Submucosal fibroids are benign hormone—dependent tumors located in the submucosal layer of the uterus and formed by smooth muscle cells of the myometrium. Almost half of the cases are asymptomatic. It can manifest itself as menorrhagia, increasing anemia, cramping pains in the lower abdomen during menstruation, inability to get pregnant or carry a child. Transvaginal ultrasound, hydrosonography, hysteroscopy, dopplerography and pelvic angiography are used to diagnose the disease. Depending on the characteristics of the course, one of the methods of conservative, combined, surgical organ-preserving or radical treatment is chosen.
Submucosal fibroids (leiomyoma) are diagnosed in 32% of all cases of detection of myomatous nodes. The disease affects women of reproductive age and never occurs in girls before the onset of the first menstruation. It is more often detected in patients aged 33-40 years. In recent years, there has been a trend towards “rejuvenation” of pathology and the detection of submucosal nodes in patients aged 20-25 years. After menopause, submucosal fibroids usually do not develop, and already existing nodes regress. There is a close interdependence between the disease and the problem of infertility – in every fifth woman who cannot get pregnant, the presence of myomatous nodes is the only pathology of the reproductive system.
The most likely causes of submucosal nodes are hormonal imbalance and changes in the sensitivity of smooth muscle cells of the myometrium to the action of female sex hormones. The development of submucosal leiomyoma can lead to:
- Hereditary predisposition. Proliferation of myometrial cells is provoked by a genetically determined change in their sensitivity to estrogen and progesterone.
- Hypothalamic-pituitary disorders. Hormonal imbalance occurs when the level of follicle-stimulating (FSH) and luteinizing (LH) hormones changes. The disorder can be observed with vascular and traumatic brain injuries, significant psychoemotional loads.
- Changes in the endocrine function of the ovaries. The level of secretion of estrogen, progesterone and the normal ratio between these hormones is disrupted in inflammatory diseases (oophoritis, salpingitis, adnexitis), trauma, tumors.
- Traumatic injury of the myometrium. The sensitivity of smooth muscle cells changes due to frequent abortions, invasive medical and diagnostic procedures.
- The effect of extragenital factors. Violation of the production of female sex hormones is observed in diabetes mellitus, thyroid damage, and some other endocrine diseases. The level of estrogen in the blood can increase against the background of obesity, since adipose tissue cells are able to produce this hormone.
- Uncontrolled use of hormonal contraceptives. With prolonged use of contraceptive drugs, the secretion of sex hormones regulating the ovulatory cycle may be disrupted.
- Stagnation in the pelvis. According to a number of authors, the causes of hormonal imbalance are venous stagnation due to the lack of regular sexual discharge and a sedentary lifestyle.
It is worth noting that not in all of these situations, submucosal fibroids occur in women. Therefore, the search for trigger factors for the development of the disease is still ongoing.
First, under the influence of provoking factors, an active zone is formed near the microvessels in the muscular layer of the uterus, in the cells of which metabolic processes are accelerated, tissue permeability increases. Subsequently, smooth muscle cells of this zone begin to accumulate into microscopically and macroscopically determined nodes. Over time, the sensitivity of the proliferating tissue to the action of hormones decreases, its own autocrine-paracrine growth mechanisms are triggered. Nutrition of submucosal fibroids is provided by vessels that have lost their adventitial sheath. A growing submucosal node increases the area of rejection of the endometrium and reduces the ability of the myometrium to contract, which provokes more abundant, prolonged and painful menstrual bleeding.
Submucosal fibroids differ in the number of nodes, localization, size and structure. The following criteria are used to classify the disease:
- The number of nodes. There are single and multiple submucosal fibroids.
- Sizes. Submucosal tumors up to 20 mm in size (up to 4-5 weeks of pregnancy) are considered small, from 20 to 60 mm (4-5 to 10-11 weeks) – medium, more than 60 mm (12 weeks or more) – large.
- Location. In most cases, neoplasms are localized in the body of the uterus, in 5% – in the cervical region.
- Morphology. Depending on the type of cells and the activity of their proliferation, simple submucosal fibroids, proliferating nodes and presarcomas are isolated.
Submucosal fibroids symptoms
The symptoms depend on the age of occurrence, the size and intensity of growth of the node. At the initial stages, symptoms are usually absent, the neoplasm becomes an accidental finding during a gynecological examination or ultrasound. The first most characteristic sign of the growth of the submucosal node is menorrhagia — copious menstrual bleeding with blood clots, the duration of which exceeds the duration of normal menstruation. Spotting can also be observed in the intermenstrual period. Due to private significant blood loss, anemia develops with general malaise, pallor of the skin, dizziness, headaches, decreased performance.
Pain with submucosal node location, according to specialists in the field of gynecology, is observed in 20-50% of patients. They usually occur during menstruation, have a cramping character, are localized in the lower abdomen and can give to the lower back. Unlike a subserous fibroid, a submucosal tumor usually does not affect nearby organs. In 10-40% of cases, there is a violation of reproductive function – the inability to get pregnant or spontaneous termination of pregnancy.
