Introduction
Uterine Myoma are among the most frequent entities encountered in
the practice of gynecology, occurring in 20–40% of women during their
reproductive years. It is the most common pelvic neoplasm of gynecologic
origin, 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 are
round, firm, benign lumps of the muscular wall of the uterus, composed of
smooth muscle and connective tissue, and are rarely solitary. Usually as
small as a hen's egg, they commonly grow gradually to the size of an orange
or grapefruit. On cutting into such a tumor, its surface is seen to be glistening
white color, with characteristic whorl-like trabeculation so that it stands out in
sharp contrast to the surrounding muscularies.
A diagnosis of uterine myoma is the most common indication for
hysterectomy. Many surgical procedures other than hysterectomy are also
commonly performed because of myomas. Women with symptoms like heavy
bleeding and pain may need surgery. If the woman is not planning to have
any more children, a hysterectomy may be recommended. This is surgery to
remove the uterus. If the woman would like to become pregnant in the
future, a myomectomy may be done instead. This is surgery to remove only
the fibroid. The uterus is left intact.
A. Current Trends
Source: http://www.sciencedaily.com/releases/2009/08/090810024819.htm
Prevalence/incidence of myoma
Every 10 minutes, 12 hysterectomies are performed. According to a
report published by Obstetrics and Gynecology, 9 of them probably didn't
meet the guidelines set out by the American College of Obstetricians &
Gynecologists for hysterectomy.
Possibly as many as 80% of all women have uterine fibroids while the
majority usually have no symptoms, 1 in 4 end up with symptoms severe
enough to require treatment.
Female Anatomy
• Vagina: The vagina is a canal that joins the cervix (the lower part of
uterus) to the outside of the body. It also is known as the birth canal.
• Ovaries: The ovaries are small, oval-shaped glands that are located
on either side of the uterus. The ovaries produce eggs and hormones.
• Fallopian tubes: These are narrow tubes that are attached to the
upper part of the uterus and serve as tunnels for the ova (egg cells) to
travel from the ovaries to the uterus. Conception, the fertilization of an
egg by a sperm, normally occurs in the fallopian tubes. The fertilized
egg then moves to the uterus, where it implants to the uterine wall.
• Uterus (womb): The uterus is a hollow, pear-shaped organ that is the
home to a developing fetus. The uterus is divided into two parts: the
cervix, which is the lower part that opens into the vagina, and the main
body of the uterus, called the corpus. The corpus can easily expand to
hold a developing baby. A channel through the cervix allows sperm to
enter and menstrual blood to exit.
Cervix
The cervix is the lower constricted segment of the uterus. It is
somewhat conical in shape, with its truncated apex directed downward and
backward, but is slightly wider in the middle than either above or below.
Owing to its relationships, it is less freely movable than the body, so that the
latter may bend on it. The long axis of the cervix is therefore seldom in the
same straight line as the long axis of the body. The long axis of the uterus as
a whole presents the form of a curved line with its concavity forward, or in
extreme cases may present an angular bend at the region of the isthmus.
The cervix projects through the anterior wall of the vagina, which
divides it into an upper, supravaginal portion, and a lower, vaginal portion.
The supravaginal portion (portio supravaginalis [cervicis]) is separated in
front from the bladder by fibrous tissue (parametrium), which extends also on
to its sides and lateralward between the layers of the broad ligaments. The
uterine arteries reach the margins of the cervix in this fibrous tissue, while on
either side the ureter runs downward and forward in it at a distance of about
2 cm. from the cervix. Posteriorly, the supravaginal cervix is covered by
peritoneum, which is prolonged below on to the posterior vaginal wall, when
it is reflected on to the rectum, forming the rectouterine excavation. It is in
relation with the rectum, from which it may be separated by coils of small
intestine.
