Fibroids is a benign mature tumor that has a connective tissue structure and emanates from the walls of the uterus. Clinical manifestations of fibroids are directly related to its growth and may include menstrual disorders, pain and pressure in the lower abdomen, dysuric disorders, constipation, lower back pain. Diagnosis according to the results of gynecological examination, ultrasound, ultrasound hysterosalpingoscopy, CT and MRI. Treatment can be conservative (medication), surgical (organ-preserving or radical), minimally invasive (endovascular).
D25 Uterine leiomyoma
Fibroid-type tumors can occur in various organs: most often there are fibroids of the ovaries, uterus, breast, skin. Disease can be represented by a single densification or nodular clusters; it grows asymptomatically and gradually. The size varies from a few millimeters to 20-30 cm or more in diameter. Uterine fibroids are practically not prone to malignancy.
Representatives of the Negroid race are more prone to fibroids than women of the European race. The incidence correlates with age: in women under 20 years of age, a fibroid tumor is diagnosed in 20%, under 30 years of age – in 30%, under 40 years of age – in 40% of cases.
Etiological moments in the development of uterine fibroids are not precisely defined. Most researchers point to the connection with increased hormonal sensitivity to estrogens and hereditary predisposition. However, even with these factors, fibroids may not always develop. The occurrence of fibroid tumors of the uterus is facilitated by additional conditions:
- the late onset of menarche;
- artificial termination of pregnancy in a woman’s anamnesis;
- absence of childbirth by the age of 30;
- complicated labor;
- frequent diagnostic curettage;
- taking estrogen-containing hormonal drugs for contraception or menopause treatment;
- concomitant chronic female diseases;
- lack of regular sexual activity, etc.
Often, the extragenital background for the development of fibroids is overweight, hypertension, obesity, thyroid diseases, diabetes mellitus, physical inactivity, stress, etc.
Uterine fibroids are hormone-dependent, therefore they do not develop in girls in premenarch and in women in the postmenopausal period. The growth of existing uterine fibroids may increase with the development of pregnancy, when the synthesis of estrogens increases. After childbirth, as a rule, there is a decrease in fibroid nodes to their initial state. In post-climacteria, with a decrease in the level of estrogens, the growth of fibroids stops, and it significantly decreases or disappears altogether.
The classification of fibroids is based on the location of the tumor within the uterus.
- Submucosal fibroids grow inside the uterine cavity, under its shell. With the growth of submucosal fibroma of the uterus, spasms and pains occur, severe bleeding often occurs.
- Subserous fibroids are formed outside the uterus, on its outer shell. Fibroid tumors of this type are asymptomatic until they grow to a size that prevents the functioning of neighboring organs.
- Interstitial uterine fibroids are a type of fibroid tumors that form in the walls of an organ. Gynecology encounters them most often. The growth of interstitial fibroids leads to an increase in the size of the uterus.
- Interlocking fibroids are localized between the supporting ligaments of the uterus. Removal of such fibroid tumors is associated with a high risk of damage to other organs or blood vessels.
- Stalked uterine fibroids are formed as a result of the appearance of a pedicle in subserous tumors. The growth of the stalk fibroma of the uterus is accompanied by an inflection of the leg and severe pain.
- Rarely occurring parasitic uterine fibroids are characterized by the attachment of a fibroid tumor to other organs. In some cases, cervical fibroids develops.
Symptoms of fibroids
In most women with this disease, the disease proceeds without any manifestations and only 15-25% develop clinical symptoms, depending on the location of the tumor in relation to the pelvic organs, the number, size and direction of growth of fibroid nodes. The presence of fibroids can be characterized by copious prolonged menstruation (menorrhagia) up to bleeding, which leads to anemia. In some cases, bleeding from the uterus is acyclic in nature (metrorrhagia).
Menorrhagia is accompanied by severe pain and abdominal cramps, the release of blood clots. With stalk fibroma of the uterus, pain often occurs during the intermenstrual period. With this pathology, a woman may feel discomfort or heaviness in the pelvic area caused by the pressure of fibromatous nodes on adjacent organs. Pain in the lower back and perineum is often noted due to compression of the nerves going to the lower extremities.
With fibroids, as a result of pressure on the bladder, the urge to urinate becomes more frequent; when the ureter is squeezed, hydronephrosis may develop; pressure on the wall of the rectum is manifested by constipation, pain during defecation. A woman with fibroids may experience painful sensations during intimacy.
Fibroids and pregnancy
Small asymptomatic uterine fibroids, as a rule, do not prevent the occurrence of pregnancy. The exception is fibroid tumors that block the fallopian tubes and block the path of sperm, which makes it impossible to fertilize an egg. The presence may adversely affect the course of pregnancy. Large nodes that reduce the free space of the uterine cavity do not allow the embryo to fully develop. Such uterine fibroids can cause late miscarriages or premature birth with the birth of a premature baby.
Large uterine fibroids can cause the wrong position of the fetus, which not only complicates the course of pregnancy, but also makes the birth act heavier. In such cases, a caesarean section is often performed. The most severe and dangerous for the birth process is the presence of cervical uterine fibroids, which creates an obstacle to the passage of the baby’s head and the threat of severe bleeding. Pregnancy management in women with uterine fibroids requires increased attention and consideration of all possible risks.
