leiomyomas , also known as fibroids , are the most frequent benign uterine tumors to develop during a woman s reproductive years ; occurrence tends to regress after menopause.1 malign transformation of uterine leiomyoma ( ul ) seems to be a very rare event,2 but they are symptomatic in 20%30% of cases and are the main reason for approximately one - third of all hysterectomies in developed countries.3,4 symptoms related to ul are menstrual disorders , mainly menorrhagia , pelvic pain , and infertility , which can adversely affect pregnancy outcomes.5,6 ul disproportionately affects black women.4,7,8 the etiology of ul is unknown , but it can be influenced by genetic liability,9 hormonal environment,10,11 and local tissue mediators.10,12 definitive prevalence of ul in the general female population is also unknown , but differs by ethnicity , age , and method used for diagnosis.13 in clinical practice , transvaginal ultrasonography ( tvs ) is the most widespread method for evaluating ul , with an estimated accuracy of 87%92%.1416 the objective of this study was to determine the prevalence of ul , diagnosed by tvs , at a private health care setting located in the central eastern part of portugal , and to explore the demographic and clinical factors related to diagnosis and symptomatology .
the study retrospectively analyzed the medical files of all female patients who consecutively attended a gynecological consultation at a private health care setting located in covilh , portugal , from december 231 , 2010 .
excluded from the study were virgins , patients who had previously undergone a hysterectomy , or those pregnant at the time of the consultation .
all included patients were caucasian , except three , who were african . the same gynecologist ( jaf ) , who has more than 20 years of gynecological experience and competence in the practice of gynecologic ultrasound , attended all patients .
policies of the private clinic include recording of demographic and clinical data from every patient in a standard digital database . in all cases ,
the sonographic equipment used was a nemio 17 ( ssa-550a ) with a pvm-651vt 6 mhz endovaginal probe ( toshiba corporation , tokyo , japan ) .
for the anonymous use of data from patient files , written consent was obtained from the clinical director of the private health care clinic .
lsb and dgt analyzed the files of 624 patients who met the inclusion criteria , and from each file they retrieved age , weight , height , age at menarche , number of pregnancies and deliveries , marital status , menstrual cycles characteristics , and contraceptive method at time of consultation .
the presence , number , and largest dimension of the uls were retrieved from tvs records . for analysis ,
ultrasound records were analyzed for the presence or absence of ul , their number , location and largest dimension .
the data were organized and analyzed in statistical package for the social sciences software ( [ spss ] v 20.0 for windows ; ibm corporation , armonk , ny , usa ) , by smn .
using tvs , ul was diagnosed in 161 ( 25.8% ) of those 624 cases included in the study . from those 161 patients with an ultrasound - based diagnosis of ul , 99 ( 61.5% ) had previous knowledge of the disease . in three patients ,
the mean age was 39.6 years ; 66.2% of the women were married ; 68.2% reported having had at least one pregnancy and 64.2% at least one delivery ; 31.6% were asymptomatic .
ul was diagnosed by ultrasound in 11.0% of all women aged 20 to 39 years old , in 45.4% of all women aged 40 to 59 years , and in 19.5% of all women aged 60 years or more .
metrorrhagia and menorrhagia were the most usual presenting symptoms , and were recorded in 11.3% of all cases and in 22.3% of all women with an ultrasound diagnosis of ul .
uls larger than 3.0 cm were identified through ultrasound imaging in 24.2% of the cases . in order to uncover significant demographic and clinical differences between women with and without ultrasound diagnosis of ul ,
significant factors associated with an ultrasound - based diagnosis of ul were the following : 40 to 59 years of age ; married ; excessive body weight ( obese ) ; prior pregnancy or delivery ; non - use of the combined pill for contraception ; and symptoms of menorrhagia .
however , after adjustment by multivariate logistic regression analysis , age 40 to 59 years remained the single demographic and clinical factor found to be statistically associated with ultrasonographic diagnosis of ul .