The vaginal portion (portio vaginalis [cervicis]) of the cervix projects
free into the anterior wall of the vagina between the anterior and posterior
fornices. On its rounded extremity is a small, depressed, somewhat circular
aperture, the external orifice of the uterus, through which the cavity of the
cervix communicates with that of the vagina. The external orifice is bounded
by two lips, an anterior and a posterior, of which the anterior is the shorter
and thicker, although, on account of the slope of the cervix, it projects lower
than the posterior. Normally, both lips are in contact with the posterior
vaginal wall. Interior of the Uterus
The cavity of the uterus is small in comparison with the size of the
organ. The Cavity of the Body (cavum uteri) is a mere slit, flattened antero-
posteriorly. It is triangular in shape, the base being formed by the internal
surface of the fundus between the orifices of the uterine tubes, the apex by
the internal orifice of the uterus through which the cavity of the body
communicates with the canal of the cervix. The Canal of the Cervix (canalis
cervicis uteri) is somewhat fusiform, flattened from before backward, and
broader at the middle than at either extremity. It communicates above
through the internal orifice with the cavity of the body, and below through
the external orifice with the vaginal cavity. The wall of the canal presents an
anterior and a posterior longitudinal ridge, from each of which proceed a
number of small oblique columns, the palmate folds, giving the appearance
of branches from the stem of a tree; to this arrangement the name arbor vitæ
uterina is applied. The folds on the two walls are not exactly opposed, but fit
between one another so as to close the cervical canal.
Posterior half of uterus and upper part of vagina.
The total length of the uterine cavity from the external orifice to the fundus
is about 6.25 cm.
Ligaments
The ligaments of the uterus are eight in number: one anterior; one
posterior; two lateral or broad; two uterosacral; and two round ligaments.
The anterior ligament consists of the vesicouterine fold of peritoneum,
which is reflected on to the bladder from the front of the uterus, at the
junction of the cervix and body. The posterior ligament consists of the
rectovaginal fold of peritoneum, which is reflected from the back of the
posterior fornix of the vagina on to the front of the rectum. It forms the
bottom of a deep pouch called the rectouterine excavation, which is bounded
in front by the posterior wall of the uterus, the supravaginal cervix, and the
posterior fornix of the vagina; behind, by the rectum; and laterally by two
crescentic folds of peritoneum which pass backward from the cervix uteri on
either side of the rectum to the posterior wall of the pelvis.
These folds are named the sacrogenital or rectouterine folds. They
contain a considerable amount of fibrous tissue and non-striped muscular
fibers which are attached to the front of the sacrum and constitute the
uterosacral ligaments. The two lateral or broad ligaments (ligamentum
latum uteri) pass from the sides of the uterus to the lateral walls of the pelvis.
Together with the uterus they form a septum across the female pelvis,
dividing that cavity into two portions. In the anterior part is contained the
bladder; in the posterior part the rectum, and in certain conditions some coils
of the small intestine and a part of the sigmoid colon.
Between the two layers of each broad ligament are contained: (1) the
uterine tube superiorly; (2) the round ligament of the uterus; (3) the ovary
and its ligament; (4) the epoöphoron and paroöphoron; (5) connective tissue;
(6) unstriped muscular fibers; and (7) bloodvessels and nerves. The portion of
the broad ligament which stretches from the uterine tube to the level of the
ovary is known by the name of the mesosalpinx. Between the fimbriated
extremity of the tube and the lower attachment of the broad ligament is a
concave rounded margin, called the infundibulopelvic ligament.
The round ligaments (ligamentum teres uteri) are two flattened bands
between 10 and 12 cm. in length, situated between the layers of the broad
ligament in front of and below the uterine tubes. Commencing on either side
at the lateral angle of the uterus, this ligament is directed forward, upward,
and lateralward over the external iliac vessels. It then passes through the
abdominal inguinal ring and along the inguinal canal to the labium majus, in
which it becomes lost.
