Uterine fibroids watery discharge

Fibroids are common in women in their 20’s and 30’s and sometimes even into their 40’s. In fact, fibroids affect more than 30% of women of reproductive age, and women of African origin are much more prone to having them than are Caucasians; the reason is unknown but they are 3-9 times more common in black women.

WHAT ARE FIBROIDS?

Fibroid is the common term that is used for what is really a MYOMA of the uterus or womb. In fact, it is more properly called a leiomyoma, but fibroid is easier and shorter, so it’s o.k. if you continue to call it that. They are masses affecting the womb in various locations and are made up of smooth muscle and, to a lesser extent, fibrous connective tissue.

While they can occur as isolated microscopic growths, they are more commonly multiple and may reach enormous proportions, weighing more than 100 pounds. So quite often when women have large waistlines, and think it’s just fat, on occasion it may be a fibroid or fibroids. I have seen them the size of watermelons in women’s abdomens. They become malignant ( cancerous) less than 0.5% of the time, or, put another way, less than 0.5% of fibroids become cancerous.

Fibroids are thought to grow under the influence of estrogen, the main female hormone, although they are not known to actually cause them. The evidence for the other female hormone, progesterone, is less convincing. This is why fibroids tend to grow in pregnancy; because more estrogen is around to maintain the pregnancy. And it’s also why they tend to decrease in size or even disappear after menopause.

TYPES OF FIBROIDS

Fibroids are classified by their location, which affects the symptoms they may cause and how they can be treated. Those that are inside the cavity of the uterus will usually cause bleeding between periods (metrorrhagia) and often cause sever cramping. These are intracavitary. Submucous myomas (fibroids, leiomyomata) are partially in the wall of the uterus. They too cause heavy menstrual periods (menorrhagia) as well as metrorrhagia (above).

Intramural ones are in the wall of the womb. They may range in size from microscopic to larger than a grapefruit. Many cause no problems except when they become quite large. There are a number of alternatives for treating these, but often they require no treatment at all. Subserous fibroids are on the outside wall of the uterus, and may even be connected to it by a stalk (pedunculated myoma). These do not need treatment unless they grow large, but those on a stalk can twist and cause pain. This type is easiest to remove by laparoscopy (cute, fancy surgery where you get one, or at most, two small cuts).

SYMPTOMS OF FIBROIDS

A fibroid does not necessarily produce symptoms, and even large ones may go undetected by the patient, especially if she is obese. As we’ve just said, symptoms depend on their locations; but also their size, and whether or not the patient is pregnant. In any event, 35-50% of patients with fibroids will have symptoms which include:

1) Abnormal endometrial bleeding (the endometrium is the lining of the womb). This is the most important manifestation of fibroids and is present in about 30% of patients, particularly those with the intracavitary or submucous varieties. Commonly, remember, there will be prolonged heavy menses, but a woman may display any variant from the entire spectrum of abnormal bleeding. Premenstrual spotting is common, as is prolonged staining following menses. Remember that some fibroids will cause metrorrhagia, bleeding between periods.

2) Pain. This is uncommon with fibroids, per se, but may result from degeneration within a tumor (fibroid) after circulatory occlusion from degeneration or infection, torsion or a pedunculated fibroid, or uterine contractions to expel a subserous fibroid from the womb cavity. Large fibroids may produce a sensation of heaviness in the pelvic area or what may be described as the ‘bearing-down’ feeling. Some may press on nerves and cause pain in the back and lower limbs. Pain from torsion of a pedunculated fibroid can be excruciating and may appear to be a severe surgical abdominal problem.

3) Pressure effects. Some fibroids may distort or obstruct other organs. Again, depending on type or location, one may get a watery- bloody vaginal discharge, vaginal bleeding, pain during sex, and infertility. Sometimes the bladder or rectum or the tubes from the kidney to the bladder may be displaced. In this case, urine gets backed up. One may get constipation, retention of urine, swelling of the legs or ankles, incontinence of urine and other unpleasant symptoms.

4) Infertility. Fibroids are the sole cause of infertility in only 2-10% of patients. I would say this is a high enough number, though.

5) Spontaneous abortion. The incidence of this is probably 2-3 times in women with fibroids as opposed to pregnant women without fibroids.

