Angeles University Foundation College of Nursing

Uterine Myoma

Submitted to: Mrs.Annita Viray Submitted by: Mariano,Kharen Gale P. BSN III-3

I. INTRODUCTION Uterine Fibroids are muscular tumors that grow in the wall of the uterus (womb). Another medical term for fibroids is "leiomyoma" (leye-oh-meye-OHmuh) or just "myoma". Fibroids are almost always benign (not cancerous). Fibroids can grow as a single tumor, or there can be many of them in the uterus. They can be as small as an apple seed or as big as a grapefruit. In unusual cases they can become very large. are among the most frequent entities encountered inthe practice of gynecology, occurring in 2040% of women during theirreproductive years. It is the most common pelvic neoplasm of gynecologicorigin, as well as the most frequently occurring tumor of the uterus. They are benign and account for the single largest indication for hysterectomy.Myomas range in size from seedlings to large uterine tumors. They areround, firm, benign lumps of the muscular wall of the uterus, composed of smooth muscle and connective tissue, and are rarely solitary. Usually assmall as a hen's egg, they commonly grow gradually to the size of an orangeor grapefruit. On cutting into such a tumor, its surface is seen to be glisteningwhite color, with characteristic whorl-like trabeculation so that it stands out insharp contrast to the surrounding muscularies.A diagnosis of uterine myoma is the most common indication forhysterectomy. Many surgical procedures other than hysterectomy are alsocommonly performed because of myomas. Women with symptoms like heavybleeding and pain may need surgery. If the woman is not planning to haveany more children, a hysterectomy may be recommended. This is surgery toremove the uterus. If the woman would like to become pregnant in thefuture, a myomectomy may be done instead. This is surgery to remove onlythe fibroid. The uterus is left intact. A.Current Trends Young Early Stage Ovarian Cancer Patients Can Preserve Fertility ScienceDaily (Aug. 10, 2009) A new study finds that young women withearly-stage ovarian cancer can preserve future fertility by keeping at leastone ovary or the uterus without increasing the risk of dying from the disease. The study is published in the September 15, 2009 issue of Cancer , apeer-reviewed journal of the American Cancer Society.Most cases of ovarian cancer are diagnosed at later stages and in older women. However, up to 17 percent of ovarian tumors occur in women 40 years of age or younger, many of whom have early stage disease. Surgery for ovarian cancer usually involves complete removal of the uterus(hysterectomy) and ovaries, which not only results in the loss of fertility, but also subjects young women to the long-term consequences of estrogen

deprivation.Researchers led by Jason Wright, M.D., of Columbia University Collegeof Physicians and Surgeons in New York City conducted a study to examine the safety of fertility-conserving surgery in premenopausal women with ovarian cancer. This type of surgery conserves at least one ovary or the uterus. The investigators analyzed data from women 50 years of age oryounger who were diagnosed with early stage (stage I) ovarian cancer between 1988 and 2004 and who were registered in the National Cancer Institute's Surveillance, Epidemiology and End Results database, apopulation-based cancer registry that includes approximately 26 percent of the US population. Patients who had both of their ovaries removed were compared with those who had only the cancerous ovary removed. A second analysis examined uterine conservation vs hysterectomy.For their first analysis, the researchers identified 1,186 ovarian cancer patients. While most had both ovaries removed, about one in three (36percent) had one ovary conserved. They found those in whom one ovary was saved had similar survival for up to at least five years. To examine the effect of uterine preservation, the investigators studied a total of 2,911 women. While most of the women underwent hysterectomy,about one in four (23 percent) had uterine preservation. Uterine preservation also had no effect on survival.Women who were younger, who were diagnosed in more recent years, and who resided in the eastern or western United States were more likely to undergo ovarian or uterine conservation. These results are promising for the many young women who are diagnosed with ovarian cancer each year. An estimated 21,650 women in the UnitedStates were diagnosed with the disease in 2008. "Given the potentialreproductive and nonreproductive benefits of ovarian and uterine preservation, the benefits of conservative surgical management should beconsidered in young women with ovarian cancer," the authors concluded. A Myoma is a solid tumor made of fibrous tissue, hence it is often called a 'fibroid' tumor. Myomas vary in size and number, are most often slow-growing and usually cause no symptoms. Myomas that do not produce symptoms do not need to be treated. Approximately 25% of myomas will cause symptoms and need medical treatment. Myomas may grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the most frequently diagnosed tumor of the female pelvis and the most common reason for a woman to have a hysterectomy. Although they are often referred to as tumors, they are not cancerous. The cause of myomas has not actually been determined, but most myomas develop in women during their reproductive years. Myomas do not develop before the body begins producing estrogen. Myomas tend to grow very quickly during pregnancy when the body is producing extra estrogen. Once menopause has begun, myomas generally stop growing and can begin to shrink due to the loss of estrogen. Symptoms In many cases, fibroids are asymptomatic. Symptoms may include:Heavy periods,Lengthy periods,Period pain,Spotting between periods,Painful intercourse,A sensation of

