Subserosal fibroid are benign hormone—sensitive neoplasms that consist of smooth muscle cells of the myometrium and are located under the serous lining of the uterus. In 60-70% of cases, the disease is not clinically manifested. Some patients are concerned about pain in the lower abdomen and lower back, violation of childbearing function, signs of pressure on the pelvic organs. To confirm the diagnosis, ultrasound, angiography and dopplerography of the uterus, pelvic tomography, laparoscopy are prescribed. Treatment involves the use of hormonal drugs, myomectomy and radical interventions.
Subserosal fibroid (leiomyomas) are most often detected in women over 30 years of age. At the same time, currently the prevalence of the disease in the age group of 20-30 years has increased by 30-35%. Women during menopause get sick extremely rarely, usually the cessation of menstrual function is accompanied by tumor involution. In girls, subserous myomatous nodes are not detected before the onset of menarche. Such statistics confirm the leading role of the hormonal factor in the development of peritoneal leiomyoma. The incidence of urban women is significantly higher than that of women living in rural areas.
According to many specialists in the field of gynecology, the main factors provoking the development of leiomyoma with an abdominal location of nodes are endocrine disorders and pathological changes at the level of myometrial cells. The immediate causes of hormonal imbalance are:
- Violations of central regulation. Injuries and damage to the vessels of the brain, tumors, constant stress affect the secretory activity of the hypothalamic-pituitary region. One of the manifestations of such disorders is the hyperproduction of FSH and LH – gonadotropic hormones that regulate the endocrine function of the ovaries.
- Extragenital endocrine pathology. Hypothyroidism, autoimmune thyroiditis, diabetes mellitus, adrenal diseases and some other diseases are accompanied by a violation of the production of estrogens and a change in the ratio of their individual fractions.
- Ovarian diseases. With neoplasms, inflammatory processes, traumatic injuries of the uterine appendages, the secretion of estrogen and progesterone, the main female hormones that affect the proliferative activity of myometrial cells, may change.
- Fatness. Adipocytes have endocrine secretory activity, are able to secrete estrogen.
- Long-term hormonal contraception. Prolonged suppression of ovulation with synthetic sex hormones can disrupt their natural production.
- Stagnation in the pelvic organs. Low physical activity, irregular sex life without sexual discharge lead to venous stagnation in the uterus and appendages, followed by the development of hormonal imbalance.
Since hormonal disorders are not detected in all patients with subserosal fibroid, some authors believe that pathological sensitivity or activity of the cells of the muscular layer of the uterus plays an essential role in the development of the disease. Such violations lead to:
- Hereditary factor. Scientists have identified two groups of genes that can influence the development of myomatous nodes. Some of them provoke increased proliferation of myometrial cells, others change sensitivity to estrogen and progesterone.
- Injuries of the myometrium. Frequent abortions, invasive diagnostic and therapeutic procedures, surgical interventions on the uterus cause local changes in smooth muscle cells.
At the first stage of the formation of a subserous node, pathological changes occur at the cellular level. In some smooth muscle cells, under the influence of sex hormones, metabolic processes are accelerated, while there is an increase in tissue permeability. The second stage of pathogenesis is characterized by the appearance of cell clusters, defined as microscopic nodes. At the third stage, neoplasms are determined macroscopically. Nodes can be formed on a wide base or a thin leg, along which the vessels feeding them pass. An important point in the pathogenesis of peritoneal fibroids is a gradual decrease in the sensitivity of proliferating cells to the stimulating effect of hormones and the further development of the tumor under the influence of its own autocrine factors. As the disease increases, it manifests itself clinically by a decrease in the contractility of the myometrium and pressure on adjacent organs.
Subserous leiomyomas can have different sizes, number of nodes, histological structure and location features in relation to the uterus. Accordingly , the disease is classified according to the following criteria:
- By size. There are small fibroids with sizes up to 4-5 weeks of pregnancy (up to 20 mm), medium – from 4-5 to 10-11 weeks (20-60 mm) and large – from 12 weeks (more than 60 mm).
- By the number of nodes. Peritoneal fibroids can be single and multiple.
- By morphological structure. Taking into account the type and proliferative activity of smooth muscle cells, tumors can be simple, proliferating and pre-sarcoma.
- According to the features of the location. Subserous neoplasms can grow on the surface of the uterus facing the abdominal cavity, or between its ligaments; have a wide base or leg.
Clinical symptoms of subserosal fibroid are detected only in 30-40% of patients and indicate a significant prescription of the disease. Single and small neoplasias usually develop asymptomatically and are first detected by gynecological ultrasound. A violation of the menstrual cycle is uncharacteristic for the abdominal growth of nodes. If the tumor has a broad base, the contractile activity of the myometrium may be impaired, which is clinically manifested by abundant and prolonged menstruation, the development of anemia with pale skin, complaints of general weakness, fatigue, low efficiency, periodic dizziness and headaches.