DIAGNOSIS OF FIBROIDS

Fibroids may be felt during a pelvic exam, but may often be missed, even when causing symptoms, if the examiner relies only on this. Also, other conditions such as adenomyosis – don’t bother your head for the time being – or ovarian cysts may be mistaken for fibroids. This is why it is wise to do an ultra sound scan. Whether by the skin or vaginally, it only takes a few minutes, and can also rule out a pregnancy if one is not previously otherwise sure there is one.

X-rays are done sometimes if symptoms suggest there is compression, distortion, or displacement of other organs. Fibroids may appear as soft tissue masses or, if calcification occurs, then the study would have been very useful. Other studies such as hysteroscopy or hysterography can be done as well. Of course, these will be done by your gynecologist.

FIBROIDS AND PREGNANCY

Removal of fibroids can result in as much as a 40% incidence of pregnancy occurring in someone who had been previously infertile.

In the second and third trimesters, fibroids may cause pain and localized tenderness. Remember that they will grow in pregnancy.

During labor, fibroids may cause the uterus not to contract, may cause abnormal presentation of the fetus, or obstruction of the birth canal. Some fibroids may allow a relatively normal vaginal delivery, others, of course, may require a caesarian section, to be performed. After delivery, they may interfere with effective contraction of the womb, so hemorrhage must therefore be anticipated.

TREATMENT OF FIBROIDS

Remember that most fibroids do not cause symptoms and don’t require treatment. They do, however, in the following circumstances.

A) Fibroids are causing pressure on other organs, such as the bladder.
B) Fibroids are growing rapidly.
C) Fibroids are causing abnormal bleeding.
D) Fibroids are causing fertility problems.

TREATMENT WITH MEDICINES

None are currently available that will permanently shrink fibroids. Often heavy bleeding can be controlled with birth control pills. A family of drugs called GNRH agonists will decrease the estrogen which fibroids need to grow, but this will induce menopause and the effect is temporary anyway because the fibroids rapidly grow back once the medication is discontinued, because it can only be used for about three months.

RU-486, the “French abortion pill” decreases their size and stops abnormal bleeding.

SURGICAL TREATMENT

I will merely mention the procedures for the different types of fibroids that are recommended by experts.

(Intracavitary fibroids)
Hysteroscopy will usually take care of these.

(Submucous)
Hysteroscopy as well. Sometimes, what we call endometrial ablation may be done at the same time.

(Intramural and Pedunculated fibroids)
Three types of procedures are essentially done for these: remove them, destroy them, or remove the uterus (hysterectomy). All of the surgical options available are variations on one of these themes.

HYSTERECTOMY

This is the only one with a guarantee: no more bleeding, and no regrowth of fibroids. And no cancer of the womb later either. But consider whether your fibroids are symptomatic and how close you are to menopause. There are advantages, but there are disadvantages too. ALWAYS DISCUSS AT LENGTH WITH YOUR GYNECOLOGIST.

REMOVAL OF THE FIBROIBS

This is called myomectomy. Usually, a couple of nights in hospital, a few weeks, and you’re back to work.

DESTRUCTION OF THE FIBROIDS

Myolysis is done through a laparoscope. A laser fiber or electrical device is placed into the fibroid and the fibroid or blood vessels feeding it, are coagulated. Cool, huh!

UTERINE ARTERY EMBOLIZATION

This is relatively new. A small catheter is placed in an artery in the groin and directed to the blood supply of the fibroid. The arteries are blocked by injecting little plugs; essentially we’re cutting off the fibroid’s blood supply and shrinking it.

Fibroid is a word on almost every woman’s tongue. It’s almost as if everyone expects to get a fibroid. Many will, but don’t worry; your gynecologist can handle it. Talk to him and discuss your options.

See you next week.

PMC

Case presentation

A 46-year-old woman presented to the emergency gynaecology unit (EGU) at the Royal Free Hospital with a two week history of worsening lower abdominal pain and profuse, offensive smelling vaginal discharge. She described the pain as constant but with frequent exacerbations.

Three weeks before this presentation to the EGU, the patient underwent a uterine artery embolisation. This was a relatively uneventful procedure with no immediate complications. Access had been gained through the right common femoral artery, and both uterine arteries were selectively cannulated and embolised with less than three bottles of PVA.

