Arterial hypertension as an inaugural sign of myomatous uterus

Discussion

Uterine fibroids have an estimated incidence of 20%–40%, two to three times greater among black women and represent the most common gynaecological tumours in women of reproductive age.5 6 They are benign and hormonally dependent monoclonal tumours of the myometrial layer of the uterus, consisting of extracellular matrix that contains collagen, fibronectin and proteoglycan. According to FIGO classification, they are classified as submucosal (0–2), other (3–8) or hybrid (2–5) depending on their location and can be defined according to their size as small (<20 mm), intermediate (20–50 mm) and large fibroids (>50 mm).7

Women with uterine fibroids can remain without symptoms in 25%–50% of cases, and the tumour may reach considerable sizes before becoming symptomatic.6 On the opposite, fibroids may cause AUB-L (the most common presenting factor that symptomatic women typically complain about) or symptoms of compression, depending on their location. It is possible to come across backache, leg pain, increased urinary frequency, hesitancy and incontinence, constipation or even tenesmus.

Compression of the urinary tract is more likely to occur with larger fibroids, but the true incidence of a secondary hydronephrosis is unknown, as most patients do not have an evaluation of the urinary tract on ultrasound.2

A palpable abdominal mass extending from the pelvis strongly suggests a myomatous uterus. The diagnosis should be confirmed by transabdominal and transvaginal scans, performed together as uterine fundus may lie beyond the effective range of the transvaginal probe.1 If a large pelvic mass is identified, ultrasound examination should also include the urinary tract. MRI is recommended for the differential diagnosis of large tumours and for fibroid mapping prior to conservative surgery.8

Hydronephrotic state frequently results in hypertension due to an increased activity of the tubuloglomerular feedback system and renin–angiotensin–aldosterone axis, although normal biochemical renal function is still possible until up to 60% of renal function has been lost. There are two mechanisms by which increased activity of the renin–angiotensin–aldosterone axis may lead to hypertension: systemic vasoconstrictor effect of angiotensin II and aldosterone-mediated intrarenal salt and water retention. Some authors describe the resolution of hypertension following relief of ureter obstruction, suggesting that the intrarenal mechanism leading to the pressor effect is reversible.9

The treatment should be individualised based on symptoms, patient’s quality of life, size and location of the fibroid, but also taking into account her age and wish to preserve fertility. Hysterectomy still accounts for almost 75% of fibroid-related surgeries in the USA, despite the alternative of conservative surgery, such as myomectomy, or even other technical procedures, such as embolisation and the use of thermoablative devices. Medical treatment is also an option to control symptoms, and tranexamic acid, oral contraceptives, levonorgestrel intrauterine device or even gonadotropin-releasing hormone agonists and progesterone receptor modulators are the most used.1

In a hydronephrotic state due to fibroid compression, surgery is the gold standard procedure.10 11 The National Institute for Health and Care Excellence guidelines recommend that a hysterectomy should be considered only when other treatment options have failed, are contraindicated or are declined by a fully informed woman who no longer wishes to retain her uterus.12 In this specific setting and considering pregnancy desire, classic myomectomy remains the first option, as uterine artery embolisation has a potential commitment of the ovarian functioning and may damage the healthy myometrium.

Although large fibroids require a differential diagnosis with uterine sarcoma, this can only be reliably done postoperatively, after histopathological workup.13 14

Multidisciplinary teamwork is essential to establish a correct diagnosis and an adequate treatment. During patient clinical management, multidisciplinary approach was held, including general and oncological gynaecology members, reproductive surgeons, and nephrology, endocrinology and image colleagues to define the most appropriate diagnostic and therapeutic plan. It is important to carry out a detailed and rigorous differential diagnosis in the preoperative period, as well as to consider the patient as a whole when we define an effective treatment. In this case, an expert reproductive surgeon led the surgical team, ensuring a successful abdominal myomectomy and allowing uterus preservation and ureter relief with posterior blood pressure normalisation.