The round ligaments consists principally of muscular tissue, prolonged
from the uterus; also of some fibrous and areolar tissue, besides
bloodvessels, lymphatics; and nerves, enclosed in a duplicature of
peritoneum, which, in the fetus, is prolonged in the form of a tubular process
for a short distance into the inguinal canal. This process is called the canal of
Nuck. It is generally obliterated in the adult, but sometimes remains pervious
even in advanced life. It is analogous to the saccus vaginalis, which precedes
the descent of the testis. In addition to the ligaments just described, there is
a band named the ligamentum transversalis colli (Mackenrodt) on either side
of the cervix uteri.
It is attached to the side of the cervix uteri and to the vault and lateral
fornix of the vagina, and is continuous externally with the fibrous tissue
which surrounds the pelvic bloodvessels. The form, size, and situation of the
uterus vary at different periods of life and under different circumstances.
Sagittal section through the pelvis of a newly born female
Structure
The uterus is composed of three coats: an external or serous, a middle
or muscular, and an internal or mucous. The serous coat (tunica serosa) is
derived from the peritoneum; it invests the fundus and the whole of the
intestinal surface of the uterus; but covers the vesical surface only as far as
the junction of the body and cervix. In the lower fourth of the intestinal
surface the peritoneum, though covering the uterus, is not closely connected
with it, being separated from it by a layer of loose cellular tissue and some
large veins.
The muscular coat (tunica muscularis) forms the chief bulk of the
substance of the uterus. In the virgin it is dense, firm, of a grayish color, and
cuts almost like cartilage. It is thick opposite the middle of the body and
fundus, and thin at the orifices of the uterine tubes. It consists of bundles of
unstriped muscular fibers, disposed in layers, intermixed with areolar tissue,
bloodvessels, lymphatic vessels, and nerves. The layers are three in number:
external, middle, and internal. The external and middle layers constitute the
muscular coat proper, while the inner layer is a greatly hypertrophied
muscularis mucosæ.
During pregnancy the muscular tissue becomes more prominently
developed, the fibers being greatly enlarged. The external layer, placed
beneath the peritoneum, is disposed as a thin plane on the vesical and
intestinal surfaces. It consists of fibers which pass transversely across the
fundus, and, converging at each lateral angle of the uterus, are continued on
to the uterine tube, the round ligament, and the ligament of the ovary: some
passing at each side into the broad ligament, and others running backward
from the cervix into the sacrouterine ligaments. The middle layer of fibers
presents no regularity in its arrangement, being disposed longitudinally,
obliquely, and transversely.
It contains more bloodvessels than either of the other two layers. The
internal or deep layer consists of circular fibers arranged in the form of two
hollow cones, the apices of which surround the orifices of the uterine tubes,
their bases intermingling with one another on the middle of the body of the
uterus. At the internal orifice these circular fibers form a distinct sphincter.
The mucous membrane (tunica mucosa) is smooth, and closely adherent to
the subjacent tissue. It is continuous through the fimbriated extremity of the
uterine tubes, with the peritoneum; and, through the external uterine orifice,
with the lining of the vagina.
In the body of the uterus the mucous membrane is smooth, soft, of a
pale red color, lined by columnar ciliated epithelium, and presents, when
viewed with a lens, the orifices of numerous tubular follicles, arranged
perpendicularly to the surface. The structure of the corium differs from that
of ordinary mucous membranes, and consists of an embryonic nucleated and
highly cellular form of connective tissue in which run numerous large
lymphatics. In it are the tube-like uterine glands, lined by ciliated columnar
epithelium. They are of small size in the unimpregnated uterus, but shortly
after impregnation become enlarged and elongated, presenting a contorted
or waved appearance. In the cervix the mucous membrane is sharply
differentiated from that of the uterine cavity. It is thrown into numerous
oblique ridges, which diverge from an anterior and posterior longitudinal
raphé.