In terms of her medical history, the woman was nulliparous and generally fit and well. In June 2010, following an abnormal smear result she had a cone biopsy of the cervix – which showed Grade III cervical intraepithelial neoplasia (CIN3). Follow-up smear results had been normal. Over the preceding months, she had developed worsening heavy menstrual bleeding and had become mildly anaemic. She had been seen in the gynaecology outpatients department where it was felt a Mirena coil might be helpful. However, on examination it was felt she had a bulky uterus, and therefore an MRI was requested. This study showed an intramural fibroid, measuring 8.9×9.7×8.4 cm, displacing the endometrial canal and impinging on the posterior aspect of her bladder. The patient was keen to avoid a hysterectomy and therefore opted for the embolisation procedure.

On examination in the EGU 3 weeks after her embolisation, the patient looked slightly flushed but was apyrexial, her heart rate was 82 and her blood pressure was 126/79. On examination of the abdomen her uterus felt bulky, at around 14-weeks size, with mild lower abdominal tenderness. Speculum examination showed a normal looking cervix, and profuse yellowish, offensive smelling discharge. Swabs showed scanty epithelial and pus cells. An ultrasound showed an intramural subserous fibroid measuring 9.3×7.5×10.4 cm. Her blood results showed a raised white cell count 16.49 with a neutrophilia, and a haemoglobin of 10.3. Her C reactive protein was 64. She was discharged with a course of cefuroxime and metronidazole and asked to return for follow-up in outpatients.

One week afterwards, she re-presented to the EGU complaining of a mass coming down into her vagina, associated with difficulty passing urine, and worsening, more profuse vaginal discharge. On examination pale, necrotic looking tissue was visible protruding 2–3 cm outside of the introitus. There was thick prurulent discharge.

An ultrasound showed that the uterine fibroid, now measuring 6.8 cm, had prolapsed in its entirety through the cervix. The uterus was normally orientated, with no evidence of inversion.

84 Possible Causes for Clear Vaginal Discharge, Uterine Fibroid

  • Vaginal Adenosis

    fibroids , vaginal adenosis , vaginal cancer 4 Comments ” hematoma Old vaginal laceration Vaginal cyst Vaginal discharge Vaginal hematoma Vaginal irritation Vaginal mass Clinical Information A clear or white discharge from the vagina Fibroids GYN Genetics Hysterectomy Stories Ask A Doctor Find a Surgeon Ted Lee, M.D.

  • Adenocarcinoma of the Ovary

    cyst Ovarian torsion Pedunculated uterine fibroid Pelvic kidney Tubo-ovarian abscess LABORATORY TESTING Because the history and examination are often non-specific for ovarian Vaginal bleeding that is heavy or irregular, especially after menopause. Vaginal discharge that is clear, white, or colored with blood. A lump in the pelvic area. fibroids, menstruation, ovarian cysts, systemic lupus erythematosus, liver disease, inflammatory bowel disease, pelvic inflammatory disease, and leiomyoma. HE4 is

  • Ruptured Ovarian Cyst

    My ultrasound showed multiple uterine fibroids (no news there!), a couple of ovarian cysts on my left ovary and a lot of fluid around the right ovary. If you have a ruptured cyst without any bleeding (clear fluid), you will experience a clear and white discharge. fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications.

  • Endometrial Adenocarcinoma

    sarcoma are similar to those of fibroids. bleeding or discharge not related to menstruation, most commonly postmenopausal bleeding Thin white or clear vaginal discharge after menopause Extremely long, heavy or frequent Fibroids (also called uterine myomas) are very common benign tumors of the muscle of the uterus (myometrium). Fibroids are not cancerous.

  • Placenta Previa

    Certain conditions may increase your risk of developing placenta previa, including: Previous surgeries involving the uterus, such as a C-section, surgery to remove uterine Bedrest, reduced activity, and avoidance of intercourse are commonly mandated, though there is no clear benefit. If the vaginal bleeding subsides for more than 48 Risk factors Placenta previa is more common among women who: Have had a baby Have scars on the uterus, such as from previous surgery, including cesarean deliveries, uterine

  • Dyspareunia

    METHODS: We used data from the Uterine Fibroid Study (enrollment 1996-1999 in a U.S. metropolitan area). reasons for pain including lesions, thin skin, ulcerations or discharge associated with vulvovaginal infections or vaginal atrophy. The preoperative diagnosis was uterine fibroid, but the exact location of the leiomyoma was uncertain.

  • Pelvic Congestion Syndrome

    May mimic gynecologic problems in females: Endometriosis, uterine fibroids, ectopic pregnancy. It is often accompanied by low back pain, aches in the legs, and abnormal vaginal bleeding. Some women occasionally have a clear or watery discharge from the vagina. The symptoms of Pelvic Congestion Syndrome can feel similar to the symptoms of endometriosis, uterine fibroids, or even uterine prolapse.

