子宮良性腫瘤（子宮肌瘤與腺肌症）臨床精華及處置

Clinical Characteristics and Management of Benign Uterine Tumors（Myoma and Adenomyosis）

子宮肌瘤是婦女最常見良性與實質骨盆腫瘤，小肌瘤常為無症狀的；而臨床可呈現3個重要表徵，即過量或延長月經或子宮出血的典型症狀，骨盆壓迫與疼痛症狀以及生殖功能異常。夠大、不規則硬性腫瘤可能內診觸知，如拳頭大子宮已突出骨盆、可能於腹部檢查而懷疑子宮肌瘤。超音波掃瞄仍舊是最常應用的評估工具。子宮腺肌症以子宮瀰漫性腫大表現，可同時與肌瘤並存；而肌腺瘤以不規則腫瘤呈現；典型症狀為子宮異常出血與經痛。這些腫瘤的最後確定診斷仍須組織病理。原則上，無症狀平滑肌瘤不治療而追蹤，至今仍舊沒有周全證據顯示內科治療有症狀肌瘤之有效性。平滑肌瘤之根本治療方式即手術。子宮肌瘤與子宮腺肌症手術治療適用於子宮異常出血與大腫瘤壓迫症狀。手術前應慎選病人，若是未完成生育婦女、希望保留子宮婦女、不孕與復發性妊娠喪失，可以選擇肌瘤切除手術。已完成生育婦女、現在或將來可能有其他疾病危險性、或確定終止症狀、或活性出血或其他治療失敗的婦女，可以選擇最後徹底之子宮切除手術。

Uterine leiomyomas (fibroids or myomas) are the most common benign and solid pelvic tumors in women. Small myomas are usually asymptomatic. Clinical characteristics attributable to uterine myomas can be classified into three distinct categories: (1)those with classical symptom of heavy or prolonged menstrual or uterine bleeding, (2)those with pelvic pressure and pain, and (3)those with reproductive dysfunction. Large irregular hard tumors can be detected by pelvic bimanual examination. Tumors that are fist-sized or bigger, and raise upward from the pelvis can be palpated abdominally, are suspected as being myomas. Ultrasonography remains the most accessible method, diagnosing uterine myomas. Adenomyosis, a condition in which the endometrium breaks through the myometrium, often presents as a diffusely enlarged uterus (“globular”enlargement) and it may simultaneously occur with myomas. However, adenomyomas usually present as nodular lesions. Heavy uterine bleeding and painful menstruation are the major symptoms of adenomyosis and adenomyoma. A final diagnosis of these tumors depends on tissue histopathology. There is generally no need to treat women with asymptomatic myomas, but there is a need to follow them up. There are few randomized trial studies of effectiveness of medical management of symptomatic fibroids in women. Surgery is the mainstay of therapy for women with myomas and adenomyosis who have abnormal uterine bleeding or bulk-related symptoms. In our department, we emphasize proper patient selection for surgical therapy. For example, we may opt to perform myomectomies for women who have not reproduced, for women who desire to preserve the uterus, and for women with infertility or recurrent pregnancy loss. We often opt to perform hysterectomies for women who have reproduced, for women at present or future risks of other diseases, for women who desire definite relief symptoms, or for women who have active bleeding and/or for those for whom other treatments have failed.