heaviness or pressure in the back, bowel and bladder,Frequent urination, and A lump or swelling in the lower abdomen.Fibroids are categorised by their location, which includes: Intramural - growing in the uterine wall. Intramural fibroids are the most common variety. Fibroids grow within the wall of the uterus. Submucosal - growing in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain. Subserosal - growing on the exterior wall of the uterus. They sometimes appear like long stalks.Fibroids can prompt the growth of Endometrial polyps in the uterine lining (endometrium). A polyp is a small protrusion that looks like a tiny ball on the end of a slim stalk. Fibroids grow on the outside of the uterus.

Endometrial polyps can also contribute to menstrual problems, such as excessive bleeding and pain.Fibroids can cause a variety of complications, including:Anemia excessive menstrual blood loss can cause anemia, a disorder characterised by the body's inability to carry sufficient oxygen in the blood. Symptoms of anaemia include breathlessness, fatigue and paleness,Urination problems - large fibroids can bulge the uterus against the bladder, causing a sensation of fullness or discomfort and the need to urinate often,Infertility - the presence of fibroids can interfere with implantation of the fertilised egg in a number of ways. For example, the egg may try to burrow into a fibroid, or fibroids close to the uterine cavity may'prop open 'the uterus, which makes

successful implantation difficult,Miscarriage and premature delivery - fibroids can reduce blood flow to the placenta, or else compete for space with the developing baby.

II.DIAGNOSIS Pelvic Examination -Clinically significant subserosal and intramural myomas can usually be diagnosed by pelvic examination based on findings of an enlarged,irregularly shaped,firm,and nontender uterus.Uterine size,as assessed by bimanual examination,correlates well with uterune size and weight at pathologic examination,even in most obese women(body mass index>30).Routine sonographic examination is not necessary when the diagnosis is almost certain.However,submucous myomas often require saline-infusion sonography,hysterectomy,or MRI for definitive diagnosis. Imaging -The optimal selection of patients for medical therapy,noninvasive procedures,or surgery depends on an accurate assessment of the size,number,and position of myomas.Imaging techniques available for confirming the diagnosis of myomas include sonography,saline-infusion sonography,hysterectomy,and MRI. Transvaginal sonography -is the most readily available and least costly technique and may be helpful for differentiating myomas from other pelvic conditions.Large myomas may be best imaged with a combination of transabdominal and transvaginal sonography.Sonographic appearance of myomas can be variable,but frequently they appear as symmetrical, well-defined, hypoechoic, and heterogenous masses.However,areas ofcalcification or hemorrhage may appear hyperechoic,and cystic degeneration may appear anechoic.Sonography may be inadequate for determining the precise number and position of myomas,although transvaginal sonography is reasonably reliable for uteri <375 ml in total volume or containing four myomas or fewer. Saline-infusion sonography -uses saline inserted into the uterine cavity to provide contrast and better define submucous myomas,polyps,endometrial hyperplasia,or carcinoma. Magnetic Resonance Imaging

-is an excellent method to evaluate the size,position,and number of uterine myomas and is the best modality for exact evaluation of submucous myoma penetration into the myometrium.The advantages of MRI include no dependence on operator techniques and the low interobserver variability in interpretation of images for submucous myomas,intramural myomas,and adenomyosis when compared with transvaginal sonography,saline-infusion sonograms,and hysteroscopy. Magnetic resonance imaging allows the evaluation of submucous,intramural,and subserosal myomas,helps define what can be expected at surgery and might help the surgeon avoid missing myomas during surgery.

