Multiple uterine fibroids – the presence of two or more myomatous nodes of different sizes, growth type and localization. Clinical manifestations and their severity depend on the size and location of fibroids. There may be abundant and prolonged menstruation; feelings of heaviness, pressure and pain in the lower abdomen, problems with conception and pregnancy. Gynecological examination, pelvic ultrasound, HSG, hysteroscopy, laparoscopy helps to detect multiple uterine fibroids. Taking into account many factors (number, size, location of nodes, age and reproductive plans of the patient), the choice can be made in favor of conservative therapy or surgical treatment (myomectomy, hysterectomy).
Multiple (multi–node) uterine fibroids (leiomyoma, fibromyoma) are several benign tumor growths emanating from the myometrium. Multiple uterine fibroids are detected in 80% of patients with this pathology. In recent decades, the age of women with myomatosis has rejuvenated – if earlier the disease was mainly diagnosed in late reproductive and premenopausal ages (40-50 years), today fibroids are increasingly detected in patients 30-35 years old.
At the same time, nodes of different sizes can occur: small – up to 2 cm, medium – up to 6 cm, large – more than 6 cm in diameter. Myomatous nodes may have the same or different localization (in the body or cervix) and the direction of growth (subserous, submucous, interstitial, interstitial uterine fibroids). In some cases, multiple uterine fibroids are detected, growing according to the “node in node” type. In 95% of all observations, the nodes are located in the body of the uterus, less often in the neck and ligamentous apparatus. Quite often, multiple uterine fibroids cause menstrual and reproductive dysfunction, so its treatment and prevention are the most important tasks of clinical gynecology.
According to most researchers, uterine fibroids occur due to a violation of the regulation of the growth of smooth muscle cells of the myometrium. Such a process can be initiated by ischemia caused by arterial spasm during menstruation, endometriosis, inflammatory diseases (metritis, metroendometritis), hormonal imbalance, damage to the myometrium during gynecological manipulations (abortions, separate diagnostic curettage), prolonged use of IUDs. These damaged smooth muscle cells become the rudiments of future myomatous nodes.
In the initial stage, the growth of uterine fibroids occurs under the influence of changes in the concentration of sex hormones during the menstrual cycle, but later due to the inclusion of autocrine-paracrine regulation mechanisms, the growth of nodes becomes relatively autonomous, independent of the general hormonal background. The increase in the size of the node occurs both due to the increase in the proportion of connective tissue in its structure, and due to the local production of estrogens.
Factors that stimulate the proliferation of multiple uterine fibroids may be hereditary predisposition, stress, endocrine and metabolic disorders (hypothyroidism, obesity), prolonged sexual abstinence, sexual dissatisfaction. An important role in the pathogenesis of the disease is played by a violation of the balance between estrogen and progesterone in the female body, which is greatly facilitated by the absence of pregnancies and childbirth, repeated artificial termination of pregnancy.
Both single and multiple uterine fibroids have similar clinical manifestations, which depend mainly on the size and nature of the growth of nodes. Fibroids of small size, especially with a subserous location, are often asymptomatic: menstruation comes regularly and on time, abdominal pain is absent. As a rule, asymptomatic multiple uterine fibroids are detected during routine ultrasound of the pelvic organs.
Submucous and interstitial (intramural) myomatous nodes are characterized by menorrhagia. Uterine bleeding of varying intensity can also occur during the intermenstrual period. Constant blood loss leads to the development of iron deficiency anemia. Menstruation is usually accompanied by severe pain. The growth of old and the appearance of new nodes in multiple uterine fibroids leads to the fact that aching pains in the pelvic region become permanent. Large interstitial and subserous uterine fibroids can exert strong pressure on neighboring organs (bladder, ureter, rectum), resulting in difficult or frequent urination, chronic constipation, hydronephrosis.
Submucous uterine fibroids, including multiple, are manifested by constant liquid whites of yellowish color, meno- and metrorrhagia, cramping pains in the lower abdomen at the “birth” of the node. Submucosal fibroids can also be complicated by surface erosion and necrosis, node, rarely by malignancy.
With multiple uterine fibroids of any localization, the transformation of the uterine mucosa is noted: from glandular-cystic hyperplasia and polyposis to endometrial atrophy. With a violation of the nutrition of one or more nodes (due to ischemia of interstitial fibroids, twisting of the leg of subserous fibroids), symptoms of acute abdominal pain develop: sharp abdominal pain, nausea and vomiting, fever, tension of the muscles of the anterior abdominal wall.