when menorrhagia was the presenting symptom , an ultrasound imaging diagnosis of ul was made in 73.3% of cases ( table 3 ) . plotting a univariate analysis , metrorrhagia and menorrhagia as presenting symptoms
were significantly related to the tvs diagnosis of multiple uls , but not with the largest ul dimension ( tables 4 and 5 ) .
although lacking statistical significance , patients diagnosed with smaller uls seemed to be more symptomatic ( table 5 ) .
ul prevalence has been evaluated by different methods , such as population surveys,17 pathologic study of surgical specimens of hysterectomy,18 postmortem of women who died without gynecological diseases,19 and pelvic ultrasonography,13,20,21 with , as expected , different results .
kratochwil et al22 introduced ultrasound imaging of feminine pelvic organs in 1972 . in 1980 ,
muram et al23 defined criteria for ul identification with tvs as a relatively spherical mass that is echogenically different from the surrounding myometrium .
since then , tvs has become the most noninvasive , lowest - cost , and widespread method for evaluation of uterine pathology , with highly accurate performance.1416 the main disadvantage of ultrasound is that it is an operator - and device - dependent technique.24 in order to improve ul diagnosis accuracy , saline contrast sonohysterography and three - dimensional ultrasound have been proposed , although with conflicting results.24,25 nowadays , two - dimensional pelvic ultrasonography remains the best method for routine detection of uls.24,25 ultrasonography has been shown to be an insufficient method of myoma mapping , and magnetic resonance imaging should preferred for surgical therapy planning.25 in the present study , we found a 25.8% overall prevalence of ul , with the highest prevalence ( 45.4% ) in women aged 3950 years , which is in accordance with previous ultrasound - based studies.13,20,26 multiple uls were present in 50.1% of cases , which is lower than that reported in surgical specimens by cramer and patel ( 84%).18 in contrast to cramer and patel s findings , only 49.1% patients had a ul larger than 20 mm .
a previous diagnosis of ul had been made in 99 ( 61.5% ) patients , who were in watchful waiting management , which has been considered as a safe management option for asymptomatic ul.27,28 except in three cases submitted to resectoscopy for treatment of symptomatic submucous myomas , the main component of the leiomyomas was intramural .
a purely intramural myoma represents a temporary status , and its growth is dependent on the existing hormonal conditions of the woman.29 most of the knowledge about demographic and clinical risk factors for ul is based on results of large populations survey studies .
risk factors such as age , ethnicity , education , hormonal factors , diet , physical exercise , oral contraceptives use , childbirth , smoking and tissue injury has been reported , with conflicting results . in accordance with other ultrasound - based studies,13,20,26 after multivariate statistical analysis , we do nt found any demographic or clinical risk factor for ul , with exception of age .
the most common symptom of ul is abnormal uterine bleeding , especially menorrhagia.5 the mechanism of leiomyoma - associated menorrhagia is unknown , but submucous localization , vascular defects , and impaired endometrial hemostasis have been suggested as possible explanations.30,31 even small uls without distortion of the endometrial cavity can alter myometrial vascularization and contractibility .
a meta - analysis conducted by benecke et al32 reported that intramural uls may have a negative impact on fertility . in our series
, menorrhagia was significantly associated with multiplicity of uls , but not with the volume of the largest one , suggesting the importance of factors other than those associated with distortion of the myometrium and endometrial cavity .
extracellular matrix that embed ul cells influence both normal myometrial and ul cells , promoting proliferative activity and decreasing apoptosis.33,34 previous ultrasound - based studies2035 have reported that the presence , number , and volume of leiomyomas are unrelated to abnormalities in the menstrual cycle .
other studies,36,37 but not all,38 suggest that menstrual symptoms are related to tissue layer location in the uterine wall and with the axial position of leiomyomas . in our study ,
multiplicity of uls was significantly related to abnormal uterine bleeding ( menorrhagia and metrorrhagia ) as a presenting symptom .
currently , most women with menstrual disorders and multiple uls are scheduled for medical therapy followed by hysterectomy or myomectomy.39 hysterectomy seems a good option when childbearing wishes have been fulfilled;39 but it is not devoid of risks , morbidity and mortality as for any surgical procedure .
