Cervical Leiomyoma

A cervical leiomyoma is a benign tumour of smooth muscle cells in the cervical stroma. It is the histological name for a cervical fibroid.

• It may be single or multiple, in the supravaginal or vaginal cervix.
• Growth depends on oestrogen and progesterone, and it often shrinks after menopause.
• Rapid growth or atypical features need exclusion of leiomyosarcoma.

Pelvic pressure, abnormal uterine bleeding, post-coital bleeding, urinary retention, rectal pressure and dyspareunia.

• Firm, round, smooth cervical swelling that distorts or displaces the os; a prolapsed tumour may appear in the vagina.
• Differential diagnosis: cervical polyp, prolapsed submucosal fibroid, cervical cancer, leiomyosarcoma, cervical endometriosis, nabothian cyst, inverted uterus.
• Complications: anaemia, hydronephrosis, obstructed labour, infection, red degeneration and, rarely, sarcomatous change.

Diagnosis is by examination and imaging, with histology after removal.

• Speculum examination and bimanual palpation; examination under anaesthesia if the mass is large.
• Transvaginal ultrasound and pelvic MRI.
• Full blood count and ferritin; pregnancy test; renal ultrasound.
• Cervical screening; biopsy of any atypical tissue.
• Histology after removal.

Observe small asymptomatic tumours and remove those that cause symptoms, taking care of the ureters.

• Supportive: observe small asymptomatic tumours with ultrasound every 6 to 12 months; menstrual diary; counsel on fertility.
• Pharmacological: tranexamic acid 1 g oral 8-hourly for up to 4 days during heavy bleeding (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) for pain; leuprorelin 3.75 mg IM every 4 weeks for up to 3 months before surgery; ferrous sulphate 200 mg oral 8-hourly for anaemia, continued for 3 months after haemoglobin normalises. Levonorgestrel 52 mg intrauterine system if the cavity is normal.
• Procedures: avulsion or excision of a prolapsed tumour by twisting and ligating the pedicle; vaginal, laparoscopic or open myomectomy for others; hysterectomy when fertility is complete, with care for the ureters; uterine artery embolisation where available.
• Special groups: in pregnancy, expectant care, paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain, and caesarean delivery if the tumour obstructs the pelvis. Avoid GnRH analogues and tranexamic acid when pregnant.
• Red flags: rapid growth, heavy bleeding with haemoglobin below 7 g/dL, hydronephrosis, fever, postmenopausal growth.
• Follow-up: review at 6 weeks after surgery; ultrasound at 6 and 12 months; histology review.