Submucosal fibroids can be complicated by massive uterine bleeding, the development of severe anemia. With significant deformation of the uterine cavity, the risk of infertility, miscarriages, pathological pregnancy and childbirth increases. In 7-16% of cases, the node undergoes dry or wet necrosis. In the presence of an ascending infection, submucosal fibroids can fester or abscess, while the patient’s temperature rises, chills occur, abdominal pain, and the general condition changes. The most formidable complication is the “birth” of the submucosal node, which is accompanied by “dagger” cramping pains in the lower abdomen, bleeding, and the risk of infection. Malignant degeneration of the tumor is rare (in 1.5-3% of cases).
Since the clinical symptoms of submucosal fibroids are nonspecific and not expressed in all patients, physical and instrumental studies play an important role in diagnosis. The survey plan usually includes:
- Gynecologist’s examination. Bimanual palpation reveals an enlarged uterus.
- Transvaginal ultrasound, hydrosonography, Dopplerography. The methods allow to determine the size, type and structure of nodes, to identify endometrial pathology, to assess the thickness of the smooth muscle layer and the intensity of blood flow.
- Hysteroscopy. In the uterus, an oval or rounded formation with a smooth pale pink surface is found, or multiple nodes on the legs hanging in the form of “clusters” into its cavity.
- Angiography of the pelvic organs. Visualization of the circulatory system of the uterus makes it possible to confirm the absence of neovascularization in a timely manner to differentiate a benign node from malignant neoplasia.
- X-ray television hysterosalpingography. Reveals a change in the shape of the uterine cavity with areas of enlightenment or filling defects. Currently, it is rarely used.
- MRI and CT of the uterus. The methods are used to accurately assess the topography of myomatous nodes.
Since submucosal fibroids are characterized by the development of anemia, erythropenia and a decrease in hemoglobin levels are often detected in the general blood test. The disease must be differentiated from pregnancy, polyps, sarcoma, internal endometriosis of the uterine body. If necessary, an oncogynecologist and an endocrinologist are involved in the examination.
Submucosal fibroids treatment
When choosing medical tactics, the age of a woman, her plans for preserving reproductive function, the size, location and intensity of node growth, the severity of the clinical picture and the presence of complications are taken into account. Patients with neoplasms of stable size in the absence of menorrhagia, pain syndrome, preserved reproductive function are recommended dynamic follow-up with an annual gynecologist examination. In other cases, choose one of the methods of conservative, combined or surgical treatment.
Drug therapy is indicated for tumors up to 3 cm in size, moderate menorrhagia, slow growth of neoplasms. Patients are recommended drugs that inhibit the secretion of female sex hormones, eliminating one of the main causes of tumor formation — hormonal growth stimulation. Such therapy is usually supplemented with symptomatic means. Conservative treatment is especially effective in premenopause, which is replaced by natural menopause. As a rule, patients are prescribed:
- Drugs that inhibit the secretion of gonadotropins. When using antigonadotropins and gonadotropin releasing hormone (A-GnRT) agonists, the size of the nodes stabilizes or even decreases, and blood loss during menstruation decreases.
- Oral or intrauterine hormonal contraceptives. It is indicated for women of childbearing age to stabilize the effect achieved by inhibiting the secretion of gonadotropins.
- Hemostatics and drugs that contract the uterus. They are used to reduce blood loss in menorrhagia.
- General strengthening agents. Vitamin and mineral complexes and iron preparations are prescribed to improve overall well-being.
Combined treatment is the best option for patients who want to preserve reproductive function in the presence of a single node or multiple formations with a size of 50 mm or more with clinical symptoms and a tendency to slow growth. With this method, the appointment of A-GnRT precedes and completes conservative myomectomy. The use of hormonal drugs on the eve of the intervention allows you to reduce the size of benign submucosal nodes, reduce blood loss, shorten the duration of surgery and postoperative recovery.
Surgical treatment is recommended if the node reaches a large size (from 12 weeks of pregnancy), grows intensively (an increase of 4-5 or more weeks per year, especially during menopause and menopause), is accompanied by increasing anemia, pain and the development of complications (including infertility). Depending on the course of the disease and a woman ‘s reproductive plans , the following types of interventions can be selected:
- Organ-preserving operations. Myomatous nodes are removed by hysteroresectoscopy (transcervical myomectomy) using mechanical, laser or electrosurgical instruments or destroyed by high-frequency focused ultrasound (FUZ-ablation) or cryomyolysis. Embolization of the uterine arteries allows you to limit the nutrition of the tumor and lead to its resorption.
- Radical interventions. With an unfavorable course of the disease, a woman is recommended transvaginal, laparoscopic, laparotomic defundation of the uterus, subtotal (supravaginal) or total hysterectomy.
Prognosis and prevention
With timely detection and adequate treatment, the prognosis of submucosal fibroids is favorable. During menopause, the tumor usually regresses. The efficiency of uterine artery embolization is up to 50%. Organ-preserving interventions can restore reproductive function in women of childbearing age. The postoperative period, depending on the volume of the operation and the type of access, lasts from 7 to 24 days. The period of dispensary follow-up after hysterectomy is 5 years, After myomectomy, due to the possibility of relapse, women are observed for life. The main methods of preventing the disease are the rational use of hormonal contraceptives, the restriction of invasive interventions, the treatment of diseases in which hyperestrogenemia is observed.