What is Uterine Fibroids?
Uterine fibroids are a benign hormone-dependent tumor in women of reproductive age (mainly 30-45 years). Uterine fibroids up to 30% of gynecological diseases.
Causes of Uterine Fibroids
The modern view of the development of uterine fibroids is based on hormonal theory. Impaired excretion and metabolic conversion of estrogen, as well as the ratio of estrogen fractions (the predominance of estrone and estradiol in follicular, and estriol in the luteal phase) lead to morphological changes in myometrium. The mass of myometrium can increase as a result of hyperplasia of smooth muscle cells, which is initiated by estrogens, and hypertrophy of these cells. Along with estrogen the growth of fibroids stimulates progesterone. Hypertrophy of smooth muscle cells with uterine myoma is similar to their hypertrophy during pregnancy and can occur only when the combined effects of relatively high concentrations of estradiol and progesterone. In the luteal phase, progesterone increases the mitotic activity of the fibroids, in addition, progesterone affects fibroid growth by inducing growth factors. In the tissue, the myoma of the estradiol and progesterone receptors is greater than in the unchanged myometrium. Disruption of sexual steroid metabolism in myomatous nodes causes autocrine stimulation of cells with the participation of so-called growth factors. Mediators of the action of estrogen in uterine tissue of the uterus are insulin-like growth factors I and II.
Along with the hormonal aspects of the pathogenesis of uterine fibroids, an important role is played by changes in the body’s immune reactivity, especially in chronic foci of infection; pronounced changes in hemodynamics of the pelvis, as well as hereditary predisposition. Growth zones of fibroids are formed around inflammatory infiltrates and endometrial foci in the myometrium. Phenotypic transformation of smooth muscle cells and degenerative changes in conditions of impaired microcirculation play a significant role in increasing fibroids. The rudiments of myoma nodes can form at the embryonic stage. The growth of progenitor cells continues for many years against the background of a pronounced ovarian activity under the action of estrogen and progesterone.
Myomas are heterogeneous in structure. In terms of tissue composition, the nodes are divided into fibroids, fibroids, angiomyomas, and adenomyomas.
According to morphogenetic features, there are 3 main forms:
- simple fibroids, developing the type of benign muscle hyperplasia;
- proliferating fibroids with morphogenetic criteria for a true benign tumor. Every 4th patient with uterine fibroids proliferating with the rapid growth of myomatous nodes. Pathological mitoses in proliferating myomas do not exceed 25%;
- predysarcomas – a stage on the path of true malignancy.
Predsarcoma includes multiple foci of proliferation of myogenic elements with atypia, heterogeneity of cell nuclei; the number of pathological mitoses reaches 75%. However, true malignancy of fibroids occurs in less than 1% of clinical observations.
Depending on the localization and growth of myoma nodes, submucous (submucosal) myomatous nodes that grow into the uterine cavity and deform it (see the section “Intrauterine pathology”) and subserous (subperitoneal) nodes are isolated. Myomatous nodes grow in the direction of the abdominal cavity. If the myoma node splits the leaves of the wide uterine ligament as it grows. It is called the intraligamentous myoma node. Interstitial (intermuscular) myomatous nodes grow from the middle layer of the myometrium and are located deep in the myometrium.
Symptoms of Uterine Fibroids
The clinical picture of subserous myomatous nodes largely depends on their topographic location and size. There is a classification of subserous nodes based on the ratio of interstitial and subserous components:
- 0 type – subserous myomatous node on a thin base;
- 1st type – less than 50% of the volume of the myomatous node is located interstitially;
- 2nd type – more than 50% of the volume of the myomatous node is located interstitially;
- 3rd type – intraligamentary subserous myomatous nodes.
Individual subserous myomatous nodes (type 0) of small sizes may not clinically manifest themselves for a long time, but as their size increases, signs of malnutrition of the tumor appear, the likelihood of torsion of the legs of the myomatous node increases. Patients may complain of discomfort in the lower abdomen, periodically arising pulling or acute pain. Pain can radiate to the lumbar region, leg, and perineum. With the complete torsion of the legs of the myomatous node or the appearance of an extensive zone of necrosis, the pain becomes intense, symptoms of peritoneal irritation and general clinical signs of peritonitis appear.