III.ANATOMY AND PHYSIOLOGY

The female reproductive system The ovaries which contain eggs are situated at either side of the uterus and are connected to it by the fallopian tubes. They produce oestrogen and prgesterone, hormones that control the menstrual cycle.

Inside the female pelvis

The female reproductive organs lie in the pelvis. At the lower end of the uterus the cervix leads into the vagina. At the top end two opening lead into the fallopian tubes, which lead to the ovaries.

The uterus, referred to since Biblical times as the womb, is a very remarkable organ, capable of expanding to contain a full-grown baby and of shedding its lining up to 500 times during your life at the time of your monthly period. The resultant stresses and strains on its supporting structures during pregnancies and the repeated shedding and re-growth of its lining may lead to problems such as prolapse or heavy menstrual bleeding. This chapter describes what the normal uterus and its related structures look like and how they work, and summarises what may go wrong. When youre not pregnant, your uterus is approximately pear-sized. It has a thick muscular wall and a central cavity with a lining that is richly supplied with blood vessels. This lining is known as the endometrium and it provides nourishment for the embryo during the very early days of life. Otherwise, the lining of the uterus is shed each month, resulting in a flow of blood lasting for several days. This is known as the menstrual flow, menstruation or the monthly period. The location of the uterus within the pelvis The uterus sits centrally in the pelvis supported by strong fibrous structures called ligaments.

The uterine muscle wall expands greatly during pregnancy and strong contractions of this muscle wall during childbirth give rise to the pains of labour. You experience similar contractions on a much smaller scale during menstruation, and this is the cause of the period pain (dysmenorrhoea) which troubles so many women.

IV.PATHOPHYSIOLOGY a.Schematic Diagram

b.1.Definition of the disease -Myoms are benign,monoclonal tumors of the smooth muscle cells of the myometrium.They are composed of large amounts of extracellular matrix containing collagen,fibronectin,and proteoglycan.Collagen type I and type III are abundant,but the

collagen fibrils are formed abnormally and are in disarray,much like the collagen found in keloid formation. b.2.Predisposing/Precipitating Factors Risk Factors Although the cause is unknown, research shows there are several key risk factors for developing uterine fibroids. Age: Because fibroids are estrogen-dependent tumors, theyre most common in premenopausal women in their 30s and 40s. After menopause, when estrogen levels naturally decrease, fibroids generally shrink or disappear.6 Heredity: If a womans mother or sister has fibroids, shes at increased risk of developing them herself. In fact, a woman whose mother has fibroids has three times the risk of developing them.6 Race: Black women are more likely to have fibroids than white women. In addition, black women tend to develop fibroids at a younger age, have more or larger tumors, and develop symptoms faster and with more severity than women in other ethnic groups. Studies have suggested that eight in 10 black women will develop fibroids at some point in their lives.3 Obesity: Obese women are considered to have two to three times the risk of developing fibroids than women of average weight.6 Eating habits. Eating a lot of red meat (e.g., beef) and ham is linked with a higher risk of fibroids. Eating plenty of green vegetables seems to protect women from developing fibroids. b.3.Signs and symptoms In many cases, fibroids are asymptomatic. Symptoms may include:

Heavy bleeding (which can be heavy enough to cause anemia) or painful periods

Feeling of fullness in the pelvic area (lower stomach area) Enlargement of the lower abdomen Frequent urination

Pain during sex Lower back pain Complications during pregnancy and labor, including a six-time greater risk of cesarean section

Reproductive problems, such as infertility, which is very rare

V.MEDICAL MANAGEMENT A.Drugs - such as hormones, used in combination to shrink the fibroids prior to surgery. B.Diet WHOLE GRAINS AND FIBER

