Cervical fibroids are a benign monoclonal tumor of smooth muscle cells of the myometrium. At the initial stage, the symptoms are not pronounced, with an increase in the size of the node, dyspareunia appears, pain in the lower abdomen. Cervical fibroids, depending on the localization, can squeeze the bladder, urethra and rectum, disrupt their functions. The tumor often develops a violation of blood flow, necrosis, its tissues become infected. Diagnosis is carried out by gynecological examination, ultrasound and MRI data are used. For treatment, minimally invasive methods of UAE, FUS-ablation are resorted to, with significant fibroids, its surgical removal is indicated.
Uterine fibroids (fibroma, leiomyoma, fibromyoma) are one of the most common benign tumors in women, diagnosed in 35% of patients of older reproductive age. Cervical fibroids account for only 5% of the total number of neoplasms. It has been established that pathology is often combined with extragenital diseases. Most women are diagnosed with obesity at the same time, symptoms of cardiovascular pathologies, neurosis and endocrinopathy are revealed. The risk is significantly increased in representatives of the African-American race.
The exact causes of cervical fibroids have not been established. According to one theory, node development begins with a progenitor cell that was damaged in the prenatal period. The second theory is based on the fact that the damage occurred in an already mature uterus. The following factors have been established that increase the likelihood of the formation of cervical fibroids:
- Microtrauma of the myometrium. During curettage, frequent medical abortions, gynecological intrauterine manipulations, damage to the muscle layer occurs. Inflammatory mediators, cytokines attack tissues, which leads to the appearance of a cell with morphological changes, which becomes the source of the development of fibroids.
- Endocrine disorders. Later menarche, obesity is accompanied by changes in the synthesis of female sex hormones. The exact mechanism of damage to the myometrium has not been established, but certain patterns can be traced. Fibroids are combined with overweight in 64% of patients.
- Absence of pregnancies and childbirth. During menstruation, vasospasm of the basal layer disrupts blood flow in the uterus, causes hypoxic cell damage. Pregnancy acts as a protective factor, reducing the number of menstruations in a woman’s life and reducing the risk of morphological rearrangements of the myometrium.
- Gynecological pathologies. Endometrial hyperplasia, endometriosis, chronic inflammatory processes lead to changes in hormonal status, damage muscle cells, contribute to the development of cervical fibroids. The danger is an increase in estrogens and progesterone.
Fibroids develop from a damaged smooth muscle cell. The nodes contain myometrium and connective tissue in various ratios. According to one hypothesis, during repeated menstrual cycles, changes in the cellular structure and disruption of the mechanisms of apoptosis occur. Non-eliminated cells become sources of uterine neck fibroids formation.
At first, tumor growth is supported by a natural fluctuation of hormones, while in obese women, due to the aromatization of androgens, the concentration of estrogens in adipose tissue is increased. Stimulate the progression of the tumor and other causes of hyperestrogenism. Progesterone in young patients at an early stage of the disease activates the mitotic activity of damaged myometrial cells.
After the increase in the size of the fibroid, it switches to autoregulation and no longer depends on the natural fluctuations of hormones in the blood. The tumor produces its own estrogens from androgens, the synthesis of connective tissue increases. Therefore, with large sizes of cervical fibroids, conservative treatment is impossible. UAE and FUS-ablation cause the death of muscle tissue, but do not affect the condition of the fibrous component of the node.
Nodes in the cervical region can be single or multiple. They are not classified with respect to the location of the tissue layers, but are attributed to a specific type of tumor. To systematize cervical fibroids, the position relative to other parts of the uterus and pelvic organs is used. The following types of fibromyoma are distinguished:
- Retroperitoneal. It is located in the post-peritoneal or post-peritoneal tissue, causes exfoliation of the peritoneum from the spine, accompanied by the early appearance of pain syndrome.
- Antecervical. It grows on the front of the neck, provokes compression of the bladder, urethra, urination disorders.
- Subperitoneal. Located on the isthmus of the uterus, exfoliates the peritoneum from the anterior abdominal wall.
- Retrocervical. It is located on the posterior surface of the cervix. With small sizes, it can cause defecation disorders.
- Paracervical. It forms on the side of the neck.
Symptoms of cervical fibroids
This type of fibroids passes from an asymptomatic form to a symptomatic one faster than other types. Clinical manifestations depend on the localization and size of the nodes. The first symptoms are associated with a painful impulse, which increases during sexual intercourse, during a gynecological examination. This leads to an increase in the volume of the node, its pressure on the nerve endings and the displacement of neighboring organs. The cervix becomes immobile, can fuse with the surrounding tissues.
Menstrual cycle disorders are often noted. Monthly periods lose their regularity, their duration increases, the volume of blood loss. Symptoms of dysfunctional uterine bleeding may appear, which occur in the middle of the cycle and lead to iron deficiency anemia. When fibroids protrude into the cervical canal, the outflow of menstrual blood is disrupted, large clots may be released.