Interstitial-subserous myomatous nodes of the 1st and 2nd types are less susceptible to destructive processes due to malnutrition, do not clinically manifest themselves for a long time and can reach a diameter of 10-25 cm or more. Patients are concerned about a feeling of heaviness and discomfort in the lower abdomen, an increase in the abdomen. Pain syndrome is associated with a stretching of the visceral peritoneum of the uterus, pressure of the myomatous nodes on the nerve plexuses of the small pelvis. With circulatory disorders in the large myomatous nodes, the pain is acute. Depending on the location of the subserous nodes, a dysfunction of neighboring organs is possible. The growth of the myomatous node anteriorly contributes to the development of dysuric phenomena: patients complain of frequent urination, incomplete emptying of the bladder, peremptory urination, acute urinary retention. The isthmus of the myomatous node on the posterior wall of the uterus leads to pressure on the rectum and disrupts bowel movements. The subserous nodes located on the side wall of the uterus in the lower and middle third, upon reaching large sizes, change the topography of the ureter, can lead to impaired passage of urine from the affected side, the occurrence of a hydroureter and the formation of hydronephrosis. Subserous myomatous nodes rarely cause menstrual dysfunction. However, with multiple subserous myomatous nodes of type 1-2, a violation of the contractility of the myometrium with menometrorrhagia is possible.
Interstitial myomatous nodes lead to an increase in the uterus and can significantly affect the contractility of the myometrium. Patients complain of profuse long periods, less often intermenstrual bleeding from the genital tract. However, there is no direct correlation between the size of the uterus and the appearance of uterine bleeding. Anemia in patients with uterine myoma can be a consequence of chronic hemorrhage and acute uterine bleeding. Without menstrual irregularities, anemia can be caused by the deposition of blood in the uterus, enlarged by myomatous nodes. Patients with large uterine fibroids (more than 20 weeks of pregnancy) may have lower vena cava syndrome – palpitations and shortness of breath when lying down. Patients may complain of pain, an increase in the abdomen, acute urinary retention, hydronephrosis are possible.
With a combination of interstitial, submucous and subserous nodes, the clinical picture is more diverse than with isolated myomatous nodes.
Diagnosis of Uterine Fibroids
During a gynecological examination, individual subserous myomatous nodes (type 0) are palpated separately from the uterus as round, dense, mobile formations. Subserous nodes of the 1-2th type lead to an increase in the uterus and a change in its shape. The uterus can reach considerable size, its surface becomes tuberous, myomatous nodes are dense, and when blood circulation is disturbed, their palpation is painful. Subserous nodes of the 3rd type (intraligamentary) are defined on the side of the uterus, performing the parametrium. The lower pole of the knot is achievable by palpation through the lateral vaginal fornix, a knot of dense consistency, limitedly mobile when trying to displace. In patients with interstitial myoma, an enlarged uterus of dense consistency with a smooth or tuberous surface is palpated, usually painless.
With ultrasound, subserous myomatous nodes are visualized in the form of round or oval formations that extend beyond the external contour of the uterus. Myomatous nodes often have a layered structure and the so-called pseudocapsule, which is formed as a result of compaction and hypertrophy of the myometrium adjacent to the myomatous node. Echogenicity and sound conduction depend on the histological structure of the myomatous node. In homogeneous hyperechoic myomatous nodes, fibrous tissue predominates. The appearance of intranodular hypoechoic inclusions indicates necrosis or cystic cavities. Hyperachogenic inclusions with an acoustic absorption effect occur with calcified degenerative changes. Ultrasound scanning allows you to detect interstitial myomatous nodes with a diameter of not more than 8-10 mm. According to ultrasound, depending on the growth direction of the interstitial myomatous nodes, it is possible to predict the appearance of submucous and subserous myomatous nodes. The centripetal location of the fibroids indicates the growth of the interstitial myomatous node in the uterine cavity, with an increase in such a node over 10 mm, a distinct deformation of the uterine cavity appears. Centrifugal growth of nodes occurs towards the abdominal cavity. Central growth occurs with true intermuscular localization of myomatous nodes and leads to diffuse enlargement of the uterus. Ultrasound scanning is supplemented by a study of peri- and intranodular blood flow to clarify the tumor morphotype. The growth of myomatous nodes depends on an increase in blood flow in the uterine vasculature. The density of blood vessels is associated with the morphological structure and localization of the myomatous node. A large number of arteries are located on the periphery of the myomatous node. Ultrasound, supplemented by dopplerography, allows you to evaluate the features of blood circulation in myomatous nodes. With a simple myoma, a single peripheral blood flow is recorded, with a proliferating myoma – an intense central and peripheral intratumoral blood flow.
