Diseases of the Myometrium

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Leiomyomas (fibroids) are the most common tumours of the uterus

Leiomyomas, also called fibroids, are the most common benign tumours of the female genital tract. They affect over half of all women over the age of 30, usually becoming symptomatic in the decade before the menopause.

Macroscopically, leiomyomas appear as rounded, rubbery, pale nodules, which have a whorled appearance on cut surface. They may arise in several locations within the uterus (e.g. intramural, sub-mucosal, polypoid sub-mucosal, and sub-serosal) and are very commonly multiple.

Leiomyomas vary in size, ranging from under 1 cm in diameter to giant lesions that are 20-30 cm in size. The typical diameter for lesions responsible for clinical problems is 2-4 cm.

Histologically, tumours are composed of smooth-muscle cells and intervening collagenous stroma. Importantly, there is no cellular atypia and very few mitoses are seen. Several uncommon histological variants of leiomyoma are also described, characterized by unusual cellular or stromal patterns, e.g. myxoid change.
Degenerative changes and complications occur in these tumours. For example, tumours may outgrow their blood supply, becoming replaced by hyaline material, as well as undergoing calcification. In pregnancy, and less commonly at other times, tumours may develop ischaemic degeneration in which lesions become soft and uniformly dark red (so-called 'red degeneration').
Pedunculated tumours may undergo torsion, developing venous infarction.

Clinically these tumours are associated with abnormal menstrual bleeding, dysmenorrhoea, or infertility. Occasionally they cause problems because of their effects as a large abdominal mass, e.g. compressing the bladder. During pregnancy, leiomyomas may cause complications such as spontaneous abortion, premature labour, and obstruction of labour.

Uterine leiomyomas depend on the trophic action of oestrogen for maintenance of size, and tumours usually shrink after the menopause. Treatment with GnRH-agonists, which induce hypo-oestrogenism, is being used to cause shrinkage of the uterus and fibroids to allow easier surgical removal by myomectomy. For most women who no longer wish to conceive, the treatment is to have a hysterectomy.

Tumours of the fallopian tube are very uncommon

Salpingitis is an important cause of late tubal obstruction and infertility

Salpingitis is nearly always caused by infection that has gained access by ascending from the uterine cavity. Most cases result in acute salpingitis with acute inflammation, but others result in a chronic inflammatory reaction.

The main associations for salpingitis are following pregnancy and endometritis, IUCD use, sexually transmitted disease (Mycoplasma, Chlamydia and gonococcus), TB, and Actinomyces.

In cases of acute salpingitis, the tubes are macroscopically swollen and congested, with a red, granular appearance to the serosal surface, due to vascular dilatation. Histologically the lumen may contain pus and there is infiltration of the tubal epithelium by neutrophils. A pyosalpinx occurs when there is massive distension of the tubal lumen by pus. 

Chlamydial colonization of the tubal mucosa is increasingly being recognized as a cause of impaired tubal function in infertile women, and this is usually in the absence of symptoms and laparoscopic signs of active infection. The histological correlates of such infection are uncertain.

Tuberculous salpingitis is acquired by haematogenous spread from a site outside the genital tract.
The tubes develop multiple granulomas in the mucosa and wall, causing adhesions to adjacent tissues (especially ovary).
In advanced cases the tube may be converted to a cavity filled with caseous necrotic material.

Infection by Actinomyces is predisposed by colonization of the female genital tract in association with IUCD use. The pus in the tubal lumen contains colonies of Actinomyces, visible macroscopically as 'sulphur granules'.

In many cases of infection of the fallopian tube, adhesions form between the tube and the ovary, and infection involves the tube, ovary and adjacent parametrial tissues. This situation gives rise to a matted clump of tissue and fibrosis, referred to as a tubo-ovarian mass, in which individual components are hard to discern.

Hydrosalpinx is dilatation of the fallopian tube, with flattening of the mucosa, the lumen being distended by clear, watery fluid. This is believed to be a sequel to previous inflammatory damage to the tube, acquired with healing of previous inflammation .
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