Submucosal fibroid of the uterus is a mature hormone–dependent tumor of connective tissue structures with the localization of the node under the endometrium and the direction of growth inside the uterine cavity. The development of submucosal fibroid of the uterus is accompanied by menorrhagia and metrorrhagia, pain syndrome, infertility. Diagnosis is carried out with the help of gynecological examination, ultrasound, hysteroscopy, separate diagnostic curettage. Treatment of submucosal fibroid of the uterus includes surgical tactics in various volumes (myomectomy, hysterectomy), minimally invasive treatment (FUZ-ablation, embolization of uterine arteries).
Submucosal localization of uterine fibroid is 20-32% among all cases of tumors of this type. The location of the node under the mucous membrane and the internal direction of its growth lead to deformation of the uterine cavity. In most cases, the presence of submucosal fibroid of the uterus serves as an indication for surgical treatment, since even small nodes give vivid clinical symptoms: they cause painful spasms and unsystematic bleeding, miscarriage and infertility. As a result of uterine contractions, spontaneous birth (expansion) of a fibromatous node may occur. Submucosal fibroids of the uterus are prone to rapid progression; the risk of malignancy of submucous nodes reaches from 0.3 to 2%.
The development of submucosal fibroid of the uterus, as a rule, is accompanied by hormonal ovarian dysfunction, accompanied by hyperestrogenism and a violation of the balance between estrogens and progesterone. This theory is supported by the fact that the growth of fibroma is facilitated by the use of estrogen-containing contraceptives, pregnancy. On the contrary, during menopause, characterized by a decrease in hormonal activity, the size of the fibroma is noticeably reduced. Meanwhile, hormone therapy initiated during menopause can again provoke the growth of fibroids.
Among the factors that cause the occurrence of submucosal fibroid of the uterus, in gynecology, there is a genetic predisposition and the presence of fibroid tumors in the closest relatives. There is a connection between the development of submucosal fibroid of the uterus and diseases of the endocrine glands (pancreas, thyroid, adrenal glands), obesity, chronic pathology (pyelonephritis, tonsillitis), genital inflammation (salpingitis, oophoritis, adnexitis, endometritis), ovarian cysts, mastopathy, varicose veins of the pelvis and lower extremities. The frequency of uterine fibroids correlates with such unfavorable moments for the reproductive sphere as artificial termination of pregnancy, long-term use of COCs, absence of pregnancies by the age of 30.
Typical manifestations of submucosal fibroid of the uterus are bleeding – menorrhagia and metrorrhagia. Menorrhagia is characterized by an increase in the number of menstrual secretions and the duration of menstruation. Against the background of mennorrhagia, acyclic intermenstrual bleeding – metrorrhagia – develops. Copious menstrual and intermenstrual blood loss leads to anemia of the patient.
Another characteristic manifestation of submucosal fibroid of the uterus is the presence of pulling or cramping abdominal pain, algomenorrhea. In some cases, intense contractions of the myometrium can lead to spontaneous expansion – the birth of a fibromatous node, i.e. its exit through the cervical canal into the vagina.
Submucosal nodes often overlap the mouths of the fallopian tubes, prevent implantation of a fertilized egg, which is accompanied by infertility or spontaneous termination of pregnancy in the early stages of gestation. Possible complications of submucosal uterine fibroma include the development of secondary iron deficiency anemia, the “birth” of a fibromatous node, uterine inversion, necrosis of the myomatous node or its malignancy.
Submucosal fibroids of the uterus increase in size faster than other types of similar tumors. With submucosal fibroid of the uterus, there may be violations of defecation, urination, heart pain, headaches, dizziness, sensations of hot flashes, which may force the patient to turn first of all not to a gynecologist, but to other specialists – a proctologist, urologist, cardiologist, neurologist.
When examining patients, attention is paid to the somatic, gynecological, reproductive anamnesis. During the gynecological examination, a dense movable node, an increase in the size of the uterus and a change in its shape are revealed.