To clarify the topographic location of subserous myomatous nodes, ultrasound tomographs that provide a three-dimensional ultrasound image can be used.
For differential diagnosis of subserous nodes and tumors of the retroperitoneal space, enlarged lymph nodes, tumors of the pelvis and abdominal cavity, along with ultrasound, computer and magnetic resonance imaging are used.
Diagnostic laparoscopy is indicated when differential diagnosis is not possible between subserous uterine myoma and tumors of the abdominal cavity and retroperitoneal space by non-invasive methods.
Hysteroscopy is indicated for menstrual irregularities in patients with the uterus, increased by no more than 12-13 weeks of pregnancy. With a larger increase in the uterus, the information content of hysteroscopy decreases. To exclude the pathology of the endometrium and the mucous membrane of the cervical canal in patients with metrorrhagia and contact blood secretions, regardless of the size of the uterine fibroids, a separate diagnostic curettage of the uterine mucosa is performed.
Uterine Fibroids Treatment
The question of the appropriateness of treatment for small uterine myoma without clinical manifestations has not been finally resolved. Nevertheless, such patients are shown dynamic observation by a gynecologist with mandatory ultrasound monitoring once a year. Patients are given recommendations aimed at preventing the further growth of fibroids and the regulation of the hypothalamic-pituitary-ovarian relationships. Excess carbohydrates and fats are excluded from the diet, spicy and salty dishes are limited. Patients are advised to avoid thermal procedures, they can not sunbathe in the sun and in an artificial tanning bed. Myoma can increase due to massage and physiotherapy for somatic diseases. In order to regulate menstrual function, vitamin therapy is recommended for the phases of the menstrual cycle (folic acid and B vitamins in the first phase and vitamins C, E and A in the second phase) or the use of hormonal contraceptives. Monophasic estrogen-progestogen drugs and low-dose progestogens are preferred.
Conservative treatment of uterine fibroids is performed to inhibit the growth or reverse development of the tumor, and to treat menometrorrhagia and anemia. For this purpose, derivatives of 19-norsteroids (norkolut, primolut-nor, norethisterone, orgametrile, gestrinone, non-mestran) are prescribed. Under the influence of these drugs, myoma and, accordingly, the uterus decrease on average by 1 – 2 weeks of pregnancy; blood loss during menstruation decreases and hemoglobin levels normalize. In reproductive age, gestagens are prescribed cyclically from the 16th to the 25th day of the menstrual cycle or from the 5th to the 25th day for 6-24 months. As a rule, the clinical effect can be obtained with a myoma, not exceeding 8 weeks of pregnancy. In patients of perimenopausal age, it is advisable to use gestagens in a continuous mode of 6 months, thereby contributing to drug-induced atrophy of the endometrium and the onset of menopause.
Medication methods for the treatment of uterine fibroids (non-hormonal and hormonal therapy) are aimed at slowing the growth of the tumor and reducing the severity of the clinical course of the disease. Women with a small (up to 2 cm) size of the myomatous node are subject to this type of treatment. Hormone therapy of this pathology takes place, however, there is an alternative – the non-hormonal drug Quinol, which has no side effects and contraindications for hormone therapy, but at the same time it softly normalizes the balance of estrogen, i.e., eliminates the main cause of the disease and fights with the repeated growth of myomatous nodes.