In the upper two-thirds of the canal, the mucous membrane is provided
with numerous deep glandular follicles, which secrete clear viscid alkaline
mucus; and, in addition, extending through the whole length of the canal is a
variable number of little cysts, presumably follicles which have become
occluded and distended with retained secretion. They are called the ovula
Nabothi. The mucous membrane covering the lower half of the cervical canal
presents numerous papillæ. The epithelium of the upper two-thirds is
cylindrical and ciliated, but below this it loses its cilia, and gradually changes
to stratified squamous epithelium close to the external orifice. On the vaginal
surface of the cervix the epithelium is similar to that lining the vagina, viz.,
stratified squamous.
The arteries of the internal organs of generation of the female, seen from
behind.
Puberty
Puberty is the time at which a growing boy or girl begins the process of
sexual maturation. Puberty involves a series of physical stages or steps that
lead to the achievement of fertility and the development of the so-called
secondary sex characteristics, the physical features associated with adult
males and females (such as the growth of pubic hair). While puberty involves
a series of biological, or physical, transformations, the process can also have
an effect on the psychosocial and emotional development of the adolescent.
Adolescent girls reach puberty today at earlier ages than were ever
recorded previously. Nutritional and other environmental influences may be
responsible for this change. For example, the average age of the onset of
menstrual periods in girls was 15 in 1900. By the 1990s, this average had
dropped to 12 and a half years of age.
A gene has been identified that appears to be critical for the normal
development of puberty. The gene, known as GPR54, encodes a protein that
appears to have an effect on the secretion of GnRH by the hypothalamus.
Menstrual Cycle
Follicular Phase
This phase starts on the first day of your period. During the follicular phase of
the menstrual cycle, the following events occur:
Ovulatory Phase
The ovulatory phase, or ovulation, starts about 14 days after the follicular
phase started. The ovulatory phase is the midpoint of the menstrual cycle,
with the next menstrual period starting about 2 weeks later. During this
phase, the following events occur:
• The rise in estrogen from the dominant follicle triggers a surge in the
amount of luteinizing hormone that is produced by the brain.
• This causes the dominant follicle to release its egg from the ovary.
• As the egg is released (a process called ovulation) it is captured by
finger-like projections on the end of the fallopian tubes (fimbriae). The
fimbriae sweep the egg into the tube.
• Also during this phase, there is an increase in the amount and a
change in the consistency of mucus produced by the cervix (lower part
of the uterus.) If a woman were to have intercourse during this time,
this receptive mucus captures the man's sperm, nourishes it, and helps
it to move towards the egg for fertilization.
Luteal Phase
The luteal phase begins right after ovulation and involves the following
processes:
• Once it releases its egg, the empty follicle develops into a new
structure called the corpus luteum.
• The corpus luteum secretes the hormone progesterone. Progesterone
prepares the uterus for a fertilized egg to implant.
• If intercourse has taken place and a man's sperm has fertilized the egg
(a process called conception), the fertilized egg (embryo) will travel
through the fallopian tube to implant in the uterus. The woman is now
considered pregnant.
• If the egg is not fertilized, it passes through the uterus. Not needed to
support a pregnancy, the lining of the uterus breaks down and sheds,
and the next menstrual period begins.
During fetal life, there are about 6 million to 7 million eggs. From this
time, no new eggs are produced.
The vast majority of the eggs within the ovaries steadily die, until they are
depleted at menopause. At birth, there are approximately 1 million eggs; and
by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will
be ovulated during a woman's reproductive lifetime. The eggs continue to
degenerate during pregnancy, with the use of birth control pills, and in the
presence or absence of regular menstrual cycles.
Menopause
1. Definition
A Myoma is a solid tumor made of fibrous tissue; hence it is often
called a 'fibroid' tumor. 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. Myomas start as small as
a pea but can grow to fill the pelvis and they are often small and
asymptomatic. Symptomatic fibroids occur in 25% of white women and 50%
of black women. Their growth is variable and not predictable.