myomectomy is indicated for those women who wish to retain their fertility.39 the major disadvantage of surgical myomectomy is leiomyoma recurrence . in next 5 years , more than one - third of that women submitted to myomectomy will need additional surgical intervention for treatment of newly developed uls.40 minimally invasive procedures , such as laparoscopic myolysis , uterine artery embolization , uterine fibroid embolization , and magnetic resonance - guided focused ultrasound , as standard practice for treatment of symptomatic multiple uls are currently limited.41 it seems obvious that new treatments better than surgical approaches are needed for the management of symptomatic ul . in recent years
the development of uls has been shown to be dependent of sex steroids , especially progesterone,42,43 and many leiomyoma - related growth factors have been identified , including epidermal growth factor , platelet - derived growth factor , transforming growth factor beta , insulin - like growth factor , activin , and myostatin .
we speculate that , in patients with multiple uls and menstrual disorders , each ul can produce different kinds of growth factors or other biological mediators that may have additive negative effects on the myometrial and endometrial environment .
discovery of selective progesterone receptor modulators ( sprms ) has provided a new paradigm for treatment of symptomatic ul .
antiproliferative , growth factors down - regulation , and proapoptotic actions of sprms had been reported in vitro studies over cultured leiomyoma cells.43 randomized , placebo - controlled clinical trials have demonstrated that the sprm ulipristal can suppress menstrual bleeding , restore normal levels of hemoglobin , reduce ul volume , and improve leiomyoma - related symptoms.44,45 the main objective of symptomatic ul treatment is to regress symptomatology , because expectant management is suitable for most asymptomatic leiomyomas.27,28 it is expected that new therapies for the treatment of ul - associated symptomatology will be developed , based on the growing knowledge of functional aspects and regulatory mechanisms of leiomyoma biology and uterine homeostasis .
to our knowledge , this is the first population study conducted in portugal to assess the prevalence and demographic and clinical factors associated with the diagnosis of ul by ultrasound . in our portuguese population , the prevalence of uterine leiomyoma increases with age , and was similar to that reported in literature for white women .
menorrhagia and metrorrhagia were the more distressing symptoms , especially in patients with multiple uls diagnosed by tvs . in patients with abnormal uterine bleeding
, special attention should be taken to search for multiple leiomyomas during pelvic ultrasound examination .
further studies are needed to assess the biology and symptomatic impact of multiple versus single uls , in order to find more efficient therapeutic approaches .
 purposeto determine the prevalence of uterine leiomyomas , diagnosed by ultrasound , in a private health care setting located in the central eastern region of portugal , and to explore the demographic and clinical factors related to diagnosis and symptomatology.patients and methodsthe files of 624 patients attending a private clinic in covilh , portugal , from january 2 to december 31 , 2010 were retrieved for evaluation . 
 pelvic ultrasound record , age , weight , height , age at menarche , number of pregnancies and deliveries , marital status , menstrual cycles characteristic , and contraceptive method at consultation were included in the analysis.resultsuterine leiomyoma ( ul ) was diagnosed by ultrasonography in 161 ( 25.8% ) patients . 
 a single ul was diagnosed in 80 ( 49.7% ) patients . in 79 ( 49.1% ) patients , 
 the largest leiomyoma had a dimension < 20 mm . 
 prevalence of ul was age dependent : at 11.0% for women 2039 years old ; 45.4% for those aged 4059 years ; and 19.5% for women 60 years or older . 
 metrorrhagia was the most distressing presenting symptom . 
 when menorrhagia was the presenting symptom , the probability of having an ultrasound diagnosis of ul was 73.3% . 
 metrorrhagia or menorrhagia , as presenting symptom , was significantly related to the ultrasound diagnosis of multiple uls.conclusionul was especially prevalent in women aged between 40 and 59 years . 
 patients with multiple uls had significantly more abnormal uterine bleeding . in patients with menorrhagia or metrorrhagia , special attention 
 should be taken in searching for the presence of multiple uls during ultrasound . 
Introduction
Materials and methods
Results
Discussion
Conclusion