The growth of fibroids may be accompanied by twisting of the leg of the node, necrosis of the node (more often submucous or interstitial), hemorrhage. Twisting of the fibroma leg occurs with the clinic of “acute abdomen”. With necrosis, pain, fever, softening and soreness of the node appear. The probability of malignant degeneration of uterine fibroids is extremely insignificant and does not exceed 1%. With severe bleeding, uterine fibroids causes the development of anemia.
Complications associated with surgical treatment of uterine fibroids include postoperative infections, bleeding, adhesions in the pelvis, the formation of intrauterine synechiae. Pregnancy after conservative myomectomy occurs in 40-60% of patients. Also, organ-preserving interventions do not exclude the development of new fibroid nodes.
The initial detection of uterine fibroids usually occurs at a gynecologist’s consultation. With a two-handed vaginal examination, an enlarged uterus of dense consistency with a bumpy surface is determined. To confirm the diagnostic hypothesis, a number of experimental studies are required:
- Sonography. With the help of a transvaginal ultrasound of the pelvis, the location of the fibroids, its size, density and relation to neighboring structures are clarified, differentiation from ovarian cysts is performed.
- GSS. X-ray or ultrasound hysterosalpingoscopy allows to determine the presence of submucosal fibroma of the uterus in the endometrial cavity.
- RDV. In case of spontaneous bleeding during the intermenstrual period, separate diagnostic curettage or endometrial biopsy with histological examination of tissues is performed to exclude uterine cancer.
- Tomography. For final confirmation of the diagnosis of uterine fibroids and its distinction with uterine sarcoma, fibroma and ovarian cysts, MRI or CT is indicated.
- Diagnostic operation. Diagnostic laparoscopy is resorted to when it is impossible to distinguish uterine fibroids from ovarian tumor by noninvasive methods. Based on the totality of diagnostic data, tactics are determined in relation to fibroids.
All women with this disease are subject to the supervision of a gynecologist or gynecologist-endocrinologist. Small asymptomatic uterine fibroids require dynamic monitoring. Waiting tactics can be shown to patients of preclimacteric age. Conservative therapy is justified when:
- the size of uterine fibroids is less than 12 weeks of pregnancy;
- subserous or interstitial arrangement of nodes;
- absence of meno- and metrorrhagia, pain syndrome;
- contraindications of surgical tactics.
Drug therapy includes taking NSAIDs, iron preparations, vitamins, hormonal agents. The basis of conservative treatment is hormone therapy with various groups of drugs. Androgen derivatives (gestrinone, danazol) can be used to suppress the synthesis of ovarian steroids. Androgens are taken in a continuous course for up to 8 months, as a result of which the size of the uterine fibroids may decrease.
The use of progestogens (didrogesterone, norethisterone, progesterone) allows to normalize the growth of the endometrium in hyperplastic processes. The effectiveness of progestogens against fibroma is low, so their use may be justified in the case of small fibroid tumors of the uterus with concomitant endometrial hyperplasia. The course of treatment with gestagens lasts up to 8 months.
The use of the intrauterine hormonal system “Mirena” containing the progestogenic hormone levonorgestrel shows good results in the treatment of uterine fibroids. Regular release of the hormone into the uterine cavity prevents the growth of fibroids and has a contraceptive effect. The use of COCs (ethinylestradiol + dienogest, ethinylestradiol + drospirenone) effectively slows down the growth of small fibroid nodes (up to 2 cm). Treatment with combined drugs is carried out for at least 3 months.
The use of GnRH analogues (gozerelin, buserelin) is aimed at achieving hypoestrogenism. As a result of their regular intake, blood flow to the uterus and fibroid nodes decreases, which causes a decrease in the size of the fibroma. The effectiveness of therapy with GnRH analogues is reversible, since after discontinuation of their use, the nodes reach their original size in 4-6 months. In gynecology, GnRH analogues are often used in the preoperative period in order to reduce the size of the nodes for easier removal. Side effects from these drugs include hot flashes, pseudomenopause, vaginal dryness, mood instability, and the development of osteoporosis.
Surgical treatment is advisable for submucous growth, pronounced clinical symptoms (bleeding, pain, compression of neighboring organs), large nodular formations, combination of fibroma with endometriosis or ovarian tumors, necrosis of the fibroid node.
- Organ-preserving operations. This group includes conservative myomectomy with vaginal, laparoscopic or laparotomic access. During the operation, the fibroid node is enucleated while preserving the uterus. With a submucous location of the node, hysteroscopic myomectomy is resorted to without incisions through the channel of a flexible optical hysteroscope. Organ-preserving operations are carried out, if possible, for women planning a subsequent pregnancy.
- Radical operations. Radical methods surgery include supravaginal amputation of the uterus or complete hysterectomy. Removal of the uterus can be performed through the vagina, laparoscopic or open access and shown to patients who are not planning to have children.
- Minimally invasive methods. The modern method of treating uterine fibroids is embolization of the uterine arteries. As a result of endovascular occlusion of the vessels feeding the fibroids, the blood supply is blocked and the growth of the tumor node stops. Embolization of fibroids is a minimally aggressive and highly effective technique. In some cases, ultrasound ablation (FUZ) is used to treat uterine fibroids – “evaporation” of the node by high-frequency ultrasound under the control of MRI.
There are no specific methods for preventing uterine fibroids. Nevertheless, the exclusion of provoking factors (abortions, uncontrolled contraception, chronic inflammation, extragenital diseases, etc.) reduces the likelihood of fibroids. An effective way to prevent uterine fibroids is a regular visit to a gynecologist and ultrasound.