With large tumors, there is a pain syndrome and signs of pressure on adjacent organs. Patients complain of periodic lower back pain, which may worsen during menstruation. Especially severe pain occurs when the myomatous node merges with the peritoneum. With the pressure of neoplasia on the bladder, the urge to urinate becomes more frequent. Compression of the rectum is manifested by constipation, increased urge to defecate, an increase in hemorrhoids. Much less often, fibroids disrupt the venous outflow from the extremities, which is accompanied by edema. Unlike submucous tumors, peritoneal neoplasms have less effect on reproductive function – the inability to get pregnant or carry a child is usually noted only by those women whose node growth has led to the formation of a bend in the uterus or a significant deformation of its cavity.
The most dangerous complications of subserosal fibroid are leg twisting, necrosis or infarction, which are accompanied by intense pain in the lower back and lower abdomen, severe weakness, sweating, vomiting, fever, violation of the functions of the rectum and bladder. With the peritoneal location of the neoplasm, secondary anemia due to blood loss, infertility and premature termination of pregnancy, myxomatous transformation of the tumor, hyperplastic processes in the endometrium can also be observed. Malignancy occurs extremely rarely (in no more than 0.25-0.75% of cases).
When making a diagnosis of subserosal fibroid, special research methods play a special role, allowing to detect neoplasms, determine their size, clarify the features of blood supply, location, structure. In diagnostic terms , the most informative:
- Gynecological examination. During a bimanual examination, an enlarged uterus and nodes on its surface are palpated.
- Transvaginal and transabdominal ultrasound. Fibroids associated with the uterus and growing towards the abdominal cavity are identified, their size, structure and localization are determined.
- Dopplerography and angiography of the uterus. They allow you to assess the intensity of blood flow, visualize the circulatory system of the uterus and detect signs indicating a malignant process.
- MRI and CT of pelvic organs. Provide the most accurate topographic picture of the pelvic organs and myomatous nodes.
- Diagnostic laparoscopy. Peritoneal leiomyomas are defined as rounded pale pink formations with a shiny smooth surface.
From laboratory tests, a general blood test may be indicative (erythropenia and low hemoglobin levels are detected) and a study of the level of sex hormones (FSH, LH, estradiol, progesterone). Differential diagnosis is performed with pregnancy, uterine sarcoma, ovarian tumors and retroperitoneal neoplasms. If necessary, the patient is advised by an oncogynecologist, endocrinologist, urologist, surgeon, therapist.
Subserosal fibroid treatment
Patients with small abdominal nodes with preserved reproductive function, the absence of complaints and signs of neoplasia growth are recommended dynamic follow-up with a gynecologist’s examination once a year. In other forms of the disease, the specialist offers appropriate conservative, combined or surgical treatment. Hormonal and symptomatic therapy is indicated for women with slow-growing neoplasms up to 12 weeks in size and moderate clinical symptoms. The treatment regimen may include:
- Inhibitors of gonadotropin secretion. The administration of antigonadotropins and GnRH agonists (gonadotropic releasing hormones) helps to stabilize and reduce the size of nodes.
- Gestagenic and estrogen-gestagenic drugs. They allow correcting hormonal imbalance and stopping tumor growth in women of reproductive age, stabilizing the effect of aGnRH and antigonadotropins.
- Androgens. For the purpose of medical termination of menstrual function, it is recommended for patients over 45 years of age who are not planning pregnancy.
- Symptomatic remedies. In the presence of pain syndrome, analgesics are prescribed, with metrorrhagia – hemostatics and drugs for uterine contractions. According to the indications, iron preparations, vitamins, mineral complexes, etc. are used.
One of the best solutions for patients of childbearing age with a single or several slow-growing neoplasms with sizes from 50 mm in the presence of clinical manifestations is combination therapy. The method involves conservative myomectomy, before which GnRH agonists are prescribed to stabilize the growth of myomatous nodes. Course treatment with drugs that inhibit the secretion of gonadotropins is also recommended in the postoperative period for the prevention of relapse.
With fast-growing peritoneal fibroids larger than 60 mm, severe pain syndrome, metrorrhagia, disorders of reproductive function and pelvic organs, surgical methods are indicated. Unlike submucosal fibroids, it is not recommended to use uterine artery embolization in the treatment of subserous neoplasms due to the high risk of necrosis. Taking into account the reproductive plans of women and the peculiarities of the course of the disease, various organ-preserving and radical interventions are performed:
- Laparoscopic and laparotomic myomectomy. Mechanical, electro- and laser-surgical instruments are used to cut off and enucleate the abdominal nodes.
- FUZ-ablation. Despite the low invasiveness, the method is used only to a limited extent. It can not be prescribed in the presence of 6 or more nodes, large neoplasms and tumors on the leg.
- Semi-radical and radical operations. During transvaginal, laparoscopic or laparotomic surgery, defundation, high and normal supravaginal amputation or total extirpation of the uterus are performed.
Prognosis and prevention
Subserosal fibroid are benign neoplasms with a low risk of malignancy and a favorable prognosis. Timely detection of the disease and proper treatment tactics allow you to restore menstrual and reproductive function. To reduce the risk of developing abdominal nodes and complications in the presence of a tumor, it is recommended to be regularly monitored by a gynecologist (especially in diseases accompanied by hyperestrogenemia), to use contraceptive methods rationally, to undergo invasive procedures strictly according to indications.