GIANT UTERINE MYOMA IN A 66-YEAR-OLD WOMAN: CASE REPORT

ABSTRACT

Uterine myoma (leiomyoma) is the most common benign tumor found in the uterus and originates from smooth muscle (myometrium). This condition most frequently occurs in women of reproductive age, with its incidence decreasing after menopause. Risk factors for developing myoma include obesity, nulliparity, hypertension, alcohol and caffeine consumption, and stress. Most cases are asymptomatic; however, large myomas can cause abnormal bleeding, pelvic pain, infertility, and dysfunction of pelvic organs. In rare cases, myomas can grow into giant myomas, posing challenges in diagnosis and management due to displacement of adjacent anatomical structures.

The management of uterine myoma depends on the patient’s age, clinical symptoms, tumor size and location, and the patient’s desire to preserve reproductive function. Surgical procedures such as myomectomy or hysterectomy are the main treatment options, and in certain cases, uterine reconstruction may be performed after myoma removal. An individualized approach is essential to achieve optimal clinical and psychological outcomes for the patient.

АННОТАЦИЯ

Миома матки (лейомиома) является наиболее распространённой доброкачественной опухолью матки и происходит из гладкомышечной ткани (миометрия). Данное заболевание чаще всего встречается у женщин репродуктивного возраста, при этом после наступления менопаузы его частота снижается. Факторами риска развития миомы являются ожирение, отсутствие родов в анамнезе (нуллипаритет), артериальная гипертензия, употребление алкоголя и кофеина, а также стресс. В большинстве случаев миома протекает бессимптомно; однако миомы больших размеров могут вызывать аномальные маточные кровотечения, боли в области таза, бесплодие и нарушение функции органов малого таза. В редких случаях миомы могут достигать гигантских размеров, что создаёт трудности в диагностике и лечении вследствие смещения соседних анатомических структур.

Тактика лечения миомы матки зависит от возраста пациентки, клинической симптоматики, размеров и локализации опухоли, а также от желания сохранить репродуктивную функцию. Основными методами лечения являются хирургические вмешательства, такие как миомэктомия или гистерэктомия; в отдельных случаях после удаления миомы возможно выполнение реконструкции матки. Индивидуальный подход к каждой пациентке является необходимым условием для достижения оптимальных клинических и психологических результатов.

Keywords: Uterine myoma, giant leiomyoma, hysterectomy, myomectomy, uterine reconstruction.

Ключевые слова: Миома матки, гигантская лейомиома, гистерэктомия, миомэктомия, реконструкция матки

Introduction. Uterine myoma is a benign tumor originating from the smooth muscle cells of the myometrial layer of the uterus and is the most common neoplasm of the female reproductive organs.[4] Its global incidence reaches 20–35% among women. The highest prevalence is found in women over 35 years old, with an increase during the reproductive period and a decline after menopause. Giant myoma is a rare case. Its diagnosis and management present particular challenges due to changes in the anatomical position of pelvic organs and the complexity of surgical procedures. In addition, determining the therapeutic strategy depends on the patient’s age, clinical symptoms, the size and location of the myoma, and the desire to preserve reproductive function

Material and Method. A 66-year-old female patient came to the Perinatal Center St. Joseph Hospital in Belgorod with complaints of lower abdominal pain that had been experienced for the past few months. The patient had her first menarche at the age of 13. Her menstrual cycles were regular, occurring every 28 days, and she had reached menopause 10 years ago. On physical examination, her vital signs were as follows: blood pressure 130/80 mmHg, pulse rate 78 beats per minute, respiratory rate 18 breaths per minute, and body temperature 36.6°C. Abdominal palpation revealed tenderness (+). The patient’s  body mass index (BMI) was 25.4 kg/m². Laboratory findings showed: leukocytes 6.97×10³/μL, erythrocytes 3.7×10⁶/μL, hemoglobin 96.0 g/L, platelets 300.3×10³/μL. Blood fibrinogen level was 6.79 g/L, and C-reactive protein (CRP) was 132.43 mg/L.

Magnetic Resonance Imaging (MRI) examination revealed an intrauterine mass measuring 17.0 cm × 21.0 cm × 15.5 cm. On a series of MRI scans with T1-and T2-weighted images using fat suppression in three planes, the uterus appeared retroverted, centrally located, significantly compressed, with clear contours and measuring 6.2 × 4.1 × 17.5 cm. The zonal structure of the uterine wall was preserved. Along the anterior wall of the uterine corpus, there was a large volumetric formation with a cystic, non-homogeneous structure, partially hemorrhagic, containing several papillary septal growths, and having smooth, well-defined borders. The dimensions were 17.0 × 21.0 × 15.5 cm, with moderate contrast accumulation observed in the walls of the formation and in the solid components. The junctional zone of the myometrium was not thickened.

