isono et al [19], we found that subserosal dominant myomas were associated with higher risk of endometriosis, and intramural myomas with lower risk. This may be because symptoms of pain or bleeding are more likely to be caused by intramural myomas [20]; thus, in women with subserosal myomas an alternative pathologic condition may be responsible for the initial symptoms.
To investigate the prevalence of and explore risk factors for the coexistence of uterine myomas and endometriosis and to assess operative outcomes during laparoscopic myomectomy.
Retrospective cohort study (Canadian Task Force classification II-2).
Tertiary referral center in London, England.
Two hundred twelve women undergoing laparoscopic myomectomy to treat symptomatic uterine myomas.
Laparoscopic myomectomy.
Coexisting myomas and endometriosis were identified in 21.2% of patients. Endometriosis was more common in those with subfertility (44% vs 25.7%; p = .02) and less common in those with bleeding disorders (20% vs 45%; p = .003). Parity, location of myoma, and race/ethnicity affected risk of endometriosis, whereas size and number of myomas did not. Of patients with endometriosis, 42% underwent surgical treatment of endometriosis during myomectomy. Significantly more patients with endometriosis also underwent ovarian cystectomy than did those without endometriosis (15.6% vs 3%; p = .004). Operative time was similar in both groups (109.6 minutes vs 116.4 minutes; p = .83), as was estimated blood loss (271 mL vs 327 mL; p = .16).
A diagnosis of concomitant endometriosis should be considered, in particular in patients with subfertility and pain. This enables optimal preoperative counseling and consent for potential additional procedures such as treatment of endometriosis or ovarian cystectomy.
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Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

Abstract

Objective

Study design

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Comment

Conflict of interest

Acknowledgment

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Best Pract Res Clin Obstet Gynaecol

Fertil Steril

Fertil Steril

Reprod Biomed Online

Lancet

Changes in tissue inflammation, angiogenesis and apoptosis in endometriosis, adenomyosis and uterine myoma after GnRH agonist therapy

Hum Reprod

ESHRE guideline for the diagnosis and treatment of endometriosis

Hum Reprod