  • Pelvic Pain

    What Are Uterine Fibroids? Symptoms, Treatment, Pictures What are uterine fibroids? Who gets uterine fibroids, and how can you prevent them? or white vaginal discharge (which may precede bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia) Rarely, a palpable Uterine Fibroids Fibroids are tumors that grow in the uterine wall that are almost never cancerous (benign tumors or growths).

  • Fallopian Tube Obstruction

    This test may help to determine issues such as uterine fibroids inside the uterine cavity. Although some women experience symptoms such as severe lower abdominal pain and unusual vaginal discharge, most women do not experience symptoms. Factors that may cause blockage in your Fallopian tubes are: Endometriosis Uterine Fibroids Ectopic pregnancy Pelvic Inflammatory Disease (PID) Tubal Ligation Removal Lower

  • Fibroids

    Symptoms Of Fibroids

    Many women have no symptoms to indicate that they have fibroids, and will find out they have them only when a medical pratitioner feels an irregularly large and rubbery uterus during a uterine size check or pelvic examination. Knowing the size and position of the fibroids will help keep track of their growth. Any number of women commonly live their entire lives with fibroids in their uteruses, bear children, and experience minimal inconvenience. Women who are aware of having fibroids tell us that their most bothersome problem is being misdiagnosed during pregnancy, being often told by physicians they are further along than they actually are. With the advent of sonogram (or ultrasound), this is less common than it used to be because fibroids can be seen on a sonogram.

    Starting within the uterine wall, a woman can have many fibroids at the same time. They often move to the lining of the cavity (myometrium), or to the outer surface of the uterus. They sometimes grow out from the uterus on a stalk, and, if the stalk twists, the blood supply can be cut off, causing pain or vaginal discharge. Women often have an increase in the growth of the endometrium, and this results in longer, heavier, clottier and sometimes more painful periods. They can also cause very heavy uterine bleeding and discharge. Some women also suffer repeated miscarriages, because the fibroids fill the cavity and irritate the uterine lining.

    Causes Of Fibroids

    Fibroid growth is believed to be stimulated by hormones. Most physicians believe that they are stimulated in particular by estrogen. When a woman is having menstrual periods, they can grow a little larger each cycle. Birth control pills can also accelerate their growth, and during pregnancy, hormone levels are higher and the fibroids grow faster. With menopause, fibroids often shrink and even disappear. Physicians assume that when a woman stops ovulating, she no longer produces estrogen. However, even though estrogen continues to be produced throughout our lives, whether or not an egg is released each month, the absence of the corpus luteum (a progesterone-producing gland which develops from a ruptured egg sac) after menopause would result in lower progesterone levels. It therefore seems more plausible that if any hormone is related to fibroid growth, it is progesterone.

    Uterine Fibroids

    What are uterine fibroids?

    Uterine fibroids are benign growths that are made up of the muscle and connective tissue from the wall of the uterus (womb). Fibroids may grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm (8 inches) in diameter. They may grow within the wall of the uterus or they may project into the interior cavity or toward the outer surface of the uterus. In rare cases, they may grow on stems projecting from the surface of the uterus. Each patient with fibroids may have varying symptoms, sizes, number, and location. Each fibroid is unique and one of a kind, which requires individualization of therapeutic options.

    Are fibroids cancer?

    It is extremely rare for a fibroid to undergo malignant or cancerous changes. In fact, one out of 350 women with fibroids will develop malignancy. There is no test that is 100% predictive in detecting rare fibroid related cancers. However, patients who have rapid growth of uterine fibroids, or fibroids that grow during menopause, should be evaluated immediately.

    Who is at risk for uterine fibroids?

    Risk factors for uterine fibroids include obesity, family history, not having children, early onset of menstruation, and late age for menopause. (A person is considered obese if he or she is more than 20% over his or her ideal body weight.)

    What causes uterine fibroids?

    The causes of fibroids are not known. Most fibroids occur in women of reproductive age, and according to some estimates, they are diagnosed in black women 2-3 times more frequently than in white women. They seldom are seen in young women who have not begun to menstruate. The symptoms of uterine fibroids usually stabilize or go away in women after menopause.

    According to the U.S. National Institutes of Health (NIH), 25%-80% of women suffer from uterine fibroids.

    What are the symptoms of uterine fibroids?