Fiber binds with excess estrogen in the digestive tract and helps remove it from the body during elimination. Eating foods high in fiber speeds up the waste process and can help remove estrogen more quickly. Whole grains are a good source of fiber and contain special anti-estrogen compounds, called lignans. Barley, buckwheat, corn, flaxseed, millet, oats, rice and wheat are especially high in antiestrogenic lignans. VITAMIN C

Foods that contain vitamin C may regulate estrogen levels in women with fibroids. According to Dr. Marilyn Glenville, an added benefit of vitamin C is that it can help reduce heavy bleeding, a common symptom associated with fibroids. Foods rich in vitamin C include cauliflower, broccoli, cranberries, summer squash, pineapple and spinach. Respectively, with 174.8mg of vitamin C per cup and 81.65mg of vitamin C per cup, red bell peppers and strawberries are a great way to load up on vitamin C. PHYTOESTROGENS

Phytoestrogens, or weak estrogens derived from plants, may reduce your body's supply of natural estrogen and help shrink fibroid tumors. Phytoestrogens help reduce the impact of estrogen in your body by

binding to your body's estrogen receptors. Foods high in phytoestrogens include soy beans, alfalfa, pinto beans and black beans. INDOLES

Indoles are enzymes that convert the strongest form of estrogen, known as estradiol, into aweaker form known as estrone. Chiropractor and acupuncturist Dr. Ben Kim says that estrogen dominance, or too much estrogen in the body, causes fibroids to grow. Foods that contain estrogen-deactivating indoles include cabbage, kale, collard greens, mustard greens, turnips and bok choy. ORGANIC

Eat organic fruits and vegetables to treat and prevent the growth of uterine fibroids. Organic fruits and vegetables are not sprayed with pesticides that contain xenoestrogens, or synthetic chemicals that produce an estrogen response in the body. According to Dr. Ben Kim, exposure to xenoestrogens is a leading cause of estrogen dominance.

Foods to avoid: RED MEAT

Red meat from mammals and duck are not recommended for those with fibroids. These foods are likely to be high in added hormones, including estrogen. Eat lean white meat for a protein source instead. HIGH-FAT DAIRY PRODUCTS Women with fibroid tumors are encouraged to limit consumption of high-fat dairy products such as whole milk, cream and butter. These products are often high in added hormones that can feed your tumors. Opt for organic hormone-free products for your dairy consumption. CAFFEINE LADEN BEVERAGES Beverages containing caffeine are on the list of foods to avoid when you have fibroids on your uterus. William E. Richardson of the Atlanta Clinic of Preventative Medicine warns against drinking these beverages due to their high level of methylanthins which, in turn, cause a high level of biochemicals in the body that can form tumors. Stay away from caffeinated sodas, tea, chocolate and coffee. According to Dr. Andrew Weil, coffee beans are often sprayed with the chemical DDT. HIGHLY SALTED FOODS Limit the amount of highly salted foods in your diet because they are hard on your liver. The liver is the organ most responsible for removing toxins and

balancing hormones. Avoid canned soup, baked beans, pretzels, chips, pickles, olives and dried foods, such as jerky. WHITE FOODS Lower the amount of "white" foods you consume. According to Healthy.net, these foods alter estrogen metabolism and can cause fibroids to grow larger. These foods include pasta, white bread, white rice, cakes and cookies. C.ACTIVITY AND EXERCISE BHARADVAJA'S TWIST

-Yoga poses to open the stomach area are associated with helping to relieve the pain of uterine fibroids and help you find more comfortable positions with fibroids. One example is Bharadvaja's Twist. To perform, sit on the floor with your legs extended in front of you. Shift your weight to your right buttocks and then fold your legs in toward your left buttocks. Inhale to sit up straighter, then twist your torso to your right side, placing your right arm behind your left, opening and stretching the stomach. Hold this position for 10 to 15 seconds, then release the stretch. SUPPORTED BRIDGE POSE