The contour at the border with the myometrium was indistinct, while the internal contour (at the endometrial border) was clear and smooth. The endometrium was well-differentiated and thickened, with a total thickness of up to 10 mm and a heterogeneous structure, giving the impression of an intramural uterine myoma (Figure 1). Laboratory tumor marker results were as follows: CA-125: 14 U/ml, HE-4: within pmol/l range, CA 72-4: 0.63 U/ml, and CA 19-9: 9.5 U/ml. RZA: 2.7. The patient underwent exploratory laparotomy with total hysterectomy. Intraoperatively, multiple uterine myomas were found, with the largest measuring 27 × 19 × 12 cm, causing the uterus to enlarge to the size equivalent of a 24–26 week pregnancy. The right ovary measured 3.5 × 2.7 cm, and the left ovary 3.5 × 12.5 cm; both were adherent to the pelvic wall, while the fallopian tubes appeared normal.

There was adhesion between the bladder and uterus, accompanied by a bladder injury, which was repaired by a urologist using a three-layer suture technique, and the ureters were evaluated to ensure patency. The procedure was performed carefully, with ligation of the uterine blood vessels, round ligaments, and paracervical tissues, followed by removal of the uterus along with the cervix and adnexa. The abdominal cavity was closed layer by layer, including peritonization and placement of an abdominal drain, with continuous Vicryl sutures applied to the muscle, aponeurosis, and skin. Intraoperative bleeding was minimal, hemodynamic status remained stable, and no major complications occurred. The excised myoma tissue was sent to the Department of Anatomical Pathology for histopathological examination. The patient received postoperative supportive therapy and showed good early recovery.

Figure 1. Giant uterine myoma after laparotomy

Figure 2. Intra-operative view of the patient’s abdomen

Discussion and Conclusion. This case illustrates a giant uterine myoma in a postmenopausal patient¹.a relatively rare condition, as most myomas regress after menopause due to a decline in estrogen levels. However, in some cases, growth may persist due to other factors such as genetic mutations, local growth factors, or peripheral conversion of androgens to estrogens in adipose tissue.Giant myomas (>15 cm), as seen in this case, can cause alterations in pelvic anatomy and compress surrounding organs, leading to symptoms such as pain, gastrointestinal disturbances, or urinary tract dysfunction. In this patient, the main complaint was persistent lower abdominal pain. Tumor marker levels within normal limits ruled out the possibility of malignancy, such as leiomyosarcoma. MRI findings were consistent with a large intramural leiomyoma.

The pathogenesis of myoma is not yet fully understood, but its growth is known to be influenced by hormones such as estrogen, progesterone, and other growth factors.[2] In addition, several risk factors have been identified, including obesity, nulliparity, positive family history, hypertension, stress, alcohol and caffeine consumption, and red meat intake. Race also plays a role, with a higher prevalence reported among women of African descent compared to other races. Myomas can develop in various locations within the uterus and are classified as intramural, subserosal, or submucosal. Their size varies greatly, ranging from very small to giant tumors. Small myomas are usually asymptomatic, while larges ones can cause symptoms such as abnormal bleeding, dysmenorrhea, pelvic pain, constipation, frequent urination, infertility, and even complications such as pseudo-Meigs syndrome and myomatous erythrocytosis syndrome.

Most cases of giant myoma are managed with total hysterectomy; however, in patients who still wish to preserve fertility or refuse hysterectomy for psychological reasons, myomectomy with uterine reconstruction can be an alternative. The choice of therapeutic strategy depends on the patient’s age, clinical symptoms, the size and location of the myoma, and the desire to preserve reproductive function. Conservative therapy may include the administration of GnRH agonists or Ulipristal Acetate to reduce the size of the myoma prior to surgery. Other alternatives, such as uterine artery embolization and HIFU (High-Intensity Focused Ultrasound) therapy, are also available as non-surgical options.[3] A comprehensive, individualized approach is crucial in the management of uterine myoma, especially in cases of giant myoma. In addition to clinical aspects, the psychological impact of procedures such as hysterectomy must also be considered, as the loss of the uterus can affect a woman’s sense of femininity and reproductive identity. Therefore, good communication between physician and patient in determining the treatment plan is key to successful management.

The main management for giant myoma in postmenopausal patients is generally total hysterectomy, particularly if the patient has no desire to preserve reproductive function. However, conservative approaches such as myomectomy or the use of Ulipristal Acetate may be considered in selected cases. In this context, the patient’s age (66 years), menopausal status, massive tumor size, and clinical symptoms were strong considerations for definitive surgical intervention.[7]

Conclusion. Uterine myoma is a common benign tumor, but it can present clinical challenges when it grows to a giant size, particularly in postmenopausal women. This case demonstrates that even after 10 years of menopause, a myoma can continue to develop and cause significant symptoms. Imaging examinations such as MRI play an important role in determining the location, size, and characteristics of the tumor. Management through laparotomic myomectomy has been shown to be effective and safe, even for large myomas, and can provide good clinical outcomes without complications. The choice of therapy should take into account the patient’s overall clinical condition, including age, symptoms, hormonal status, and the desire to preserve fertility. This case highlights the importance of early detection, regular monitoring, and an individualized approach in the management of uterine myoma to prevent long-term complications such as uterine prolapse and dysfunction of surrounding organs.

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