    Most fibroids do not cause any symptoms and do not require treatment other than regular observation by a doctor. Fibroids may be discovered during routine gynecologic examinations or during prenatal care. Some women who have uterine fibroids may have the following symptoms:

    • Excessive or painful bleeding during menstruation
    • Bleeding between periods.
    • A feeling of fullness in the lower abdomen
    • Frequent urination resulting from a fibroid that compresses the bladder
    • Pain during sexual intercourse
    • Low back pain
    • Constipation
    • Chronic vaginal discharge
    • Inability to urinate
    • Severe menstrual cramps
    • Infertility

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    Spontaneous Vaginal Expulsion of the Uterine Myomas – Vaginal Expulsion of Myomas

    Keywords

    Abdominal pain; Myoma; Uterus; Vaginal discharge; Pyomyoma

    Introduction

    Myomas are benign tumors of the reproductive organ that originate in the smooth muscles of the uterine wall. The incidence is approximately 40% of Caucasian women by age 35 and almost 70% by age 50 . Although histopathologically benign, myomas are associated with increased morbidity due to abdominal pain, metrorrhagia, adjacent organ pressure or infertility .

    Because of many complications caused by myomas it seems necessary to remove them when they give symptoms. Major modalities of the treatment include pharmacotherapy, embolisation and surgery. Very interesting, but still unknown way of removing myomas from the uterine cavity is their total vaginal expulsion. Till now, there are only few articles available which present cases of sloughing off myomas.

    However, in all cases causative factor is presented . By this study authors want to document an extremely rare case of a young woman with a spontaneous vaginal expulsion of the myomas.

    Case Report

    A 22-year-old woman was admitted to our department because of an intense, prolonged menstrual bleeding, lower abdominal pain lasting 3 weeks, anemia and low- grade fever. The patient had no history of chronic diseases, however during her last 4 menstrual cycles she was complaining of heavy menstrual bleeding with clots.

    She had never taken any medicaments, had never used contraception and was not sexually active. Pregnancy test was negative. She had never had any surgeries. Clinical examination during the admission revealed the enlarged uterus, a little bit painful during the palpation and mild bleeding from the vagina.

    The blood tests showed the mild anemia (9.3 g/dl) and the increase of C-reactive protein level (10.31 mg/l) with the normal white blood cell count (8.4 × 10-3/uL) – ciprofloxacin with metronidazole were administered to limit the infection and oral iron therapy to compensate anemia.

    The tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, cancer antigen 125) were negative. An ultrasound revealed a big uterus (110 × 120 mm) with two heterogenous masses – intramuscular (92 × 100 mm) and supracervical (diameter 37 mm), which could suggest myomas (Figure 1).

    Figure 1: Pelvic sonograms (A) A big heterogenous myoma in the body of the uterus (arrow), (B) The enlarged uterus with two heterogenous masses – intramuscular (white arrow) and supracervical (black arrow), (C) Supracervical myoma with the diameter approximately 3 cm (arrow), (D) Opened cervical canal (arrow).

    Because of the diagnosis uterine myomas, long lasting pain and bleeding the surgery was arranged to remove myomas. However, few days after a purple-grey, flaccid, stinking tissue, which did not resemble a myoma, were excreted from the vagina, which postponed the planned surgery to broaden diagnosis.

    The tissues were crumbling, floppy, supple, without any pedicle and were forwarded to the histopathological examination. The vaginal swab was taken that day. Subsequently during the next few days multiple, spontaneous expulsions of necrotic, flabby, stinking tissue were observed. The volume of expelled, crumbling tissues was different every day, from several to several dozen cubic millimeters. The ultrasound scanning done two weeks after admission showed respectively disappearance of the small supracervical myoma and the size reduction of the intramuscular myoma. Four weeks from the admission the dimensions of the intramuscular myoma were reduced to 75 × 70 mm. Although the vaginal tissue did not resemble macroscopically a myoma (especially the prolapsed myoma) the histopathological image of the specimens confirmed the myoma’s tissue with purulent effusion and multiple colonies of bacteria (Figure 2).

    Figure 2: Hematoxylin and eosin-stained section of the leiomyoma shows, (A) necrosis in the leiomyoma without malignant change, (B) gangrenous necrosis with bacteria, (C) necrosis and purulent infiltration.