Ultrasound with submucosal fibroid of the uterus makes it possible to accurately establish a diagnosis in 92.8-95.7% of cases. Submucous nodes are visualized as oval or rounded formations with localization inside the expanded uterine cavity. With the help of ultrasound hysterosalpingoscopy, it is possible to differentiate the submucosal fibroid of the uterus from the endometrial polyp, to more accurately determine the localization of the node and the degree of deformation of the uterine cavity. The use of ultrasound Dopplerography makes it possible to assess blood flow and structural changes in the fibroid node.
During hysteroscopy, even small submucosal fibroids of the uterus are detected, which are characterized by a spherical shape, clear contours, and dense consistency. On their surface, under the thinned endometrium, a network of dilated vessels, extensive or small-point hemorrhages can be viewed. Also, hysteroscopy allows you to exclude the presence of other intrauterine pathology – foreign bodies, polyps, synechiae, malformations.
According to the hysteroscopic picture, the type of submucous node is determined: type 0 – a node on a leg devoid of an intramural component; type 1 – a node on a wide base with an intramural (intramural) location of less than 50%; type 2 – a node with an intramural location of more than 50%. Knowing the value of the intramural component allows you to choose the optimal therapeutic tactics for submucosal fibroid of the uterus.
To exclude endometrial pathology in patients with menometrorrhagia, it is necessary to conduct separate diagnostic curettage of the uterus with histological analysis of scraping. Diagnostic laparoscopy may be required to differentiate submucosal uterine fibroma from ovarian cysts or fibroids, uterine sarcoma, abdominal tumors.
In relation to submucosal fibroid of the uterus, modern gynecology uses only surgical tactics. Indications for surgical access and the volume of surgery for submucosal fibroid of the uterus are determined individually, taking into account the patient’s age, her intentions to preserve reproductive function, the type and size of the node, symptoms, complications, the presence of concomitant extragenital and gynecological pathology. With submucosal fibroid of the uterus, organ-preserving intervention (conservative myomectomy) or radical surgery (hysterectomy) is possible.
Myomectomy can be performed by means of glandular section (laparotomy) or endoscopic access (laparoscopy, hysteroscopy). The technique of transhysteroscopic myomectomy (electrosurgical, mechanical, laser) depends on the type of submucous node, its size, localization, and technical equipment of the clinic. Mechanical transhysteroscopic myomectomy is performed for submucosal uterine fibroids of types 0 and 1 with a minor intrahepatic component. In this case, the submucous node is fixed and “unscrewed” with an abortion rod or dissect its leg or capsule with a resector and extract the tumor from the uterine cavity through the vagina.
Electrosurgical myomectomy is performed with submucosal fibroid of the uterus of type I or II with a significant intramural component or with hard-to-reach localization of nodes. Sometimes, with large submucous nodes of type 2, preoperative hormone therapy with gozerelin or triptorelin is performed, which helps to reduce submucosal fibroid of the uterus by 30-70% within 3-4 months. In the future, such nodes become available for conservative removal.
In recent years, minimally invasive methods have been increasingly used in the treatment of uterine fibroids – uterine artery embolization and fuso-ablation. Radical interventions in submucosal fibroid of the uterus are performed in the volume of supravaginal amputation or complete removal of the uterus. The question of the preservation of appendages is solved taking into account their condition and the factor of the patient’s age.
Prognosis and prevention
After performing a conservative myomectomy, pregnancy may occur. Since submucosal fibroids of the uterus often provoke miscarriage, pregnancy management in patients with non-removed fibroma requires taking into account possible risks.
After any type of treatment of submucosal fibroid of the uterus, observation of the patient by a gynecologist or gynecologist-endocrinologist is indicated. Prevention of submucosal fibroid of the uterus consists in passing regular preventive examinations, competent selection of contraception, exclusion of abortions, timely treatment of gynecological pathology.