Pressure on the bladder causes symptoms of dysuria. A woman feels frequent urges, urine stagnation may develop, which creates conditions for the addition of acute cystitis. Localization of fibroids on the posterior lip of the cervix is accompanied by a violation of defecation, a tendency to constipation. When the rectum is full, the pain over the womb increases due to compression of the tumor.
Frequent heavy bleeding leads to the development of severe anemia, which cannot be treated with oral iron-containing drugs. It causes symptoms of tissue hypoxia, worsens the general condition. Violation of blood flow in the arteries feeding the fibroids causes necrotic changes, ulceration of the tumor. The addition of infection is accompanied by the appearance of acute pain, symptoms of intoxication and requires emergency medical care.
Large-sized cervical fibroids can cause infertility, increases the risk of complications during pregnancy. Sometimes a high level of progesterone stimulates the active growth of nodes during the gestation period. In childbirth, the myomatous node does not allow the neck to open normally, which causes anomalies of labor activity, can lead to ruptures of the cervix and other complications.
For examination, a woman should contact an obstetrician-gynecologist. Diagnosis is carried out by non-invasive methods. With ulcerated cervical fibroids, an examination and consultation of an oncogynecologist is necessary to exclude a primary malignant tumor. A pronounced violation of defecation is a reason to visit a proctologist. The following examination methods are used to make a diagnosis:
- Gynecological examination. Cervical fibroids are clearly visible in mirrors as a tumor-like formation, with large sizes it is impossible to determine the external pharynx. With bimanual examination, the vagina is elongated and narrowed, fibroids are often of a soft consistency due to blood flow disorders. Palpation can be sharply painful.
- Transvaginal ultrasound. A myomatous node localized in the tissues of the cervix is determined. The size of the uterine body often lags behind the enlarged cervix. When using color Doppler mapping, there is a slight deterioration in blood flow in the vessels feeding the fibroids.
- MRI of the pelvis. Reflects the exact topography, size and number of myomatous nodes. Often, a cervical tumor is combined with fibroids of the uterine body. These studies are used when choosing treatment tactics.
Treatment of cervical fibroids
The choice of the method of treatment of fibroids depends on its size and on the woman’s desire to preserve reproductive function. With small neoplasias, therapy is not always prescribed, some doctors offer a wait-and-see tactic with stability and lack of node growth. A rapid increase in size, a violation of the function of neighboring organs is an indication for surgical removal of a neoplasm.
Treatment of fibroids with the help of medications is carried out under the supervision of a doctor of a women’s consultation with periodic ultrasound of the pelvis. Modern methods of non-surgical therapy do not require prolonged hospitalization, a one-day stay in the gynecology department is enough. One of the following methods is selected individually:
- Drug therapy. With small nodes, combined oral contraceptives can be used to normalize the hormonal background. As a stage of preoperative preparation, gonadotropin-releasing hormone agonists are prescribed to suppress ovarian function. Anti-progestogens are also used.
- UAE. In the treatment of cervical fibroids, uterine arteries embolization leads to a disruption of the node’s nutrition and its gradual regression. The method is ineffective in large neoplasms with a predominance of connective tissue. Does not affect a woman’s fertility.
- FUS-ablation. The effect of focused ultrasound through the anterior abdominal wall occurs under the control of MRI. Myoma warms up, its tissues necrotize. The healthy part of the uterus remains intact. One procedure is enough for treatment, after which the node resolves within a few weeks.
Surgery as the main method of treatment of cervical fibroids is indicated for node sizes greater than 4 cm, symptoms of local blood flow disorders. Organ-preserving techniques can be used, which are contraindicated if sarcoma is suspected due to the risk of recurrence and metastasis. The choice of the volume of intervention is carried out intraoperatively based on the results of an emergency histological analysis. The main methods of surgical treatment are as follows:
- Myomectomy. With the cervical location of the tumor, laparotomic access is used, since laparoscopy does not allow a good view, and displacement of the bladder and uterus increases the risk of bleeding during surgery. After peeling the node, a thorough suturing of its bed is carried out, anti-adhesive treatment is prescribed.
- Hysterectomy. Surgical treatment by removing the uterus together with the cervix is indicated for older women, with fibroids larger than 14-16 weeks of pregnancy, rapid progressive growth, especially in postmenopause. Ovaries are preserved to avoid the development of premature menopause.
Prognosis and prevention
Small cervical fibroids do not prevent the onset of pregnancy, but under the influence of increased progesterone, its intensive growth may begin with the appearance of unpleasant symptoms. With timely access to a doctor and the right treatment tactics, it is possible to preserve reproductive function and successful treatment of fibroids. After a myomectomy of one node, there is a possibility of tumor growth in another part of the organ.
Prevention consists in preventing abortions, treating gynecological and extragenital diseases, and maintaining a normal body weight. It has been proven that long-term use of combined oral contraceptives, high parity of labor and the absence of gynecological diseases significantly reduce the risk of cervical fibroids.