    After the breeding of bacteria also the microbiological cultures from the vagina were positive for Escherichia coli and a broad-spectrum antibiotic (cefuroxim) according to antibiogram was administered to treat the infection. Despite of the visible reduction of the myoma’s size the patient was still symptomatic with persistent abnormal vaginal discharge, continuous bleeding and abdominal pain. When the hemoglobin level was 7.8 g/dl the patient received transfusion of a group-specific blood. Although the patient was histopathologically diagnosed with myomas, the symptomatology was still unclear and continuous, abnormal vaginal discharge which did not approximate to prolapsed uterine myoma (crumbling tissues) was observed. A magnetic resonance imaging (MRI) was done to complete pre-operative diagnosis. It showed the myoma (42 × 43 × 47 mm) in the anterior wall of the uterus protruding into its cavity (Figure 3).

    Figure 3: Correlative MRI scans one month after admission to the hospital. Myoma (arrows) inside the uterine cavity. Magnetic resonance T2 weighted images in sagittal (A) and transverse (B) cross sections.

    After a contrast injection the signal of the uterus was strengthened and the myoma was with low signal. Based on the clinical presentation, imaging examinations and the histopathological results the diagnosis of a self-expulsion of the intrauterus myomas was finally made. To accelerate expulsion of the myoma methyloergometrin was administered additionally to applied treatment. The surgery was once more postponed.

    After 7 weeks of observation with the above-mentioned treatment, the vaginal discharge, bleeding and abdominal pain were absent, the temperature and C-reactive protein level normalized. The ultrasound showed only small intramuscular myoma (28 mm), no surgery was needed.

    The follow-up ultrasound after 4 months was unremarkable with no pathological lesions in the uterus.

    Discussion

    A spontaneous vaginal expulsion of the uterine myomas is an extraordinary phenomenon, especially considering young women. The cause of self-expulsion is not well-known. One of the theories suggests that ischemia followed by necrosis of a myoma is a principal cause of the dead tissue expulsion. However, necrosis generally occurs in postmnopausal women because of systemic vascular insufficiency. Other reasons of necrosis with vaginal expulsion might be connected with drugs administration, intra uterine device, abortion, cesarean section or uterine artery embolization. Our patient denied all these factors, so probably immunodeficiency should be considered, as the reason of expulsion .

    The beginning of the removal process is non-characteristic as well as symptoms presented by patients. Mostly abdominal pain, fever, vaginal bleeding and elevated inflammatory markers are present. All these symptoms may suggest both benign or malignant process of the abdominal cavity. Among others, gynecologic tumors, tubo-ovarian abscess, septic abortion, pyometra, sarcoma or even gastrointestinal stromal tumor and mucocele of the appendix should be considered . Firstly, the differentiation between pedunculated submucosal myoma should be considered. Although some women with prolapsed uterine fibroid are symptomless, in most cases vaginal bleeding, discharge, or pelvic pain are present, as in our patient. All prolapsed myomas require surgical intervention. It might be vaginal or abdominal myomectomy because pedunculated fibroids dilate the cervix and can stuck there or in the vagina. . In contrast with pedunculated submucosal myomas, removal of myomas by self-expulsion is totally different, long lasting process, because tissues of myoma are excreted in small pieces (after necrosis and decomposition of myoma).

    Self-expulsion of myoma might be potentially mortality condition due to the delay in diagnostic process and implementation of treatment. If fragments of degenerated myoma become trapped in the uterine cavity or the evacuation process is slow, the necrotic tissue can become infected with the resultant development of pyomyoma. To prevent potential sepsis, it is recommended to administered smooth muscle constrictors to accelerate expulsion and broadspectrum antibiotics. Sometimes small surgical intervention like an evacuation of the necrotic tissue from the cervix might be needed. Also, daily control of the body temperature and inflammation indicators are necessary to prevent some major complications. According to the literature the mortality from pyomyomas remains high because of concomitant sepsis .

    Considering this, the MRI scan should be planned at the beginning of diagnostic process since ultrasonographic findings might be nonspecific. In our case the MRI (both with histopathological examination) finally confirmed the benign character of remaining myoma. The MRI T2 weighted sequences did not show the enhancement in the myoma after contrast agent administration, which confirmed the lack of blood supply in the myoma. In sequence, it suggested that the myoma’s tissue were necrotic and could be expelled in small pieces. MRI is also good diagnostic exam to confirm or exclude pyomyomas. Air bubbles seen in the MRI highly suggest the infection and abscess formation inside the myoma, which requires intensification of treatment . It is always the matter of debate whether proceed with hysterectomy or myomectomy because of high risk of sepsis. In our patient the MRI did not show air however histopathological exam showed fragments of myoma with purulent effusion and colonies of bacteria. The decision about the surgery was postpone because of the unclear process and mild deviations in laboratory results accepted by gynecological team. However, the patient stayed in the hospital and the level of expulsion of the myoma was checked by ultrasound examination.