-The Supported Bridge Pose is another exercise that can relieve uterine fibroid pain. To perform, lie on the floor with your arms extended and your palms facing upward. Lift your buttocks and torso up to lift your legs and torso off the ground. Leave your shoulders on the ground with your eyes toward the ceiling. If needed, you can place a rolled-up towel between your knees to make the position more comfortable. Hold in place for 10 to 15 seconds, then release the stretch and lower the buttocks toward the ground. Repeat two to three times. CARDIOVASCULAR EXERCISE

-Cardiovascular exercise burns calories and can help you to lose weight. However, jarring, high-impact exercises can cause pain to existing fibroids, making it difficult for you to exercise. Instead, choose low-impact cardiovascular exercises like water aerobics or swimming. Walking, using an elliptical machine or cycling also burn calories and fat, helping to reduce unhealthy estrogen production. Exercise at least three to five times per day for at least 30 minutes to create a calorie deficit that helps you lose weight.

VI.SURGICAL MANAGEMENT

 Hysteroscopy - the fibroids are removed via the cervix, using a hysteroscope. Laparoscopy - or 'keyhole surgery', where a thin tube is inserted through the abdomen to remove the fibroids. Open surgery - larger fibroids need to be removed via an abdominal incision. This procedure weakens the uterine wall, and makes Caesarean sections for subsequent pregnancies more likely. Hysterectomy - the surgical removal of some, or all, of the uterus. Pregnancy is no longer possible after a hysterectomy

VII.SUMMARY Uterine fibroids (myomas or leiyomymas) are benign, monoclonal tumors of the smooth muscle cells found in the human uterus. Also called as myomas, fibromyomas or leiomyomas, Fibroids are non-cancerous tumours of the uterus that appear during your childbearing years. Fibroids can appear on the inside or outside lining of your uterus, or within its muscular wall. They usually develop from a single smooth muscle cell that continues to grow. Fibroids often cause no problems, but may occasionally be associated with infertility, miscarriage and premature labour. Other possible problems include heavy, lengthy and painful periods. Despite the fact that their cause is still unknown, yet there is considerable evidence that estrogens and progestogens proliferate tumor growth, as the fibroids rarely appear before menarche and regress after menopause. Uterine fibroids are the most common benign tumors in women and the leading indication for hysterectomies in the USA , nevertheless, epidemiological data on fibroid prevalence and incidence are limited and reliable population-based research is lacking. Available data are difficult to compare due to differences in the study population and screening methods. Treatment depends on the size, number and location of the fibroids, but may include drugs and surgery. Fibroids rarely turn cancerous.

VII.CONCLUSION Uterine fibroid is a common concern in women at fertile age causing multiple bleeding and pain symptoms which can have a negative impact on different aspects in women's life.Although the precise causes of myomas are unknown,advances have been made in the understanding of the hormonal factors,genetic factors,and molecular biology of these benign tumors. The results are consistent with available data and underline that uterine fibroids are a common concern for women in fertile age,

especially in the age group of the over 40s. Uterine fibroids can cause multiple bleeding and pain symptoms which might have a negative impact on women's life, influencing their sexual, social and work life. Despite these consequences uterine fibroid data, especially on epidemiology, symptomatology and their impact on women's health are still limited and further research is required.

VIII.RECOMMENDATION

I therefore recommend to the Student Nurses to constantly provide health teachings to the pregnant women to have their regular pre-natal visits to diagnose early if there is a occuring pregnancy complication.They must also give emphasis about the proper diet to ensure the avoidance of acquiring Uterine Myoma.These can be done in a hospital setting or in a community setting To the researchers,their contributions are a great help on todays society specially to the pregnant women that is why they must continue doing researches about new treatments and management not only for uterine myoma but also to other certain complications that is being experience by a pregnant women.

IX.REFERENCES Anatomy and Physiology Book Maternal and Child Health Nursing http://www.scribd.com/doc/47652530/UTERINE-MYOMA http://www.livestrong.com/article/285179-uterine-fibroids-diet/#ixzz2CY6mGFAa http://www.livestrong.com/article/269511-foods-to-avoid-with-fibroids-on-theuterus/#ixzz2CY6sRkQQ http://www.livestrong.com/article/261530-what-nutritional-foods-help-uterinefibroids-shrink/#ixzz2CY6yyIIl