Multiple uterine fibroids and pregnancy
The effect of multiple uterine fibroids on a woman’s ability to conceive, bear and have a normal child is ambiguous. Some fibroids (subserous, small in size) may not have any significant effect on reproductive abilities. At the same time, during pregnancy, the myomatous nodes themselves may behave differently: slightly increase, decrease or stabilize in size.
The inability to conceive with multiple uterine fibroids may be due to the following factors: anovulation due to hormonal imbalance; violation of the patency of the cervical canal or fallopian tubes, preventing fertilization; endometrial pathology, complicating implantation. As a rule, reproductive function decreases in the presence of fibroids with submucous and interstitial growth.
However, even if pregnancy has occurred, multiple uterine fibroids are a risk factor for its complicated course. First of all, due to the increased tone of the myometrium, the probability of miscarriage in the early stages increases, and in the second or third trimester there is an increased risk of developing placental pathology (premature aging, detachment), bleeding, premature birth. With large nodes deforming the uterine cavity, fetal hypotrophy and the formation of various anatomical defects are possible. Immediately during and after childbirth, multiple uterine fibroids can cause weak labor, uterine atony and postpartum bleeding, prolonged uterine involution.
It is possible to confirm the presence of multiple uterine fibroids only with the help of instrumental imaging methods. Gynecological examination and analysis of complaints allow only a rough estimate of the size and type of growth of nodes. With a two-handed examination, the gynecologist determines the enlargement of the uterus, its bumpy surface, the presence of nodes of various sizes and mobility.
The standard examination is supplemented by a combined gynecological ultrasound (TA + TV). During the study, the number, size, location and condition of the multi-node fibroids are specified. Color Doppler mapping and Dopplerometry allow us to obtain information about the nature of blood flow in myomatous nodes, which is important for the subsequent choice of therapeutic tactics. Ultrasound hysterosalpingoscopy significantly expands the possibilities of ultrasound in the diagnosis of submucous fibroids, in which the uterine cavity is contrasted with liquid media.
To clarify diagnostic information, it is possible to conduct hysterosalpingography, hysteroscopy (with submucous fibroids), MRI of the pelvic organs. If it is necessary to exclude the malignancy of multiple uterine fibroids, an SDC is performed with a histological examination of the scraping or an aspiration biopsy with the cytology of the aspirate. Diagnostic laparoscopy is indicated mainly for the differential diagnosis of subserous fibroids with solid ovarian tumors and retroperitoneal neoplasms.
The decision on conservative or surgical treatment of multiple uterine fibroids is made taking into account many factors: the age of the woman, the availability of pregnancy plans, the number and localization of nodes, as well as their size, clinical manifestations, and the effect on childbearing function.
Patients of reproductive age with small neoplasms may be treated with low-dose combined oral contraceptives to slow their growth. The use of the intrauterine hormonal system “Mirena” has a positive therapeutic effect. The possibilities of using gonadotropin releasing hormone agonists (gozerelin, triptorelin, buserelin) in the treatment of multiple uterine fibroids are limited due to a number of side effects. Firstly, their intake causes a temporary regression of fibroids, and after the withdrawal of drugs, the size of the nodes quickly increases again. Secondly, GnRHa causes pharmacological menopause in a woman with all the symptoms inherent in her, therefore, in young patients, the course of treatment should not exceed three months. Antigonadotropins (danazol, gestrinone), antiestrogens (tamoxifen), progestogens (norethisterone, didrogesterone) and progesterone antagonists (mifepristone), etc. can be prescribed individually.
Indications for surgical treatment of multiple uterine fibroids are uterine bleeding, rapid growth or large size of nodes, infertility and miscarriage, pain and anemia syndrome, compression of neighboring organs, malnutrition in the myomatous node. In women of reproductive age, preference is given to the removal of nodes with the preservation of the uterus and, consequently, the possibility of pregnancy. In these cases, laparoscopic myomectomy, conservative myomectomy with laparotomy access, hysteroresectoscopy of nodes can be performed. Organ-preserving methods of treatment of multiple uterine fibroids also include embolization of the uterine arteries. In women who do not plan childbirth, at perimenopausal age, with a combination of multiple uterine fibroids with adenomyosis, signs of fibroid malignancy, supravaginal amputation of the uterus or hysterectomy is performed – removal of the uterus together with the cervix.
Patients who are being observed by a gynecologist for multiple uterine fibroids are recommended to have an pelvic ultrasound twice a year. It is necessary to limit exposure to the sun, exclude visits to the solarium, baths and saunas, conducting thermal procedures on the lumbar and abdominal area, massage of the lumbar-sacral spine, since these procedures can provoke the growth of nodes and aggravate the clinical manifestations of multiple uterine fibroids.