    Above mentioned process of expulsion of necrotic myoma’s tissue is similar to the sloughing off myomas after embolisation, where MRI images are almost identical to presented above . Also, symptoms presented by our patient (abdominal pain, fever, increase of CRP level) may suggest ‘post-embolisation syndrome’, which is an acute reaction for ischemia of myoma. It occurs within 72-hours after embolisation and then subside. In such situation the therapy with pain killers and broad-spectrum antibiotics is necessary, like in our patient. Also trigger factors, for example medicaments or previous uterine interventions, should be considered to prevent a recurrence of symptoms .

    Conclusion

    To sum up, the whole process of the expulsion described in the study might bring to mind the sloughing off process of myomas after embolisation. Ischemia of the myoma, protrusion to the uterine cavity and vaginal expulsion are similar steps of the cascade . If no complications are present the only treatment are antibiotics. Furthermore, we would like to highlight the difficulties during the diagnostic process and the necessity of quick diagnosis using MRI. Although, the study presents the case of healthy, young woman it is also necessary to remember that life-threatening complications may occur during the treatment process. The decision about rapid surgical intervention should be consider on clinical condition of patient as well as her desire for fertility.

    1. Parker WH (2007) Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 87: 725-736.
    2. Wen L, Tseng JY, Wang PH (2006) Vaginal expulsion of a submucosal myoma during treatment with long-acting gonadotropin-releasing hormone agonist. Taiwan J Obstet Gynecol 45: 173-175.
    3. Kim KA, Yoon SW, Yoon BS, Park CT, Kim SH, et al. (2011) Spontaneous vaginal expulsion of uterine myoma after magnetic resonance-guided focused ultrasound surgery. J Minim Invasive Gynecol 18: 131-134.
    4. Stott D, Zakaria M (2012) The transcervical expulsion of a large fibroid. BMJ Case Rep.
    5. Rashmi B, Rakhi R, Jasvinder K, Saha KP, Singh T, et al. (2017) An unusual cause of postabortal fever requiring prompt surgical intervention: A pyomyoma and its imaging features. Oman Med J 32: 73-76.
    6. Murakami T, Niikura H, Shima Y, Terada Y, Okamura K (2007) Sloughing off of a cervical myoma after cesarean section: A case report. J Reprod Med 52: 962-964.
    7. Golan A, Zachalka N, Lurie S, Sagiv R, Glezerman M (2005) Vaginal removal of prolapsed pedunculated submucous myoma: A short, simple, and definitive procedure with minimal morbidity. Arch Gynecol Obstet 271: 11.
    8. Nguyen QH, Gruenewald SM (2008) Sonographic appearance of a postpartum pyomyoma with gas production. J Clin Ultrasound 36: 186-188.
    9. Gutierrez LB, Bansal AK, Hovsepian DM (2012) Uteroenteric fistula resulting from fibroid expulsion after uterine fibroid embolization: A case report and review of the literature. Cardiovasc Intervent Radiol 35: 1231-1236.
    10. Martins JG, Gaudenti D, Crespo F, Ganesh D, Verma U (2016) Uncommon complication of uterine artery embolization: Expulsion of infarcted myoma and uterine sepsis. Case Rep Obstet Gynecol.
    11. Chantraine F, Poismans G, Nwachuku J, Bestel E, Nisolle M (2015) Expulsion of a uterine myoma in a patient treated with ulipristal acetate. Clin Case Rep 3: 240-242.

    Discharge Instructions for Uterine Fibroid Embolization

    You just had a uterine fibroid embolization. This is also called a uterine artery embolization. Uterine fibroids are tumors that are not cancerous (benign). Uterine fibroid embolization stops the blood supply to the tumor without surgery. This treatment causes the fibroids to shrink. To do this, a doctor injects small bits of plastic into the blood vessel that brings blood to the fibroid tumor. These pieces of plastic build up in the artery and block the blood supply. During this procedure, your doctor makes a cut (incision) in your groin. A thin tube called a catheter is put through a blood vessel in your leg that runs to your uterus. Here’s what to do at home after this procedure.