Antigonadotropins having a steroid structure (danazol, gestrinone), and gonadoliberin agonists (zoladex, dipherelin, buserelin, etc.) affect the growth of myomatous nodes. Under the influence of GnLH agonists, a decrease in the volume of myomatous nodes up to 55% is possible. However, after discontinuation of the drug and restoration of menstrual function, 67% of patients begin an expansive growth of fibroids with signs of malnutrition. The use of GnLH agonists is advisable in patients of the perimenopausal period, since it causes a steady reduction in steroidogenesis and the onset of menopause. Antigonadotropins (nemistran, gestrinone) are also used to create drug menopause.
GnLH agonists are used for preoperative preparation for conservative myomectomy. Under the influence of GnLH agonists, the structure of the myomatous node becomes denser, and the intranodular and perinodular blood flow decreases. A decrease in intratumoral blood flow, as well as a decrease in fibroids and myometrial density around myomatous nodes, are most pronounced after 2-3 injections of the drug. With a longer course of hormonal preparation, due to the progressive reduction in arterial blood flow, destructive and necrobiotic processes in myomatous nodes are possible, which complicate conservative myomectomy.
GnLH agonists can change the topography of interstitially submucous nodes towards the uterine cavity, and interstitially-subserous nodes – towards the abdominal cavity.
The use of GnLH agonists can facilitate laparoscopic conservative myomectomy and hysterectomy in 76% of patients due to a decrease in the uterus and myomatous nodes. With all conservative myomectomies after hormonal preparation, blood loss is reduced by 35-40%.
In order to prevent menometrorrhagia and the growth of fibroids, the Mirena intrauterine hormonal system containing a capsule with levonorgestrel (gestagen) is used. “Mirena” is administered for a period of 5 years, it provides regular intake of levonorgestrel into the uterine cavity and local action on the endometrium and myometrium with minimal systemic effects. Menstruation becomes scarce, in some cases, drug amenorrhea occurs. Contraindications for the use of Mirena: submucous myomatous nodes, large uterine cavity, as well as absolute indications for surgical treatment.
Surgical treatment of uterine fibroids remains leading, despite fairly effective conservative methods. The frequency of radical operations is 80%. Surgical interventions for uterine fibroids account for 45% of abdominal interventions in gynecology.
Indications for surgical treatment of patients with uterine myoma:
- large fibroids (13-14 weeks of gestation);
- rapid growth of fibroids (more than 4 weeks per year);
- submucous node location;
- subserous node 0 type;
- malnutrition, necrosis of the myomatous node;
- cervical myoma;
- uterine fibroids and menometrorrhagia, anemizing the patient;
- growth of fibroids in postmenopausal women;
- impaired function of neighboring organs;
- infertility and habitual miscarriage.
Surgical treatment of uterine fibroids can be radical or functional (organ-preserving). Currently, there is a tendency to reduce the number of radical surgical interventions for uterine fibroids and to expand indications for organ-sparing surgeries. Functional surgery of the uterus, in addition to preserving menstrual and reproductive functions, helps to prevent disruption of the activity of the pelvic organs and helps prevent their omission.
The volume of surgery depends on various factors. Surgical treatment of uterine fibroids is considered radical when performing a hysterectomy and includes uterine extirpation or supravaginal amputation of the uterus without appendages. The cervix plays an important role in the formation of the pelvic floor and blood supply to the genitourinary system, so the volume of surgical intervention expands to the extirpation of the uterus in women of reproductive age with recurrent background processes of the cervix, leukoplakia with dysplasia of the stratified squamous epithelium, as well as with the cervical and isthmus location of the myomatous. In patients with a newly diagnosed background disease of the cervix, conservative treatment of this pathology should be performed at the first stage, and supravaginal amputation of the uterus should be performed at the second stage.
A hysterectomy can be performed by abdominal, laparoscopic and vaginal approaches. The choice of surgical access depends on the size of the uterus, the size and location of the myomatous nodes, as well as on the experience and qualifications of the surgeon.
Functional surgery of fibroids. There are methods of surgical intervention that allow you to maintain adequate blood supply to the ovaries by highlighting the ascending branches of the uterine arteries and preserve menstrual function with high supravaginal amputation, as well as uterine defunding.
