Intramural fibroid is an intermuscular connective tissue tumor localized in the thickness of the uterine wall. As the interstitial fibroma grows, it causes an increase in the size of the uterus, a violation of the menstrual cycle, feelings of pressure and pain in the pelvic area, anemia. Intramural fibroid is diagnosed by gynecological examination, ultrasound, echohysterosalpingoscopy, tomographic examination. Depending on the severity of the clinic, fibroma treatment may include hormone therapy, uterine artery embolization, myomectomy, hysterectomy.
Intramural fibroid develops in the middle muscle layer of the uterine wall. Intramural fibroid is more often diagnosed in patients of reproductive age and does not occur at all before puberty. Studies conducted by modern gynecology indicate that interstitial fibroma is the most common and accounts for about 70% of all fibroid tumors of the uterus. Such fibroids can be located within the muscle layer, grow inwards or towards the abdominal wall. Intramural fibroid can be represented by a single seal or nodular cluster.
In the process of growth, interstitial fibroma deforms the uterine cavity, increases its size, presses on the fallopian tubes, intestines, ureters, bladder, causing clinical symptoms. The probability of malignant degeneration of intramural fibroid is no more than 1% of cases; malignancy is possible only in the absence of treatment.
Despite numerous studies in the field of the etiology of fibroma, the exact causes of its development in each individual case remain unknown. The main predisposing factors for the development of intramural fibroid are heredity, late formation of menstrual function, lack of a history of pregnancies; numerous surgical or medical abortions or diagnostic curettage; uncontrolled contraception with estrogen-containing drugs; chronic endometritis and salpingoophoritis, endometriosis; disorders in the hypothalamic-pituitary-ovarian regulation system leading to hypergonadotropism, hyperestrogenism or progesterone deficiency.
A favorable background for the development of intramural fibroid creates an artificial termination of pregnancy, especially the first one. The development of intramural fibroid correlates with obesity, varicose veins, arterial hypertension, thyroid diseases, diabetes mellitus, stress factors, immunodeficiency.
In the initial period, intramural fibroid may not manifest itself symptomatically for a long time, therefore it is often detected during a planned consultation with a gynecologist on the basis of enlargement and compaction of the uterus. With further growth of intramural fibroid, there is an increase and prolongation of menstrual bleeding (menorrhagia) and their soreness (dysmenorrhea), as well as the appearance of dysfunctional uterine bleeding. Abundant, monthly recurring blood loss eventually leads to the development of anemia.
The growing interstitial fibroma of the uterus can manifest itself with constant pulling and aching pains, as well as sensations of strong pressure in the pelvic area and abdomen. With an increase in the size of the fibroma, depending on the direction of its growth, compression of neighboring organs (fallopian tubes, bladder, rectum) occurs with the development of their dysfunction. Compression of the urethra may be accompanied by reflux (backflow of urine) with the development of cystitis or pyelonephritis. Therefore, patients with intramural fibroid often turn to a urologist, gastroenterologist or proctologist for dysuric disorders, abdominal pain, constipation.
Deformation of the uterine cavity and compression of the fallopian tubes by a growing fibroid node can cause termination of an already existing pregnancy or secondary infertility. Large interstitial fibroids, which sometimes enlarge the uterus to the size of a full-term pregnancy, can lead to venous stagnation in the pelvis, varicose veins and thrombophlebitis.
During gynecological vaginal examination, attention is drawn to the increase in the size of the uterus, the abrupt transition of the cervix to the fibroid node and their simultaneous displacement, the impossibility of separate palpation of the uterine body. In the presence of interstitial fibroma, the shape of the uterus becomes spherical or asymmetric. To clarify the size, density and location of the fibroid tumor, gynecological ultrasound and ultrasound hysterosalpingoscopy are performed, which, among other things, allow differentiating the tumor of the uterus from ovarian cysts.
Diagnostic hysteroscopy is informative for the recognition of interstitial fibroids with centripetal growth leading to deformation of the uterine cavity. In doubtful cases, CT and MRI, laparoscopy, intrauterine phlebography are resorted to. To detect endometrial hyperplasia and exclude endometrial cancer, diagnostic curettage of the cervical canal and uterine cavity is performed.
Conservative treatment of intramural fibroid is aimed at stopping tumor growth, relieving symptoms and is carried out under the supervision of a gynecologist-endocrinologist. The patient is prescribed hemostatic, immunomodulatory and hormonal therapy (with progestogens, estrogen-progestogenic, antigonadotropic drugs, GnRH agonists, etc.), including the installation of an intrauterine system. Conservative management of intramural fibroid can only delay surgical intervention or restrain the growth and manifestations of the tumor until the menopause, when fibroid nodes usually shrink by themselves.
Surgical tactics in relation to intramural fibroid are indicated for large (over 12 weeks. pregnancy) fibroid nodes, their rapid growth (over 5 weeks. per year), pronounced clinical manifestations, combination with endometriosis, ovarian tumors, infertility, suspected node necrosis, etc. situations. The methods of organ-preserving surgical treatment of intramural fibroid include laparoscopic conservative myomectomy. In this case, only the fibroid node is removed, which preserves the possibility of subsequent pregnancy for the woman.
Radical surgical treatment of intramural fibroid is hysterectomy (laparoscopic or open removal of the uterus) or supravaginal amputation of the uterus. Such interventions are more often carried out for women who have passed the childbearing age or do not plan to have children. New minimally invasive methods of treatment of intramural fibroid are uterine artery embolization and ultrasound ablation of the fibroid node.
Most often, with interstitial uterine fibroids, degenerative tumor changes (heart attacks, aseptic necrosis) develop, which more often occur during pregnancy or shortly after childbirth. In case of secondary infection, the situation may be complicated by limited or diffuse peritonitis, sepsis.
Pregnancy that has occurred against the background of the existing interstitial fibroma of the uterus can provoke rapid growth of the node or be complicated by miscarriage, premature birth, delayed fetal development, anomalies of placental presentation, incorrect position and presentation of the fetus, discoordinated labor, fetal hypoxia, postpartum bleeding. Therefore, the management of pregnancy and the postpartum period in patients with intramural fibroid requires increased monitoring by an obstetrician-gynecologist.