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British Journal of Healthcare and Medical Research - Vol. 10, No. 2
Publication Date: April 25, 2023
DOI:10.14738/jbemi.102.14485.
Sena-Martins, M., Tadini, V., Yamamoto, S. T., Mariani Neto, C., Kuroda, C. M., Santos, D. F., Moreira, J. M. S., Carnauba, L. A. B.,
Sousa, M. C., Novaczyk, M. B., & Figueiredo, P. E. E. (2023). A Case Report of Laparotomic Myomectomy After the Use of GnRH
Analogue in A Brazilian Woman. British Journal of Healthcare and Medical Research, Vol - 10(2). 471-478.
Services for Science and Education – United Kingdom
A Case Report of Laparotomic Myomectomy After
the Use of GnRH Analogue in A Brazilian Woman
Sena-Martins, M.
Leonor Mendes de Barros Hospita
Tadini, V.
Leonor Mendes de Barros Hospita
Yamamoto, S. T.
Leonor Mendes de Barros Hospita
Mariani Neto, C.
Leonor Mendes de Barros Hospita
Kuroda, C. M.
Leonor Mendes de Barros Hospita
Santos, D. F.
Leonor Mendes de Barros Hospita
Moreira, J. M. S.
Leonor Mendes de Barros Hospita
Carnauba, L. A. B.
Leonor Mendes de Barros Hospita
Sousa, M. C.
Leonor Mendes de Barros Hospita
Novaczyk, M. B.
Leonor Mendes de Barros Hospita
Figueiredo, P. E. E.
Leonor Mendes de Barros Hospita
ABSTRACT
Uterine leiomyoma is the most common genital benign tumor in the female
population. It is estimated that about 20 to 40% of women will have leiomyoma
during their reproductive stage. IBGE (Brazilian Institute of Geography and
Statistics) estimated the Brazilian population to be over 200 million Brazilians, of
which half are women and approximately 50% are of reproductive age; hence, by
calculating the prevalence of leiomyomatosis, there would be just over 6 million
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British Journal of Healthcare and Medical Research (BJHMR) Vol 10, Issue 2, April- 2023
Services for Science and Education – United Kingdom
women with symptomatic fibroids in Brazil that require clinical or surgical
treatment.[1-3-4] Due to its presence during the reproductive period, it can be
caused by infertility or recurrent spontaneous pregnancy loss. Hence, myomectomy
can be necessary when the fibroid itself causes distortion of the endometrial cavity,
or competes with the embryo for the same place, or when conservative treatment
was ineffective. This report describes a case of myomectomy which was performed
after treatment with goserelin acetate with considerable reduction of fibroids
volume, probably facilitating surgical approach, decreasing the blood loss and the
risk of hysterectomy conversion. In addition, other GnRH analogue benefits before
surgery such as doctor’s impression of decrease in size and better mobility of the
tumor and patients feeling of decrease of the abdominal volume and the bleeding.
This subjective approach can optimize the timing of surgery and establish the
number of injections.
Keywords: Uterine myomectomy, GnRH, myoma
INTRODUCTION
Uterine leiomyoma is the most common benign tumor in the female genital tract and it
originates from smooth muscle cells and increased extracellular matrix. Black women have
more risk of having clinically relevant myomas, while other risk factors are obesity, nulliparity,
early menarche and late menopause. There is a strong relation between sexual steroids
(estrogen and progesterone) and the growth of myomas, thus being hormonal exposure a risk
factor.
The prevalence in women of reproductive age is 20-40% and 40% in women above age of 40.
About 20-50% of women over 40 years old will present anemia, dysmenorrhea, pelvic pain,
constipation and changes in urinary habit because of the location or size of the tumor. Myomas
can also cause obstetric complications like reduced fertility, miscarriage, anomalous placenta
implantation, preterm labor and pos-partum hemorrhage [3-4].
The diagnosis can be suspected by physical examination by noticing an enlarged and irregular
uterus during the vaginal exam, but it is confirmed through imaging. Imaging exams (MRI or
ultrasound) allow a better understanding of the tumor, its localization, measurements and a
more strategic surgical planning.
The main treatment for symptomatic patients was to surgically remove the uterus; however,
new treatments are being studied, targeting the preservation of women’s fertility and avoiding
invasive procedures. These new treatments are the laparotomic, laparoscopic or endoscopic
myomectomy, use of drugs and uterine artery embolization.
Drug options include GnRH analogues, which have shown good efficacy. This medication
initially improves gonadotropin production and release, leading to down regulation,
desensitization and hypogonadotropic hypogonadism status. This case report aims to discuss
the associated use of the therapeutic options in uterine leiomyoma, specially laparotomic
myomectomy and GnRH analogue.
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Sena-Martins, M., Tadini, V., Yamamoto, S. T., Mariani Neto, C., Kuroda, C. M., Santos, D. F., Moreira, J. M. S., Carnauba, L. A. B., Sousa, M. C.,
Novaczyk, M. B., & Figueiredo, P. E. E. (2023). A Case Report of Laparotomic Myomectomy After the Use of GnRH Analogue in A Brazilian Woman.
British Journal of Healthcare and Medical Research, Vol - 10(2). 471-478.
URL: http://dx.doi.org/10.14738/jbemi.102.14485.
CASE REPORT
A nulligravid, caucasian, 34-year-old woman who wants to get pregnant was forwarded from
primary care to the ambulatory surgical service in Leonor Mendes de Barros Maternity Hospital
due to large volume uterine myomas, diagnosed through ultrasound. No comorbidities or
previous surgeries were related. BMI 34,3 kg/m2.
Clinical complaints included abnormal uterine bleeding, abdominal pain and increasing
abdominal volume in the last 2 years. The patient also presented iron deficiency anemia, treated
with iron III-hydroxide saccharate tablets.
At clinical examination, the tumor extended from the pubic symphysis to the xiphoid process,
size compatible with 32 weeks of pregnancy, with diffuse pain on abdominal palpation. To
vaginal examination, an indurated mass was identified. There was no vaginal bleeding at first
evaluation.
The MRI scan revealed more detailed results (images 1 and 2). One tumor located on the fundal
wall, suggesting subserosal leiomyoma, extended to the epigastric area, measuring
28,4x13,4x22,9 cm. It also revealed other myomas: in the right wall (5,7x4,4 cm) and left wall
(3,9x4,3 cm). Laboratory tests evidenced anemia (hemoglobin 9,3 and hematocrit 28,4%).
Image 1: axial view