Menstrual and reproductive functions in uterine myoma can be preserved by conservative myomectomy. Myomectomy consists in the removal of myomatous nodes and the preservation of the uterine body and can be carried out by laparotomy, laparoscopic and hysteroscopic access.
The choice of surgical access depends on:
- size of the uterus;
- localization of myomatous nodes;
- the number and size of myomatous nodes;
- preoperative hormonal preparation;
- endoscopic equipment;
- surgeon’s experience in performing endoscopic operations.
Laparotomy access is preferred for multiple interstitial myomatous nodes more than 7-10 cm, with low cervical-isthmal localization of nodes, especially along the posterior and lateral walls of the uterus. Laparotomy access allows you to adequately compare the edges of the bed of the removed large site with the imposition of double-row vicryl stitches. The course of the planned pregnancy and the management of childbirth depend on the usefulness of the uterine scar.
Laparoscopic access is indicated for subserous myomatous nodes of the 0-3th type, as well as for interstitial myomatous nodes with a diameter of not more than 4-5 cm.
Individual subserous myomatous nodes (type 0) do not present difficulties for endoscopic removal. The node after fixation with serrated forceps is separated from the uterus, coagulating the leg, after which it is crossed with scissors or a coagulator. Modern marcelitors allow nodes of various sizes and weights to be removed from the abdominal cavity; small myomatous nodes can be removed through mini-laparotomy and colpotomy openings.
Interstitial-subserous myomatous nodes are removed by decapsulation and enucleation with phased coagulation of the bleeding vessels of the bed. With a significant size of the bed remaining after conservative myomectomy, along with electrosurgical coagulation, endoscopic two-row sutures are applied. Suturing the site of the node allows for additional hemostasis, helps prevent adhesions in the pelvis and forms a full scar.
Intraligamentary nodes are removed after dissection in the transverse or oblique direction of the anterior leaf of the wide uterine ligament and enucleation.
Of particular difficulty is the removal of small interstitial myomatous nodes. Located in the thickness of the myometrium, myomatous nodes do not deform the external contours of the uterus, which complicates visual diagnosis during surgery. An indication for the removal of myomatous nodes in these cases is preparation for pregnancy or to stimulate ovarian function in women with infertility. For accurate topical diagnosis, intraoperative ultrasound is performed using vaginal, rectal and transabdominal sensors. This allows you to accurately localize and remove interstitial nodes with a diameter of I to 3 cm with minimal trauma. After ultrasonic localization, a small deep incision is made above the site of the site, the myomatous site is captured with gear forceps or a corkscrew. The feeding vessels coagulate after enucleation of the node.
There is no consensus on the number of myomatous nodes removed. The tactics of the doctor depend on the goal – to maintain reproductive or menstrual function. It is important that after conservative myomectomy, pregnancy can be prolonged.
Endoscopic myomectomy allows you to save menstrual function in all operated patients and restore fertility in every 3rd patient. Pregnancy can be planned 6 months after surgery. After removal of the large interstitial-subserous myomatous nodes, as well as after removal of the interstitial nodes, it is preferable that cesarean section be used.
With submucous myomatous nodes, conservative hysteroscopic myomectomy is possible by mechanical, electrosurgical method and using a laser.
Conservative surgical methods for treating uterine fibroids include laparoscopic myolysis (vaporization of the myomatous node with a laser) and uterine artery embolization.
Uterine artery embolization (EMA) is carried out under radiological control by catheterization of the femoral artery and emboli to the uterine artery. Thus, the blood supply is disturbed and dystrophic processes occur in the myomatous nodes. Myomatous nodes are reduced, their further growth is prevented.
Forecast. Uterine fibroids refers to benign tumors with rare malignancy, so the prognosis for life is favorable. However, the growth of fibroids may require surgical treatment with the exception of menstrual and reproductive functions in young women. Even small myomatous nodes can cause primary and secondary infertility.
Uterine Fibroids Prevention
Prevention of uterine fibroids is the timely detection of the disease in the early stages.