    Activity level

    • Limit your activity for 2 days after the procedure.
    • Ask a friend or family member to stay with you as you rest in bed or on the couch.
    • Slowly increase your activities during the week after the procedure.
    • Don’t drive for 24 hours.
    • Don’t climb stairs for 2 days after the procedure.
    • Don’t lift anything heavier than 10 pounds for 1 week after the procedure.
    • Don’t bend at the waist for 2 days.
    • Ask your healthcare provider when you can go back to work.

    Other home care

    • Don’t be alarmed by vaginal discharge that is grayish or brown in color. This is from the breakdown of the fibroid tumor. It is normal.
    • Expect your next 2 or 3 periods to be heavier than normal.
    • Take your medicines as directed. Don’t skip doses.
    • Unless otherwise directed, drink 6 to 8 glasses of water every day. This helps to prevent dehydration. It also helps flush your body of the dye that was used during the procedure.
    • Take your temperature and check your incision site every day for a week. Look for signs of infection such as redness, swelling, or warmth. Tell your healthcare provider if you have any of these symptoms.
    • Ask your healthcare provider when it is safe to swim or take a bath.

    Follow-up care

    Make a follow-up appointment with your healthcare provider, or as directed.

    When to seek medical care

    Call your healthcare provider right away if you have any of the following:

    • Constant or increasing pain or numbness in your leg
    • Severe or worsening abdominal pain
    • Fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider
    • Signs of infection, such as redness, swelling, or warmth at the incision site
    • Shortness of breath
    • A leg that feels cold or looks blue
    • Blood in your urine
    • Black or tarry stools

    Date Last Reviewed: 11/1/2017

    Uterine Fibroids

    Uterine Fibroids

    A uterine fibroid is a noncancerous growth of muscle tissue in the uterus. They are also called leiomyomas or myomas. The shape, size and location of the fibroid can vary. They may be inside the uterus, outside or attached by a stem-like structure. They can vary in size from very small to large. Women can have one more many fibroids in her uterus.

    Uterine fibroids are very common, and occur more often in women aged 30-40 years; however, they are seen at any age. Fibroids arise more often in Black and Asian women more than in White women. Their cause is unknown.

    Although most of the time fibroids are without symptoms, they can be the cause of excessive vaginal bleedeing, vaginal bleeding at times other than menustruation, abdominal pain, pain with intercourse, an enlarged abdomen, trouble voiding or having bowel movements, or pelvic pressure.

    Complications from fibroids are uncommon. Fibroids that are attacehd to the uterus by a stem may twise on their blood supply. This can cause pain, nausea, and/or fever. Fibroids can rarely become infected. In most cases this only happens when an infection is already in the area. Fibroids can grow rapidly, and outgrow their blood supply, causing degeneration of the tissue in the middle of the fibroid. Again, this can cause fever, pain, and abnormal bleeding patterns. In very rare cases, rapid growth of the fibroid may be the cause of infertility, especially if they are obstructing the entrance of a fallopian tube, or growing in the uterine cavity. Since this is not very common in women of reporductive age, other factors should be explored before fibroids are considered the cause of a caouple’s infertility.

    Diagnosis

    There are a number of tests for the diagnosis of uterine fibroids.

    Ultrasound uses sound waves to create a picture of the uterus, tubes and ovaries.

    Hysteroscopy uses a slender deviced (the hysteroscope) to help the doctor see the inside of the uterus. It is inserted through the vagina and cervix (the opening of the uterus). Many times, this can be down in a physician’s office.

    Hysterosalpingography (HSG) is a special x-ray test. It may detect abnormal changes in the size and shape of the uterine cavity and the fallopain tubes.

    Laparoscopy uses a slender device (the laparoscope) to help the doctor see inside of the abdomen. It is inserted through a small cute below or through the navel. The doctor can see the fibroids on the outside of the uterus with the laparoscope.

    Treatment

    Treatment for fibroids may include observation of symptoms, hormonal treatment (may help excessive bleeding), uterine fibroid embloization (a radiologist blocks blood flow to the fibroid). surgery (myomectomy is the surgical removal of fibroids while leaving the uterus in place) or hysterectomy (the removal of the uterus).

    If you have a history of fibroids or are having any of the symptoms of fibroids, you should consult your physician.

    for more information. (American College of Obstetricians and Gynecologists)

    Uterine Fibroids

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