2. Predisposing/Precipitating Factors
a. Race
Although the basis for the higher prevalence among black women is
unknown, ethnic differences have been found in circulating estrogen levels
while on control diets, and differences in estrogen metabolism have been
noted. In control groups of healthy, premenopausal women placed on a high-
fat, low-fiber diet similar to their usual diet, African-American women had
significantly higher serum levels of estrone, estradiol, and free estradiol than
Caucasian women.
b. Obesity and overweight
Estrogen can increase for a number of reasons; including excessive
weight gain (estrogen is stored in adipose (fat) tissue and the use of estrogen
replacement therapy during menopause. being overweight increases the
amount of natural estrogen formed in the body's fat cells. Since fat cells
produce estrogen, overweight can lead to overproduction of estrogen.
c. Early menarche
The early onset of menstrual cycles may increase the number of cell
divisions that the myometrium undergoes during the reproductive years,
resulting in an increased chance of mutation in genes controlling myometrial
proliferation (Marshall et al. 1998a).
d. Age
• They can grow in pregnancy, not just because of high estrogen, but
because of increased blood flow to the - uterus.
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.
Myomas can cause acute severe pain, due to torsion of the stalk or
degeneration. In such cases, the pain will be localized to the specific area
that is affected. This can usually improve with pain relievers and go away
after two-three weeks. Obviously, if the pain is unbearable, it is best to see a
doctor right away.
Chronic pelvic pain, which is mild but persistent, can also occur. Again,
this is generally localized to a specific area. Low back pain may be
experienced, when the fibroids can press against the nerves of the lower
back.
Avoid weight gain after age 18 and maintain a normal body weight
compared to your height. Body weight tends to increase estrogen production,
thus aggravating fibroid growth. Exercise can help control your weight and
additionally decrease hormone production that stimulates fibroid growth.
3. NURSING MANAGEMENT
A. MEDICAL MANAGEMENT
a. IVFs
Medical Date General Indication( Clients
Managemen Ordered Descriptio s) Response
t/ Date n Or Purpose to
Treatment Performed Treatment
Date
Changed
-no insertion
of IVF
Nursing Responsibilities
b. Drugs
Name of Date Route General Indicati Clients
Drug: Order of Action on(s) Respon
Generic ed Admin. Classificatio or se to
Name Date Dosage n Purpos the
Brand Perfor & Mechanism es Meds
Name med Freque of Action with
Date ncy of actual
Chang admin. Side-
ed effects
Generic DO: General
Name: Action:
Brand Classification
DP:
Name: :
Mechanism
of Action:
Nursing Responsibilities
Diet
Type of Date General Indication( Clients
Diet Ordered Descriptio s) Response
Date n Or Purpose and
Performed Reaction
Date to the Diet
Changed
DO: DO:
DP: DP:
Nursing Responsibilities
Nursing Responsibilities
VII. CONCLUSION
Most fibroids (95%) are intramural, being located in the middle of the
myometrium. Subserosal, or exophytic, fibroids are located in the subserosal
layer and tend to cause a focal bulge in the exterior surface of the uterus;
they can become pedunculated. Rarely, subserosal fibroids occur in the broad
ligament. Submucosal, or subendometrial, fibroids are the least common.
They distort the overlying endometrium and can become extruded or
pedunculated (ie, fibroid polyps) in the endometrial canal.
Recommendation:
Learning derived:
Handling this kind of patient is interesting. Although it’s quite difficult
for the researchers, but it has a purpose to the researching to gain more
experience in the field of nursing. At first the researchers did not know what
to do in this case, because we have no background about it. But when the
researchers did this case study about myoma we were challenge to do it.
VIII. BIBLIOGRAPHY
Internet resources:
http://www.sciencenews.org/search/seek?for=uterine+myoma
http://www.sciencedaily.com/releases/2009/08/090810024819.htm
Books:
l
TABLE OF CONTENTS
I. INTRODUCTION
VII. CONCLUSION
VIII. BIBLIOGRAPHY
Presented by:
Marilou S. Limiac, RN
Clinical Instructor